Carpal Tunnel Syndrome¶
VERSION: 1.1 CREATED: January 27, 2026 REVISED: January 30, 2026 STATUS: Draft - Pending Review
DIAGNOSIS: Carpal Tunnel Syndrome
ICD-10: G56.00 (Carpal tunnel syndrome, unspecified upper limb); G56.01 (Carpal tunnel syndrome, right upper limb); G56.02 (Carpal tunnel syndrome, left upper limb); G56.03 (Carpal tunnel syndrome, bilateral upper limbs)
CLINICAL SYNONYMS: CTS, median neuropathy at wrist, median nerve compression, carpal tunnel entrapment, median nerve entrapment neuropathy, wrist compression syndrome, occupational hand numbness
SCOPE: Evaluation and management of carpal tunnel syndrome from initial presentation through conservative treatment, injection therapy, and surgical referral. Covers clinical diagnosis, electrodiagnostic testing, severity grading, and treatment options. For acute median nerve injury or severe CTS with thenar atrophy, early surgical referral is indicated.
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
SECTION A: ACTION ITEMS¶
1. LABORATORY WORKUP¶
1A. Essential/Core Labs¶
| Test | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| Fasting glucose (CPT 82947) | STAT | STAT | ROUTINE | STAT | Screen for diabetes (common CTS risk factor) | <100 mg/dL |
| HbA1c (CPT 83036) | - | ROUTINE | ROUTINE | - | Diabetes/prediabetes screening (diabetic neuropathy overlap) | <5.7% |
| TSH (CPT 84443) | - | ROUTINE | ROUTINE | - | Hypothyroidism causes CTS (myxedematous tissue infiltration) | 0.4-4.0 mIU/L |
1B. Extended Workup (Second-line)¶
| Test | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| Rheumatoid factor (CPT 86431) | - | ROUTINE | ROUTINE | - | RA-associated CTS (synovial hypertrophy) | Negative |
| Anti-CCP antibody (CPT 86200) | - | ROUTINE | ROUTINE | - | More specific for RA if RF negative | Negative |
| ESR (CPT 85652) | - | ROUTINE | ROUTINE | - | Inflammatory arthritis screen | <20 mm/hr |
| CRP (CPT 86140) | - | ROUTINE | ROUTINE | - | Inflammatory marker | <3.0 mg/L |
| Uric acid (CPT 84550) | - | ROUTINE | ROUTINE | - | Gout/tophaceous deposits in carpal tunnel | Normal (3.5-7.2 mg/dL male; 2.5-6.2 mg/dL female) |
| BUN/Creatinine (CPT 84520/82565) | - | ROUTINE | ROUTINE | - | Renal disease (dialysis-associated CTS from amyloid deposition) | Normal |
| CBC (CPT 85025) | - | ROUTINE | ROUTINE | - | Anemia workup, infection screen | Normal |
| Pregnancy test (CPT 81025/84702) | URGENT | ROUTINE | ROUTINE | - | Pregnancy-associated CTS (common, often resolves postpartum) | Document status |
| Vitamin B12 (CPT 82607) | - | ROUTINE | ROUTINE | - | Concomitant peripheral neuropathy | >300 pg/mL |
| Serum protein electrophoresis (SPEP) (CPT 86335) | - | EXT | ROUTINE | - | Amyloidosis, myeloma (bilateral CTS may be presenting sign of AL amyloid) | No M-spike |
1C. Rare/Specialized (Refractory or Atypical)¶
| Test | ED | HOSP | OPD | ICU | Rationale | Target Finding |
|---|---|---|---|---|---|---|
| Free light chains (kappa/lambda) (CPT 83883) | - | EXT | EXT | - | AL amyloidosis if bilateral CTS with cardiac/renal involvement | Normal ratio (0.26-1.65) |
| TTR gene testing (CPT 81404) | - | - | EXT | - | Hereditary transthyretin amyloidosis if young onset bilateral CTS | No pathogenic variant |
| Fat pad biopsy (CPT 88305) | - | EXT | EXT | - | Confirm amyloidosis if strongly suspected | No amyloid deposits |
| Acromegaly workup (IGF-1, GH) (CPT 84305/83003) | - | EXT | EXT | - | Bilateral CTS in patient with acromegalic features | Normal |
2. DIAGNOSTIC IMAGING & STUDIES¶
2A. Essential/First-line¶
| Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| Nerve conduction studies (NCS) (CPT 95907-95909) and EMG (CPT 95885) | - | ROUTINE | ROUTINE | - | Recommended for diagnosis confirmation and severity grading; optimal before surgery | Prolonged median sensory and/or motor distal latency; reduced SNAP amplitude; denervation in thenar muscles (severe) | Anticoagulation for needle EMG (relative) |
| Wrist X-ray (CPT 73110) | URGENT | ROUTINE | ROUTINE | - | If fracture, arthritis, or bony abnormality suspected | Normal or degenerative changes; exclude fracture | None |
2B. Extended¶
| Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| Wrist/carpal tunnel ultrasound (CPT 76882) | - | ROUTINE | ROUTINE | - | Alternative to MRI; can measure median nerve CSA; operator-dependent | Median nerve CSA >10-12 mm² at pisiform level; flattening at tunnel | None |
| MRI wrist without contrast (CPT 73221) | - | ROUTINE | ROUTINE | - | Mass lesion, ganglion cyst, tenosynovitis, anatomic variant | No mass, normal median nerve signal | Pacemaker; claustrophobia |
| MRI cervical spine with and without contrast (CPT 72156) | - | ROUTINE | ROUTINE | - | Rule out cervical radiculopathy if double crush suspected or atypical presentation | No foraminal stenosis at C6-C7 | GFR <30; pacemaker; gadolinium allergy |
2C. Rare/Specialized¶
| Study | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications |
|---|---|---|---|---|---|---|---|
| CT wrist (CPT 73200) | - | EXT | EXT | - | Bony pathology not visible on X-ray; post-traumatic | No fracture or bony deformity | Pregnancy (relative) |
| MRI with contrast (CPT 73222) | - | EXT | EXT | - | Suspected tumor or inflammatory mass in carpal tunnel | No enhancing mass | GFR <30; pacemaker; gadolinium allergy |
| Comparative NCS (ulnar and radial) (CPT 95907-95909) | - | ROUTINE | ROUTINE | - | Distinguish CTS from polyneuropathy or brachial plexopathy | Normal ulnar and radial studies | None |
3. TREATMENT¶
3A. Acute/Emergent¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Wrist splinting (neutral position) | External | First-line conservative therapy; nocturnal use prevents wrist flexion | Neutral position splint :: External :: Nightly (minimum) :: Wear nightly x 4-6 weeks; may use during day if symptomatic; neutral wrist position (0-5 degrees extension) | None | Skin irritation; compliance | ROUTINE | ROUTINE | ROUTINE | - |
| NSAID therapy (short-term) | PO | Acute symptom relief; limited evidence for CTS-specific benefit | 400 mg :: PO :: TID :: Ibuprofen 400 mg TID or Naproxen 500 mg BID; short course (7-14 days); take with food; not for long-term use | GI bleeding; renal impairment; cardiovascular disease; third trimester pregnancy | GI symptoms; renal function | ROUTINE | ROUTINE | ROUTINE | - |
3B. Symptomatic Treatments¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Gabapentin | PO | Neuropathic pain/paresthesias (adjunctive) | 300 mg :: PO :: qHS :: Start 300 mg qHS; increase by 300 mg q3-7d; max 1800 mg/day for CTS | Renal impairment (dose adjust per CrCl) | Sedation, dizziness, edema | - | ROUTINE | ROUTINE | - |
| Pregabalin | PO | Neuropathic pain/paresthesias | 75 mg :: PO :: BID :: Start 75 mg BID; may increase to 150 mg BID after 1 week | Renal impairment; Class V controlled | Sedation, weight gain, edema | - | ROUTINE | ROUTINE | - |
| Duloxetine | PO | Neuropathic pain with comorbid anxiety/depression | 30 mg :: PO :: daily :: Start 30 mg daily; increase to 60 mg after 1 week | Hepatic impairment; CrCl <30; MAOIs; narrow-angle glaucoma | Nausea, BP; taper to discontinue | - | ROUTINE | ROUTINE | - |
| Amitriptyline | PO | Nocturnal paresthesias (second-line) | 10 mg :: PO :: qHS :: Start 10 mg qHS; increase by 10 mg weekly; max 50 mg qHS | Cardiac conduction abnormality; urinary retention; glaucoma; elderly | ECG if >50 mg; anticholinergic effects | - | - | ROUTINE | - |
| Topical diclofenac | TOP | Localized pain/inflammation | Apply gel :: TOP :: TID-QID :: Apply to wrist area TID-QID; max 4 weeks | Aspirin-sensitive asthma; open wounds | Local skin irritation | - | - | ROUTINE | - |
| Lidocaine 5% patch | TOP | Localized pain | 1 patch :: TOP :: 12h on/12h off :: Apply to wrist/forearm 12h on, 12h off | Broken skin; severe hepatic impairment | Minimal systemic absorption | - | - | ROUTINE | - |
3C. Second-line/Refractory (Injection Therapy)¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Methylprednisolone acetate injection | Local injection | Moderate CTS failing conservative therapy; bridge to surgery; pregnancy-related CTS | 40 mg :: Local injection :: Single injection :: 40 mg (1 mL) injected into carpal tunnel under ultrasound guidance preferred; may repeat x1 at 4-6 weeks | Local infection; bleeding disorder; uncontrolled diabetes | Blood glucose (diabetics) 24-48h post-injection; tendon rupture (rare) | - | ROUTINE | ROUTINE | - |
| Triamcinolone acetonide injection | Local injection | Alternative corticosteroid for injection | 20-40 mg :: Local injection :: Single injection :: 20-40 mg injected into carpal tunnel; ultrasound guidance recommended | Local infection; bleeding disorder; uncontrolled diabetes | Blood glucose (diabetics); skin depigmentation | - | ROUTINE | ROUTINE | - |
| Dexamethasone injection | Local injection | Alternative corticosteroid (shorter acting) | 4 mg :: Local injection :: Single injection :: 4 mg injected into carpal tunnel; shorter duration than triamcinolone | Local infection; bleeding disorder | Blood glucose (diabetics) | - | ROUTINE | ROUTINE | - |
| Platelet-rich plasma (PRP) injection | Local injection | Experimental; refractory cases; patient preference to avoid surgery | 2-3 mL PRP :: Local injection :: Single injection :: Single injection under ultrasound; emerging evidence | Infection; thrombocytopenia; malignancy | Observe 15 min post-injection | - | - | EXT | - |
Injection Therapy Notes: - Corticosteroid injection provides short-term relief (1-3 months) in most patients - Efficacy decreases with repeated injections - Best as bridge to surgery or for patients with contraindications to surgery - Ultrasound guidance improves accuracy and reduces median nerve injury risk - Pregnancy-related CTS often responds well to injection; many resolve postpartum
3D. Definitive Surgical Treatment¶
| Treatment | Route | Indication | Dosing | Pre-Treatment Requirements | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|---|
| Carpal tunnel release (CTR) - open | Surgical | Moderate-severe CTS; thenar atrophy; failed conservative therapy x 3-6 months; constant numbness | Surgical release :: Outpatient surgery :: Single procedure :: Open technique; divide transverse carpal ligament; 15-30 min procedure | NCS confirmation of diagnosis recommended; optimize diabetes; discuss expectations | Active infection; unstable medical status; anticoagulation (relative) | Post-op pain; wound healing; grip strength; pillar pain | - | - | ROUTINE | - |
| Carpal tunnel release (CTR) - endoscopic | Surgical | Same indications as open CTR; faster return to work; surgeon preference | Surgical release :: Outpatient surgery :: Single procedure :: Endoscopic technique (1 or 2 portal); divide transverse carpal ligament | NCS confirmation recommended; optimize diabetes | Active infection; prior carpal tunnel surgery (relative); anatomic variants | Post-op pain; transient nerve injury (1-2%); wound healing | - | - | ROUTINE | - |
Surgical Indications (Absolute): - Thenar muscle atrophy (abductor pollicis brevis wasting) - Constant numbness with loss of two-point discrimination - Severe denervation on EMG (fibrillations, positive sharp waves in APB) - Failed conservative therapy for 3-6 months
Surgical Indications (Relative): - Moderate CTS with occupational impairment - Failed 2 corticosteroid injections - Patient preference after informed discussion - Recurrent symptoms after initial improvement with splinting
4. OTHER RECOMMENDATIONS¶
4A. Referrals & Consults¶
| Recommendation | ED | HOSP | OPD | ICU |
|---|---|---|---|---|
| Hand surgery or orthopedic surgery referral for carpal tunnel release evaluation when conservative therapy fails or severe CTS present | - | ROUTINE | ROUTINE | - |
| Electrodiagnostic medicine/neurology for NCS/EMG to confirm diagnosis and grade severity before surgical intervention | - | ROUTINE | ROUTINE | - |
| Occupational medicine for workplace ergonomic assessment and work restrictions if occupational risk factors present | - | - | ROUTINE | - |
| Physical/occupational therapy for nerve gliding exercises, ergonomic training, and activity modification | - | ROUTINE | ROUTINE | - |
| Rheumatology referral if inflammatory arthritis suspected as underlying cause (RA, gout) | - | ROUTINE | ROUTINE | - |
| Endocrinology for diabetes optimization or hypothyroidism management if contributing to CTS | - | ROUTINE | ROUTINE | - |
| Primary care for management of modifiable risk factors (diabetes, obesity, hypothyroidism) | - | ROUTINE | ROUTINE | - |
| Pain management if refractory neuropathic symptoms despite treatment | - | - | ROUTINE | - |
4B. Patient Instructions¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Wear wrist splint nightly in neutral position for minimum 4-6 weeks; may wear during day if symptoms persist with activities | - | ROUTINE | ROUTINE |
| Avoid prolonged wrist flexion or extension (typing, gripping tools, driving) as this increases carpal tunnel pressure | - | ROUTINE | ROUTINE |
| Take frequent breaks during repetitive hand activities (every 30-60 minutes) to rest wrists | - | ROUTINE | ROUTINE |
| Perform nerve gliding exercises as instructed by therapist to improve median nerve mobility | - | ROUTINE | ROUTINE |
| Apply ice for 10-15 minutes if wrist swelling present; avoid direct ice contact with skin | ROUTINE | ROUTINE | ROUTINE |
| Report worsening numbness, weakness in thumb, or dropping objects (may indicate progression requiring surgery) | ROUTINE | ROUTINE | ROUTINE |
| Avoid sleeping with wrists curled under pillow; maintain neutral wrist position during sleep | - | ROUTINE | ROUTINE |
| If pregnant, symptoms often improve after delivery; conservative management preferred during pregnancy | - | ROUTINE | ROUTINE |
| After corticosteroid injection, temporary increase in symptoms may occur first 24-48 hours before improvement | - | ROUTINE | ROUTINE |
| Post-surgical: Keep incision clean and dry; elevate hand; start motion as directed; full grip strength recovery may take 3-6 months | - | ROUTINE | ROUTINE |
4C. Lifestyle & Prevention¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Optimize glycemic control (HbA1c <7%) as diabetes worsens nerve function and CTS outcomes | - | ROUTINE | ROUTINE |
| Weight loss if overweight/obese as obesity is modifiable risk factor for CTS | - | ROUTINE | ROUTINE |
| Ergonomic workstation setup: keyboard at elbow height, wrists neutral, avoid resting wrists on hard surfaces | - | ROUTINE | ROUTINE |
| Use ergonomic keyboard, mouse, and tools if occupation involves repetitive hand use | - | ROUTINE | ROUTINE |
| Smoking cessation to improve microvascular circulation and nerve healing | - | ROUTINE | ROUTINE |
| Avoid prolonged use of vibrating tools or take breaks every 15-30 minutes when using such equipment | - | - | ROUTINE |
| Reduce caffeine and alcohol intake as these may worsen paresthesias in some patients | - | ROUTINE | ROUTINE |
| Treat underlying thyroid disease as hypothyroidism contributes to CTS through tissue edema | - | ROUTINE | ROUTINE |
| Stretch and warm up hands before repetitive activities | - | ROUTINE | ROUTINE |
| Vitamin B6 supplementation not recommended (evidence does not support benefit; high doses cause neuropathy) | - | ROUTINE | ROUTINE |
SECTION B: REFERENCE (Expand as Needed)¶
5. DIFFERENTIAL DIAGNOSIS¶
| Alternative Diagnosis | Key Distinguishing Features | Tests to Differentiate |
|---|---|---|
| Cervical radiculopathy (C6-C7) | Neck pain, dermatomal pattern (not strictly median), reflex changes (C6: brachioradialis; C7: triceps), negative Phalen/Tinel | MRI cervical spine; NCS/EMG shows radicular pattern; neck range of motion limited |
| Pronator syndrome | Forearm pain/tenderness at pronator teres, symptoms with resisted pronation, no nocturnal worsening, palmar cutaneous branch affected | NCS/EMG; tenderness at pronator teres on exam; provocative testing |
| Anterior interosseous syndrome | Weakness only (FPL, FDP to index, pronator quadratus); no sensory loss; pinch weakness | NCS/EMG; cannot make "OK" sign (pinch between thumb and index) |
| Thoracic outlet syndrome | Shoulder/arm pain, positional symptoms, vascular symptoms (pallor, cyanosis), C8-T1 distribution | Adson test; ROOS test; X-ray for cervical rib; MRA; NCS |
| Ulnar neuropathy at elbow (cubital tunnel) | Numbness in ring and small finger, hand weakness, elbow symptoms, positive Tinel at elbow | NCS/EMG shows ulnar slowing at elbow; sensory exam (ulnar digits spared in CTS) |
| Peripheral polyneuropathy | Symmetric symptoms, length-dependent, feet often affected first, multiple nerve territories | NCS shows generalized abnormalities; HbA1c; B12; metabolic panel |
| De Quervain tenosynovitis | Radial wrist pain, positive Finkelstein test, no numbness, tenderness over 1st dorsal compartment | Finkelstein test positive; ultrasound shows tendon thickening; no NCS abnormalities |
| Raynaud phenomenon | Color changes (white-blue-red), cold-triggered, bilateral, no weakness | No NCS abnormalities; may have positive ANA; capillaroscopy |
| Brachial plexopathy | Shoulder/arm weakness and sensory loss in plexus pattern, may have Horner syndrome | NCS/EMG; MRI brachial plexus; distribution beyond median nerve |
| Trigger finger | Finger locking/clicking, palm nodule, no numbness in median distribution | Palpable nodule at A1 pulley; no NCS abnormalities; triggering on exam |
| Ganglion cyst (volar wrist) | Palpable mass, may transilluminate, compresses median nerve | Ultrasound or MRI shows cystic structure; NCS may be normal or show CTS |
| Multiple sclerosis | Central demyelination; other neurologic symptoms; sensory symptoms may mimic CTS | MRI brain/spine; CSF oligoclonal bands; NCS normal |
| Syringomyelia | Dissociated sensory loss (pain/temp preserved, vibration lost), cape distribution, central cord lesion | MRI cervical spine shows syrinx cavity |
| Amyloidosis | Bilateral CTS, cardiac involvement, macroglossia, renal disease, family history (hATTR) | SPEP/UPEP; free light chains; TTR gene; tissue biopsy |
6. MONITORING PARAMETERS¶
Venue column indicates where monitoring is typically ordered/initiated.
| Parameter | Frequency | Target/Threshold | Action if Abnormal | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| Symptom severity (numbness, tingling, nocturnal symptoms) | Each visit | Improvement or stable | Consider escalation: injection if splinting fails; surgery if injection fails | - | ROUTINE | ROUTINE | - |
| Grip strength | Baseline and q4-8 weeks if weakness | Normal for age/sex; no decline | Expedite surgical referral if progressive weakness | - | ROUTINE | ROUTINE | - |
| Thenar muscle bulk | Each visit | No atrophy | If atrophy developing, urgent surgical referral (indicates severe CTS) | - | ROUTINE | ROUTINE | - |
| Two-point discrimination | Baseline and periodic | Normal (<6 mm) | If abnormal/worsening, indicates sensory axonal loss; consider surgery | - | ROUTINE | ROUTINE | - |
| Splint compliance | Each visit | Nightly use minimum | Re-educate; consider injection if compliant but not improving | - | ROUTINE | ROUTINE | - |
| HbA1c (diabetic patients) | Every 3 months | <7% or individualized | Intensify diabetes management | - | ROUTINE | ROUTINE | - |
| TSH (if hypothyroid) | Every 6-12 months | 0.4-4.0 mIU/L | Adjust thyroid replacement | - | - | ROUTINE | - |
| Post-injection response | 2-4 weeks after injection | Symptom improvement | If no improvement, discuss surgical options | - | ROUTINE | ROUTINE | - |
| Post-surgical wound healing | 7-14 days post-op | Clean, healing, no infection | If infection signs, antibiotics and wound care | - | ROUTINE | ROUTINE | - |
| Post-surgical sensory/motor function | 6 weeks, 3 months, 6 months post-op | Progressive improvement | If not improving, NCS/EMG; consider incomplete release or scarring | - | ROUTINE | ROUTINE | - |
| Recurrence after surgery | Annual if risk factors present | No symptom recurrence | NCS; consider revision surgery if confirmed recurrence | - | - | ROUTINE | - |
7. DISPOSITION CRITERIA¶
| Disposition | Criteria |
|---|---|
| Discharge home | Mild-moderate CTS; can use splint; outpatient neurology/hand surgery follow-up arranged; no thenar atrophy; no progressive weakness |
| Admit to floor | Acute compartment syndrome of forearm/hand (rare); post-operative complication requiring observation; severe medical comorbidities requiring inpatient management |
| Admit to ICU | Not typical for CTS; only if concurrent critical illness |
| Urgent surgical referral | Thenar atrophy; progressive weakness; constant numbness with sensory loss; failed conservative therapy >6 months; severe CTS on NCS with denervation |
| Routine surgical referral | Moderate CTS with inadequate response to splinting and injection; patient preference; occupational impairment |
| Outpatient follow-up | Most patients; splinting trial with reassessment in 4-6 weeks; post-injection follow-up in 2-4 weeks |
8. EVIDENCE & REFERENCES¶
| Recommendation | Evidence Level | Source |
|---|---|---|
| Nocturnal wrist splinting is effective first-line treatment for CTS | Class I, Level A | Page MJ et al. Cochrane Database Syst Rev 2012 |
| NCS/EMG recommended for diagnostic confirmation before surgery | Class II, Level B | Werner RA et al. Muscle Nerve 2011 |
| Corticosteroid injection provides short-term symptom relief | Class I, Level A | Marshall S et al. Cochrane Database Syst Rev 2007 |
| Carpal tunnel release surgery is effective for moderate-severe CTS | Class I, Level A | Verdugo RJ et al. Cochrane Database Syst Rev 2008 |
| Ultrasound-guided injection improves accuracy and outcomes | Class II, Level B | Ustun N et al. Arch Phys Med Rehabil 2013 |
| Diabetes mellitus is significant risk factor for CTS | Class II, Level B | Pourmemari MH et al. Diabet Med 2016 |
| Clinical examination (Phalen, Tinel) has moderate sensitivity/specificity | Class II, Level B | Middleton SD et al. J Hand Surg Eur Vol 2014 |
| Severe CTS with thenar atrophy should be referred for surgery | Class II, Level B | Graham B et al. J Am Acad Orthop Surg 2016 |
| Endoscopic and open CTR have equivalent long-term outcomes | Class I, Level A | Scholten RJ et al. Cochrane Database Syst Rev 2007 |
| Pregnancy-related CTS often resolves postpartum | Class III, Level C | Padua L et al. Muscle Nerve 2010 |
| Median nerve CSA >10-12 mm² on ultrasound supports CTS diagnosis | Class II, Level B | Cartwright MS et al. Muscle Nerve 2012 |
| Nerve gliding exercises may provide modest benefit as adjunct therapy | Class II, Level C | Ballestero-Perez R et al. J Orthop Sports Phys Ther 2017 |
| AAOS Clinical Practice Guideline for CTS | Guideline | AAOS Guideline 2016 |
| AANEM practice parameter for electrodiagnosis of CTS | Guideline | Jablecki CK et al. Muscle Nerve 2002 |
CPT CODE QUICK REFERENCE¶
Laboratory CPT Codes¶
| Test | CPT Code | Description |
|---|---|---|
| Fasting glucose | 82947 | Glucose, quantitative |
| HbA1c | 83036 | Hemoglobin A1c |
| TSH | 84443 | Thyroid stimulating hormone |
| Rheumatoid factor | 86431 | Rheumatoid factor, quantitative |
| Anti-CCP antibody | 86200 | Cyclic citrullinated peptide antibody |
| ESR | 85652 | Sedimentation rate, Westergren |
| CRP | 86140 | C-reactive protein |
| Uric acid | 84550 | Uric acid, blood |
| BUN | 84520 | Blood urea nitrogen |
| Creatinine | 82565 | Creatinine, blood |
| CBC with differential | 85025 | Complete blood count |
| Vitamin B12 | 82607 | Cyanocobalamin |
| SPEP | 86335 | Protein electrophoresis, serum |
| Free light chains | 83883 | Kappa/lambda |
| Pregnancy test (urine) | 81025 | Urine pregnancy test |
| Pregnancy test (serum) | 84702 | Gonadotropin, chorionic, quantitative |
Diagnostic Studies CPT Codes¶
| Study | CPT Code | Description |
|---|---|---|
| NCS, 1-2 studies | 95907 | Nerve conduction, 1-2 studies |
| NCS, 3-4 studies | 95908 | Nerve conduction, 3-4 studies |
| NCS, 5-6 studies | 95909 | Nerve conduction, 5-6 studies |
| Needle EMG, limited | 95885 | EMG, limited (1 extremity) |
| Wrist X-ray, 2 views | 73100 | Radiologic exam, wrist, 2 views |
| Wrist X-ray, complete | 73110 | Radiologic exam, wrist, complete (minimum 3 views) |
| MRI wrist without contrast | 73221 | MRI, upper extremity joint, without contrast |
| MRI wrist with and without contrast | 73223 | MRI, upper extremity joint, with and without contrast |
| Ultrasound wrist/soft tissue | 76882 | Ultrasound, extremity, limited |
| MRI cervical spine without contrast | 72141 | MRI cervical spine without contrast |
| MRI cervical spine with and without contrast | 72156 | MRI cervical spine complete |
Treatment/Procedure CPT Codes¶
| Procedure | CPT Code | Description |
|---|---|---|
| Carpal tunnel injection | 20526 | Injection, therapeutic, carpal tunnel |
| Ultrasound guidance for injection | 76942 | Ultrasound guidance for needle placement |
| Carpal tunnel release, open | 64721 | Neuroplasty, median nerve at carpal tunnel |
| Carpal tunnel release, endoscopic | 29848 | Endoscopy, carpal tunnel release |
| Splint application, forearm-wrist | 29125 | Application of short arm splint |
Note: CPT codes are updated annually. Verify codes against current CMS fee schedule.
APPENDIX A: Clinical Examination Techniques¶
Provocative Tests for Carpal Tunnel Syndrome¶
Phalen Test (Wrist Flexion Test) - Technique: Hold both wrists in full flexion for 60 seconds - Positive: Reproduction of paresthesias in median distribution within 60 seconds - Sensitivity: 68-73%; Specificity: 73-83%
Reverse Phalen Test (Prayer Test) - Technique: Hold both wrists in full extension for 60 seconds - Positive: Reproduction of paresthesias in median distribution - Less commonly used than standard Phalen
Tinel Sign at Wrist - Technique: Tap over carpal tunnel at wrist crease - Positive: Electric/tingling sensation radiating into thumb, index, middle finger - Sensitivity: 50-60%; Specificity: 67-77%
Carpal Compression Test (Durkan's Test) - Technique: Apply direct pressure over carpal tunnel for 30 seconds - Positive: Reproduction of paresthesias - Sensitivity: 64-87%; Specificity: 83-90% - May be more sensitive than Tinel sign
Flick Sign - Technique: Ask patient what they do when symptoms occur at night - Positive: Patient demonstrates shaking/flicking hands for relief - Sensitivity: 93%; Specificity: 96% - Highly suggestive of CTS when present
Hand Elevation Test - Technique: Raise hands above head for 1-2 minutes - Positive: Reproduction of numbness/paresthesias - Sensitivity: 75-89%; Specificity: 87-98%
Severity Assessment¶
Clinical Severity Grading - Mild: Intermittent paresthesias, nocturnal symptoms only, normal exam - Moderate: Frequent paresthesias, daytime symptoms, mild sensory loss, no weakness - Severe: Constant numbness, thenar weakness/atrophy, impaired two-point discrimination
Electrodiagnostic Severity (AANEM Classification) - Mild: Prolonged sensory latency only; normal motor studies - Moderate: Prolonged sensory and motor distal latencies; reduced SNAP amplitude - Severe: Absent sensory response; prolonged motor latency with reduced CMAP; fibrillations/positive sharp waves in APB
APPENDIX B: Nerve Conduction Study Criteria for CTS¶
Standard Electrodiagnostic Criteria¶
Sensory Studies - Median sensory distal latency >3.5 ms (14 cm distance) OR - Median-ulnar sensory latency difference >0.5 ms OR - Median-radial sensory latency difference >0.5 ms
Motor Studies - Median motor distal latency >4.2 ms
Combined Sensory Index (CSI) - Robinson Criteria - Sum of: (median-ulnar palm latency difference) + (median-ulnar digit 4 difference) + (median-radial thumb difference) - CSI >0.9 ms is abnormal
Electrodiagnostic Severity Classification¶
| Severity | Sensory | Motor | EMG |
|---|---|---|---|
| Minimal | Abnormal comparative studies only (palm or digit) | Normal | Normal |
| Mild | Prolonged absolute sensory latency | Normal | Normal |
| Moderate | Prolonged sensory latency; reduced SNAP amplitude | Prolonged motor latency | Normal |
| Severe | Absent sensory response | Prolonged motor latency; reduced CMAP | Fibrillations/PSWs in APB |
| Very Severe | Absent sensory response | Absent or very low CMAP | Chronic denervation in APB |
CHANGE LOG¶
v1.1 (January 30, 2026) - Reformatted lab tables (1A/1B/1C) and imaging tables (2A/2B/2C) to match approved plan column order - Added inline CPT codes to all lab and imaging test names - Cleaned structured dosing: starting dose only in first field - Version bump and date update
v1.0 (January 27, 2026) - Initial creation - Comprehensive outpatient-focused plan for carpal tunnel syndrome evaluation and management - Includes clinical examination techniques (Phalen, Tinel, flick sign, Durkan) - EMG/NCS criteria for severity grading with AANEM classification - Conservative management: splinting, ergonomics, nerve gliding - Corticosteroid injection protocols with ultrasound guidance recommendation - Surgical indications for open and endoscopic CTR - Complete differential diagnosis including cervical radiculopathy, pronator syndrome - Risk factor evaluation: diabetes, hypothyroidism, pregnancy, RA, amyloidosis - All treatment dosing in structured format for order sentence generation - CPT code reference for billing - Appendices with clinical examination techniques and electrodiagnostic criteria