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Orthopedics - Carpal and Cubital Tunnel Syndrome

Orthopedics & Podiatry Main Menu

Carpal and Cubital Tunnel Syndrome

Diagnosis/Definition

Pain, loss of strength or sensory changes (paresthesias) in the distribution of the median or ulnar nerves not associated with neck pain.

Initial Diagnosis and Management

  • History and physical exam (screen for associated conditions, i.e., diabetes, pregnancy, Rheumatoid Arthritis, Systemic Lupus Erythematosus (SLE).
  • Assessment with provocative tests to include Tinel's and Phalen's sign tests of specific nerves.
  • Plain radiographs are not required (unless there was trauma); MRI/CT are not indicated.
  • For Carpal Tunnel Syndrome (CTS) symptoms prescribe a wrist splint (wrist in a neutral position) to wear at night and during the day for aggravating activities (take splint off every 2 hours and move wrist to prevent stiffness).
  • For cubital tunnel syndrome, educate the patient to avoid pressure on elbow.
  • For both, try work simplification techniques using ergonomic principles and activity modification to decrease symptoms.

Ongoing Management and Objectives

  • Expect resolution or decreasing symptoms within two to four weeks.
  • Consider confirming the diagnosis with Electromyography/Nerve Conduction Velocity (EMG/NCV),   (PM&R or Neuro diagnostics)  if symptoms have not resolved within 6 weeks or if there has been no response to treatment.  
  • Continue NSAID and splint use.

Indications for Specialty Care Referral

  • For cubital tunnel syndrome refer to Occupational Therapy (OT) for night elbow splints.
  • If the patient exhibits no relief of pain, sensory changes, decreases in AROM or strength to the upper extremity within 3-4 weeks, refer to OT for evaluation and treatment.
  • Chronic CTS or cubital tunnel syndrome with symptoms >6months can be referred to OT for evaluation and treatment.
  • If the patient has completed a full course of treatment through OT and referred back to primary care with no improvement, referral to Orthopedic Surgery is indicated.
  • Orthopedic Hand Clinic referral is indicated if a sensory (2 point discrimination >5mm) or motor deficit is demonstrated in patients with CTS.

Criteria for Return to Primary Care

  • Resolution of symptoms.
  • Chronic condition that can be managed at primary care level with intermittent specialty care evaluation/intervention as needed.

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