Carpal tunnel syndrome: relationship between clinical and patient-oriented assessment

Diagnostic utility of anteroposterior measurements of the median nerve on sagittal ultrasonographic images and their correlation with clinical findings in carpal tunnel syndrome

PURPOSE

To investigate the efficacy of sagittal ultrasonography of the median nerve in diagnosing carpal tunnel syndrome (CTS).

METHODS

Seventy-six hands with idiopathic CTS and 80 hands of asymptomatic subjects were included. All patients with CTS underwent ultrasonographic examination, electrodiagnostic testing, and CTS-6 assessment. In the sagittal ultrasonographic examination, the maximum and minimum median nerve diameters (MNDs) were measured at the proximal and distal ends of the carpal tunnel, respectively. The median nerve stenosis rate (MNSR) was computed as (1 - minimum MND/maximum MND) × 100 (%). The cross-sectional area (CSA) of the median nerve at the level of the pisiform was measured.

RESULTS

In the sagittal ultrasonographic examination, the mean maximum MNDs were 0.252 cm and 0.202 cm, mean minimum MNDs were 0.145 cm and 0.165 cm, and mean MNSRs were 41.83% and 17.35% in the CTS and control groups, respectively; the mean maximum MND and MNSR were considerably larger in the CTS group. The maximum MND and MNSR were correlated with the electrodiagnostic testing results and CTS-6 score. The MNSR with a cut-off value of 34.0% had a higher sensitivity and specificity than the CSA in diagnosing CTS.

CONCLUSIONS

Sagittal ultrasonographic examination is useful in diagnosing CTS.

Efficacy of Diagnosing Carpal Tunnel Syndrome Using the Median Nerve Stenosis Rate Measured on Ultrasonographic Sagittal Imagery: Clinical Case-Control Study

BACKGROUND

The purpose of the present study was to evaluate the usefulness of the median nerve stenosis rate (MNSR) measured on sagittal sonographic images of the median nerve in the diagnosis of carpal tunnel syndrome (CTS).

METHODS

The study population consisted of 45 hands from 37 patients with idiopathic CTS (CTS group), and 60 hands from 35 asymptomatic healthy subjects (control group). Carpal tunnel syndrome was diagnosed by clinical findings and positive electrophysiological study results. All patients and control subjects underwent ultrasonographic examination. At the carpal tunnel level, the transducer was placed longitudinally to the median nerve, and an image of the longitudinal median nerve was obtained. The minimum median nerve diameter (MND) was measured at the middle part of the capitate level, while the maximum MND was measured at the distal radioulnar joint level. The MNSR was calculated as (1 - minimum MND/maximum MND) × 100 (%). The cross-sectional area of the median nerve was also measured at the level of the pisiform.

RESULTS

On longitudinal sonographic images, the MNSR was significantly larger in the CTS group than the control group. When the cut-off value of the MNSR was 26.73%, the sensitivity and specificity were 91.1% and 80%, respectively. The area under the receiver operating characteristic curve was larger for the MNSR than for the cross-sectional area.

CONCLUSION

The results suggest that the MNSR proposed in the present study may be useful as an auxiliary method for CTS diagnosis on ultrasonographic examination.

Deep CTS: a Deep Neural Network for Identification MRI of Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a common peripheral nerve disease in adults; it can cause pain, numbness, and even muscle atrophy and will adversely affect patients' daily life and work. There are no standard diagnostic criteria that go against the early diagnosis and treatment of patients. MRI as a novel imaging technique can show the patient's condition more objectively, and several characteristics of carpal tunnel syndrome have been found. However, various image sequences, heavy artifacts, small lesion characteristics, high volume of imagine reading, and high difficulty in MRI interpretation limit its application in clinical practice. With the development of automatic image segmentation technology, the algorithm has great potential in medical imaging. The challenge is that the segmentation target is too small, and there are two categories of images with the proximal border of the carpal tunnel as the boundary. To meet the challenge, we propose an end-to-end deep learning framework called Deep CTS to segment the carpal tunnel from the MR image. The Deep CTS consists of the shape classifier with a simple convolutional neural network and the carpal tunnel region segmentation with simplified U-Net. With the specialized structure for the carpal tunnel, Deep CTS can segment the carpal tunnel region efficiently and improve the intersection over union of results. The experimental results demonstrated that the performance of the proposed deep learning framework is better than other segmentation networks for small objects. We trained the model with 333 images, tested it with 82 images, and achieved 0.63 accuracy of intersection over union and 0.17 s segmentation efficiency, which indicate great promise for the clinical application of this algorithm.

Comparison of clinical findings and electromyography results in patients with preliminary diagnosis of carpal tunnel syndrome

OBJECTIVE

To evaluate the link between EMG findings and clinical status, the Boston questionnaire and the severity of pain in patients with pre-diagnosis of carpal tunnel syndrome.

METHODS

A total of 85 patients (133 hands) who presented to the Physical Therapy and Rehabilitation outpatient clinic consecutively with complaints of numbness, tingling, pain and weakness in their hands were evaluated for their demographic and clinical features. After the initial evaluation, the diagnosis of CTS was confirmed by EMG. Visual analog scale (VAS), the Boston Questionnaire (Symptom Severity Scale = SSS, Functional Status Scale = FSS) and nerve conduction study results (sensory conduction velocity = SCV, distal motor latency = DML, compound muscle action potential = CMAP) were enrolled.

RESULTS

Eighty-five patients (58 female and 27 male) participated in this study yielding 133 hands (73 right hands, 60 right hands) with CTS. The mean age was 48.3 ± 10.41 years. Of all patients, 68.2 % were female and 31.8 % were male. A statistically significant relationship was found between SSS and duration of symptoms, VAS, both right and left SCV, DML and CMAP. A statistically significant relationship was found between FSS and duration of symptoms, VAS and only right SCV, DML and CMAP.

CONCLUSION

The diagnosis of CTS should be evaluated not only as an electrodiagnostic finding, but also the clinical picture of the patients. According to our results, both SSS and FSS had good correlations with VAS and the findings of EMG. Therefore, the Boston Questionnaire can provide a standardized measure of symptom severity and functional status in patients with CTS.

Surgeon Ratings of the Severity of Idiopathic Median Neuropathy at the Carpal Tunnel Are Not Influenced by Magnitude of Incapability

BACKGROUND

Accurately distinguishing the severity of pathophysiology from the level of symptom intensity and incapability is a foundation of effective treatment strategies under the biopsychosocial paradigm of illness. With respect to idiopathic median neuropathy at the carpal tunnel (the symptoms and signs of which are referred to as carpal tunnel syndrome), surgeons who are more likely to recommend surgery based on the magnitude of symptoms and incapability rather than the severity of neuropathy may be underappreciating and undertreating mental health opportunities and overtreating mild, and on occasion unmeasurable, disease. A survey-based experiment that randomizes elements of the patient presentation can help determine the relative influence of magnitude of incapability on ratings of pathology severity.

QUESTION/PURPOSE

What factors are associated with severity rating of idiopathic median neuropathy at the carpal tunnel on an 11-point ordinal scale?

METHODS

One hundred eight hand and wrist members of the Science of Variation Group (among approximately 200 participants who complete at least one survey-experiment a year related to the upper extremity on average) reviewed seven scenarios of fictional median neuropathy with seven randomized variables: age, gender, limitations of daily activity (incapability), Tinel and Phalen test results, duration of numbness episodes, prevention of numbness with nocturnal splint immobilization, constant numbness, and weakness of palmar abduction. Participants had a mean age of 51 ± 10 years, 90% (97 of 108) were men, and 74% (80 of 108) were subspecialized in hand surgery. Surgeons were asked to rate the severity of idiopathic median neuropathy at the carpal tunnel on a on an 11-point ordinal scale. Factors associated with rated severity were sought in multilevel ordered logistic regression models. Fifteen surgeons did not complete all of their assigned randomized scenarios, resulting in a total of 675 ratings.

RESULTS

After controlling for potentially confounding variables such as magnitude of incapability, factors associated with severity rating on the 11-point ordinal scale included palmar abduction weakness (odds ratio 11 [95% confidence interval 7.7 to 15]), longer duration of symptom episodes (OR 4.5 [95% CI 3.3 to 6.2]), nocturnal numbness in spite of splint immobilization (OR 3.2 [95% CI 2.3 to 4.3]), constant numbness (OR 2.5 [95% CI 1.9 to 3.4]), positive Tinel and positive Phalen test results (OR 2.2 [95% CI 1.6 to 2.9]), and older age (OR 1.6 [95% CI 1.2 to 2.1]).

CONCLUSION

Our results suggest that surgeons rate the severity of idiopathic median neuropathy at the carpal tunnel based on evidence of worse pathophysiology and are not distracted by greater incapability.

CLINICAL RELEVANCE

Surgeons who consider greater incapability as an indication of more severe pathology seem to be practicing outside the norm and may be underappreciating and undertreating the unhelpful thoughts and feelings of worry or despair that consistently account for a notable amount of the variation in symptom intensity and magnitude of incapability.

MRI criteria for diagnosis and predicting severity of carpal tunnel syndrome

OBJECTIVE

To study MRI criteria for diagnosing and predicting severity of carpal tunnel syndrome (CTS).

METHODS

Sixty-nine wrists in 41 symptomatic CTS patients and 32 wrists in 28 asymptomatic subjects were evaluated by MRI. Circumferential surface area (CSA), flattening ratio, relative median nerve signal intensity, and retinacular bowing were measured. CTS severity was classified as mild, moderate, or severe. Parameters for patients with and without CTS and for the three severity groups were compared. ROC curves were plotted to assess accuracy for CTS diagnosis and severity prediction.

RESULTS

Significant differences were found between CTS and control wrists for median nerve CSA, flattening ratio at inlet, relative median nerve signal intensity, and retinacular bowing. ROC curve analysis revealed a sensitivity, specificity, and accuracy of median nerve CSA > 15 mm² proximal to the tunnel (CSA_p) of 85.5, 100, and 90.1%. Using either CSA_p or CSA_d > 15 mm² as a diagnostic criterion, MRI could achieve a sensitivity of 100% and specificity of 94% for diagnosis of CTS while overall accuracy was 98%. Significant differences were found among the three severity groups. Sensitivity, specificity, and accuracy of prediction of severe CTS using for CSA_p > 19 mm² were 75.0, 65.9, and 69.6%, respectively.

CONCLUSIONS

MRI is highly accurate at diagnosing CTS and moderately accurate at determining CTS severity. We recommend using CSA > 15 mm² either proximal to or distal to the tunnel as a diagnostic criterion for CTS and CSA > 19 mm² proximal to the tunnel as a marker for severe CTS.

Importance of Recognizing Carpal Tunnel Syndrome for Neurosurgeons: A Review

Idiopathic carpal tunnel syndrome (CTS) is a common complaint, reflecting entrapment neuropathy of the upper extremity. CTS produces symptoms similar to those of other conditions, such as cervical spondylosis or ischemic or neoplastic intracranial disease. Because of these overlaps, patients with CTS are often referred to a neurosurgeon. Surgical treatment of CTS was started recently in our department. Through this experience, we realized that neurosurgeons should have an increased awareness of this condition so they can knowledgeably assess patients with a differential diagnosis that includes CTS and cervical spinal and cerebral disease. We conducted a literature review to gain the information needed to summarize current knowledge on the clinical, pathogenetic, and therapeutic aspects of CTS. Because the optimal diagnostic criteria for this disease are still undetermined, its diagnosis is based on the patient’s history and physical examination, which should be confirmed by nerve conduction studies and imaging modalities such as magnetic resonance imaging and ultrasonography. Treatment methods include observation, medication, splinting, steroid injections, and surgical intervention. Understanding the clinical features and pathogenesis of CTS, as well as the therapeutic options available to treat it, is important for neurosurgeons if they are to provide the correct management of patients with this disease.

Patients' Perceptions of Carpal Tunnel and Ulnar Nerve Decompression Surgery

Background:

Carpal tunnel syndrome and ulnar nerve entrapment at the elbow are the most common entrapment neuropathies seen in adults. Surgery for nerve decompression is a safe and effective treatment option, and is usually performed under local anesthesia and as an outpatient procedure. This study aimed to explore patients' satisfaction and other aspects of the overall experience with this type of surgery.

Methods:

Qualitative research methodology was used. Semi-structured, open-ended interviews were conducted with 30 adult patients who had undergone carpal tunnel release or ulnar nerve decompression at the elbow 6-24 months prior. Interviews were digitally audio recorded and transcribed, and the data subjected to thematic analysis.

Results:

Four overarching themes emerged from the data: (1) most patients did not perceive their condition to be serious; (2) patients were satisfied with the overall surgical experience; (3) the outcome was more important to patients than the process; and (4) majority of patients had a realistic expectation of outcomes.

Conclusions:

Patients had a positive experience with carpal tunnel and ulnar nerve decompression surgery, although their level of satisfaction was dependent on the surgical outcome. Areas requiring improvement, specifically information about post-operative care and expectations of recovery, will be implemented in the future care of patients.

The long-term follow-up of treatment with corticosteroid injections in patients with carpal tunnel syndrome. When are multiple injections indicated?

The objective of this prospective study was to investigate the long-term effect of one or more local corticosteroid injections in patients with carpal tunnel syndrome and whether a good response can be predicted. Follow-up visits took place at 3 weeks, 6 months, and 1 year after the first corticosteroid injection. Thirty of the 120 patients (25%) had a good outcome with a single injection, 11 additional patients (9%) needed a second injection, and five patients (4%) needed a third injection to reach a good outcome after 1 year. Of patients with an initial good treatment response, 28 (52%) had a good outcome after 1 year compared with 18 (27 %) who had an initially moderate or no response to treatment. One-third of patients with carpal tunnel syndrome had a long-term beneficial effect from corticosteroid injection, especially when they had a good initial response.

Total oxidative stress and antioxidant status in patients with carpal tunnel syndrome

OBJECTIVES

Studies in the carpal tunnel syndrome (CTS) are supported ischemia-induced changes rather than inflammation of the flexor tenosynovium. In this study, total antioxidant status (TAS), total oxidative stress (TOS) and oxidative stress index (OSI) in patients with CTS has been investigated.

METHODS

Forty-three patients (38 female and 5 male, 81 hands in total) diagnosed as CTS after the physical examination and electrophysiological findings included in study. The mean age of patients was 43.30 ± 10.49 years.

RESULTS

Bilateral CTS in 38 (88%) patients and unilateral CTS in five patients were detected. Dominant hand was involved in all patients. The mean symptoms duration was 30.9 months (range, 5-67 months). TAS in patients with CTS was significantly lower compared with control (1.01 ± 0.14 versus 1.11 ± 0.20 mmol Trolox equiv./l), (P = 0.008). TOS and OSI in patients with CTS were significant higher compared with control (15.60 ± 7.03 versus 11.86 ± 2.18 µmol H2O2 equiv./l and 1.57 ± 0.72 versus 1.09 ± 0.28), (respectively P = 0.002 and <0.001).

CONCLUSION

This study shows that there is a change in the oxidative stress and antioxidant defences in patients with CTS. Increased TOS and OSI and decreased TAS might be stimulate fibrosis through disturbed signaling pattern in the tenosynovium and median nerve. These processes might play a role in occurrence and progression of CTS.

Carpal tunnel syndrome: a review of the recent literature

Carpal Tunnel Syndrome (CTS) remains a puzzling and disabling condition present in 3.8% of the general population. CTS is the most well-known and frequent form of median nerve entrapment, and accounts for 90% of all entrapment neuropathies. This review aims to provide an overview of this common condition, with an emphasis on the pathophysiology involved in CTS. The clinical presentation and risk factors associated with CTS are discussed in this paper. Also, the various methods of diagnosis are explored; including nerve conduction studies, ultrasound, and magnetic resonance imaging.

Oxidative stress in subsynovial connective tissue of idiopathic carpal tunnel syndrome

Ischemic-reperfusion injury is thought to be a cause of idiopathic carpal tunnel syndrome (CTS). The purpose of this study was to determine whether oxidative stress caused by ischemia-reperfusion injury in subsynovial connective tissue is associated with idiopathic CTS and its symptoms. Bioptic samples of tenosynovial tissue were collected from 20 idiopathic CTS patients during surgery. Control specimens of tenosynovial tissue were collected from eight non-CTS patients. Analysis included histological and immunohistochemical examination for the distribution of endothelial nitric oxide synthase (eNOS), nuclear factor (NF)-κβ, and transforming growth factor (TGF)-β RI in subsynovial connective tissues. Histological examinations showed a marked increase in fibroblast density and vascular proliferation in specimens from CTS patients. The expressions of eNOS, NF-κβ, and TGF-β RI in fibroblasts and vascular endothelial cells of subsynovial connective tissues of patients were significantly higher than in those of controls. A significant positive correlation was found between the subjective symptom severity of CTS, and the immunoreactivities of eNOS and NF-κβ. This study suggests that oxidative stress in subsynovial connective tissue is related to CTS and its symptoms.

The expression of estrogen receptors in the tenosynovium of postmenopausal women with idiopathic carpal tunnel syndrome

The purpose of this study was to investigate estrogen receptor (ER) expression in tenosynovial tissues of postmenopausal woman with idiopathic carpal tunnel syndrome (CTS) to determine whether estrogen contributes to the pathogenesis of this condition. Biopsy samples of tenosynovial tissues were collected from 14 postmenopausal women (mean age; 57, range; 46-69 years) undergoing surgery for idiopathic CTS, and control specimens of tenosynovial tissue were collected from 6 postmenopausal women (mean age; 59, range; 48-68 years) without CTS. Histological and immunohistochemical examinations were performed to determine the distributions of ER-α and ER-β in tenosynovial tissues. Histological examinations showed a significant increase in fibroblast cell densities in the specimens from the carpal tunnel syndrome patients. ER-α and ER-β immunoreactivities were observed in fibroblasts and in the synovial lining cells of tenosynovial tissues, and these were significantly greater in patients than in controls. This study suggests that the up-regulations of ERs in the tenosynovial tissue are associated with idiopathic CTS in postmenopausal women.

Functional outcomes post carpal tunnel release: a modified replication of a previous study

STUDY DESIGN

Exploratory cohort study.

INTRODUCTION

To compares the outcome of self-administered questionnaires and physical measures in assessing change in function for participants after carpal tunnel surgery.

METHODS

The self-administered questionnaires were the Carpal Tunnel Questionnaire (CTQ), the Disabilities of the Arm, Shoulder, and Hand (DASH), and Short Form-36. The physical measures were grip, pinch, range of motion, sensibility, and dexterity. Twenty-nine participants from five hand clinics were enrolled in the study.

RESULTS

The results revealed that self-administered questionnaires were sensitive to change in function and three of ten physical measures showed a change in function.

CONCLUSIONS

The authors concluded that select physical measures coupled with a disease-specific assessment, such as the CTQ and a region-specific questionnaire, such as the DASH would result in a comprehensive assessment of outcomes. This combination of assessments provides both physical measures of recovery and measures of perceived level of function.

LEVEL OF EVIDENCE

4.

Patients' health beliefs and adaptation to carpal tunnel syndrome based on duration of symptomatic presentation

The purpose of this paper was to examine the health beliefs and adaptation of patients receiving hand therapy treatment for carpal tunnel syndrome (CTS). A maximum variation sample of five patients referred for treatment of CTS was used to provide a diverse group of patients with varied backgrounds of age, gender, race, and occupation. Qualitative interviews based on the Health Beliefs model were conducted at the initial evaluation. Adaptive comments were recorded throughout the process. A grounded theory method was used to code and analyze the information gathered. Four themes emerged as to why and when persons wait to seek treatment for CTS: 1) denial of symptoms; 2) work/positioning the cause; 3) life changes; and 4) last resort. In conclusion, a low level of perceived seriousness and a low level of perceived susceptibility to CTS appeared to interfere with persons' seeking treatment for CTS.

The relationship of VEGF and PGE2 expression to extracellular matrix remodelling of the tenosynovium in the carpal tunnel syndrome

Tenosynovial thickening within the confined space of the carpal tunnel is thought to be the cause of the carpal tunnel syndrome (CTS). However, little is known about the pathological mechanism of tenosynovial thickening. In this study, the role of prostaglandin E(2) (PGE(2)) and vascular endothelial growth factor (VEGF) (two representative molecules that can induce oedema by increasing vascular permeability) was analysed in CTS by using immunohistochemistry and enzyme-linked immunosorptive assay (ELISA). Expression of these molecules was compared with the patients' clinical histories and a temporary increase in production of these molecules was found in cells within the vessels and synovial lining during the intermediate phase of the syndrome when the histology of the tenosynovium changes from oedematous to fibrotic. Statistical analysis clearly demonstrated that there is a close correlation between the expression of PGE(2) and VEGF. Furthermore, immunohistochemical analysis with anti-proliferating cell nuclear antigen (PCNA) revealed that the area with distinct VEGF expression closely matched the area where endothelial cells, vascular smooth muscle cells, and synovial lining cells proliferate. In contrast, despite marked alteration in the extracellular matrix (ECM) component of the tenosynovium, the fibroblasts responsible for most ECM framework production do not proliferate during any phase of CTS. Histological analysis demonstrated that angiogenesis takes place only during the intermediate phase. Since clusters of capillaries and arterioles are often surrounded by type III collagen-rich, disorganized, degenerate connective tissue, which contains fewer fibroblasts than normal, angiogenesis appears to take place as a part of a regenerative reaction that results in fibrosis. These findings strongly indicate that both PGE(2) and VEGF are expressed in the tenosynovium in CTS during the intermediate phase and induce the histological changes seen in the tenosynovium.

MMP-2 expression is associated with rapidly proliferative arteriosclerosis in the flexor tenosynovium and pain severity in carpal tunnel syndrome

Due to the lack of correlation between symptom severity and electrophysiology or nerve function, the 'container hypothesis' has emerged as a new concept in carpal tunnel syndrome (CTS). This proposes that symptoms relate to connective tissue alteration rather than to nerve fibre pathology. This study was conducted to investigate the pathology of the flexor tenosynovium and its relationship with symptomatology. The subjects comprised 40 patients with electrophysiologically proven CTS who underwent open carpal tunnel release (age range: 31-79 years). In all patients, subjective symptom severity was assessed with a Likert scale and symptom duration was recorded preoperatively. Flexor tenosynovium biopsied during surgery was analysed for arterial and connective tissue alteration. Proliferative arteriosclerosis was graded using the modified Banff score. Gelatin zymography and immunohistochemistry were also performed to investigate the role of gelatinase in CTS. Relationships were evaluated using Spearman rank correlation coefficients. Proliferative arteriosclerosis occurred with disease progression in the flexor tenosynovium, in the absence of inflammation. This event did not correlate with patient age but correlated closely with symptom duration. Immunohistochemistry with antibodies against MMP-2 and elastic van Gieson staining revealed that arterioles express high levels of MMP-2 within 3 months of symptom onset and that intimal hyperplasia proceeded rapidly between 4 and 7 months, resulting in severe vascular narrowing. Gelatin zymography showed that MMP-2 activity correlated negatively with symptom duration and positively with pain severity.

Conservative interventions for carpal tunnel syndrome

The assessment and conservative interventions in patients with carpal tunnel syndrome (CTS) are described in this paper. Information about surgical procedures and postoperative care has also been included. It is difficult to make definitive conclusions about the literature regarding success of treatment for CTS due to variations in outcome measures, severity of CTS, and inconsistencies in duration, dosage, and follow-up time for interventions. Based on what is known to date, this author recommends that patients with mild or moderate CTS be provided with a conservative program of splinting the wrist in neutral for nocturnal wear. In addition, intermittent exercise (nerve-gliding exercises) and activity modification, including avoidance of protracted periods of sustained gripping activities and awkward wrist positions, can be useful. This conservative program may be complemented by pain-relieving modalities during times of activity and supplemental participation in other exercise such as yoga. If symptoms are not relieved to the satisfaction of the patient, or they recur, then it is incumbent upon the therapist to refer the patient to a hand surgeon for injection or possible surgical decompression.

Clinical and electrodiagnostic testing of carpal tunnel syndrome: a narrative review

Carpal Tunnel Syndrome (CTS) is a pressure-induced neuropathy that causes sensorimotor disturbances of the median nerve, which impair functional ability. A clear history that elicits relevant personal and work exposures and the nature of symptoms can lead to a high probability of a correct diagnosis. Hand diagrams and diagnostic questionnaires are available to provide structure to this process. A variety of provocative tests have been described and have variable accuracy. The Phalen's wrist flexion and the carpal compression tests have the highest overall accuracy, while Tinel's nerve percussion test is more specific to axonal damage that may occur as a result of moderate to severe CTS. Sensory evaluation of light touch, vibration, or current perception thresholds can detect early sensory changes, whereas 2-point discrimination changes and thenar atrophy indicate loss of nerve fibers occurring with more severe disease. Electrodiagnosis can encompass a variety of tests and is commonly used to assess the presence/severity of neuropathic changes and to preclude alternative diagnoses that overlap with CTS in presentation. The pathophysiologic changes occurring with different stages of nerve compression must be considered when interpreting diagnostic test results and predicting response to physical therapy management.