Available online at www.sciencedirect.com Joint Bone Spine 75 (2008) 451e457 http://france.elsevier.com/direct/BONSOI/ Original article Clinical diagnosis of carpal tunnel syndrome: Old testsenew concepts Yasser El Miedany a,*, Samia Ashour b, Sally Youssef a, Annie Mehanna c, Fatma A. Meky d a Rheumatology and Rehabilitation, Ain Shams University, Cairo, Egypt b Neurology, Ain Shams University, Cairo, Egypt c Radiology, Ain Shams University, Cairo, Egypt d Community, Environmental and Occupational Medicine, Ain Shams University, Cairo, Egypt Accepted 27 September 2007 Available online 2 May 2008AbstractBackground: The diagnosis of carpal tunnel syndrome (CTS) continues to be neurophysiologically and clinically controversial. Earlier data con-cluding that the higher prevalence of persons with symptoms suggestive of CTS but without evidence of median mononeuropathy highlights theneed for a better understanding of the underlying pathophysiology and natural history of CTS to provide a less empirical foundation for diag-nosis and clinical management.Objective: To examine the relationship between the clinical manifestations of CTS with the outcome of the diagnostic tools (nerve conductiontests and ultrasonography), and its implication for clinical practice.Methods: Two-hundred and thirty-two patients (69 male and 163 female, ages ranging between 20 and 91 years) with CTS manifestations and182 controls were included in this study. Diagnosis of CTS was based on the American Academy of Neurology clinical diagnostic criteria. Allpatients and controls completed a patient oriented questionnaire, were subjected to clinical testing for provocative tests for carpal tunnelsyndrome (Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel compression tests), blood check for secondary causes of carpal tunnelsyndrome, nerve conduction testing as well ultrasonographic assessment of the carpal tunnel and median nerve.Results: One-hundred and seventy-seven out of 232 (76.3%) had abnormal nerve conduction studies. Forearm symptoms and tenosynovitis con-ﬁrmed by US examination were found in 51.3% of cases. No signiﬁcant difference was found on comparing anthropometric measures in theaffected hands to the control group hands. A higher prevalence of positive Phalen’s and CT compression were found in patients sufferingfrom tenosynovitis regardless of their nerve conduction study results. Sensitivity of Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel com-pression tests was higher for the diagnosis of tenosynovitis than for the diagnosis of CTS (Tinel, 46% vs. 30%; Phalen’s, 92% vs. 47%; ReversePhalen’s, 75% vs. 42%; carpal tunnel compression test, 95% vs. 46%). Similarly, higher speciﬁcity of these tests was found with tenosynovitisthan CTS.Conclusion: The results of this study revealed that Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel compression tests are more sensitive, aswell as being speciﬁc tests for the diagnosis of tenosynovitis of the ﬂexor muscles of the hand, rather than being speciﬁc tests for carpal tunnelsyndrome and can be used as an indicator for medical management of the condition.Ó 2008 Elsevier Masson SAS. All rights reserved.Keywords: Carpal tunnel syndrome; Nerve conduction testing; Ultrasound; Phalen test; Tinel test; Carpal tunnel compression test 1. Introduction Carpal tunnel syndrome (CTS) is a common clinical condi- tion with an estimated lifetime risk of 10% and an annual incidence of 0.1% among adults [1,2]. These estimates are * Corresponding author. 2 Italian Hospital St., Abbassia, Cairo, 11381, undoubtedly conservative because they are based on data col-Egypt. Tel.: þ20 441322428425; fax: þ20 441322428415. lected prior to the substantial increase in work related cases of E-mail address: firstname.lastname@example.org (Y. El Miedany). CTS in the 1980s and early 1990s and the concomitant1297-319X/$ - see front matter Ó 2008 Elsevier Masson SAS. All rights reserved.doi:10.1016/j.jbspin.2007.09.014
452 Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457increased awareness of this condition [3,4]. More recent esti- posture or by shaking the hand; sensory deﬁcit or hypotrophymates of the prevalence of CTS in the general population of the median innervated thenar muscle.are 0.6% in men and 5.8% in women . Data from Swedenreported by Atroshi and colleagues suggest an overall preva- 2.3. Clinical testing for CTSlence of 2.1% . Despite the large number of original re-search studies on carpal tunnel syndrome, considerable A detailed clinical history, with thorough examination anduncertainty and even controversy exist in the medical commu- extended musculoskeletal as well as neurophysiological eval-nity about its extent and aetiology, the contribution of work uation were carried out. Careful consideration was paid to as-and non-work risk factors to its development, the criteria sessing the possibility of the presence of forearm symptomsused to diagnose it, the outcomes of various treatment methods and in particular tendonitis. Four tests were performed forand the appropriate strategies for intervention and prevention. both hands of every subject included in this study. TheyIn addition, there is insufﬁcient evidence to identify a single were considered positive when applying the test would repro-‘‘best’’ examination-based clinical test. Certain clinical tests duce presenting symptoms of pain or numbness in digits 1, 2,have been in use as components of a clinical diagnosis of and 3 (median nerve distribution). The tests were: Tinel’s test,CTS, however, their sensitivity and speciﬁcity have been a mat- percussion of the median nerve at the wrist; Phalen’s test,ter of controversy . Furthermore, it is relatively difﬁcult for complete palmer wrist ﬂexion for 60 s; Reverse Phalen’sthe treating physician to distinguish between CTS and other test, complete dorsal wrist ﬂexion for 60 s; carpal tunnel com-conditions with similar symptoms such as tendonitis. There pression test, even pressure exerted by the examiner on theis ample evidence that the accuracy of the available diagnostic space between thenar and hypothenar eminence for 30 s whiletools is not very good [8,9]. arm is supinated . The patient was questioned with regard In recent years, imaging techniques such as magnetic reso- to symptoms at 15-s intervals during the 30-s period.nance imaging [10e13] and sonography [14e19] have been Laboratory investigations to diagnose any secondary causeshown to be of value in the diagnosis of CTS. Both have the for CTS were done for all patients, namely full blood count,advantage of providing insight into the possible focal causes haemoglobin A1C, thyroid functions, liver and kidney proﬁles.of CTS such as localized space occupying lesions, rheumatoid Patients who underwent decompression surgery and showed noarthritis, tenosynovitis or synovitis of the wrist [20,21]. US signiﬁcant improvement in their symptoms (less than 25% im-and MRI enabled the researchers to assess the presence of te- provement in the score of symptom severity assessed by visualnosynovitis of the ﬂexors of the hands or any other localized analogue scale) were included in the study (35 patients). Pa-swelling . However, no studies meeting the inclusion cri- tients with the following conditions were excluded from theteria addressed the frequency with which forearm conditions study: (1) patients who had cervical nerve impingement asco-exist with CTS. This study was carried out to examine proved by MRI cervical spine; (2) patients suffering from otherthe relationship between the clinical manifestations of CTS neurological diseases causing motor weakness of the hands (3)as well as the possible related forearm conditions with the out- patients suffering from diabetes mellitus or thyroid dysfunction.come of the diagnostic tools (nerve conduction tests and ultra-sonography), and its implications for clinical practice. 2.4. Control group2. Methods One-hundred and eighty-two healthy, age-matched subjects with no signs or symptoms of CTS were studied as a control2.1. Patients group: 121 females and 61 males. The control subjects were from the healthy subjects accompanying the patients during Two-hundred and thirty-two patients were included in this their visits to the hospital (mostly housewives) or from thestudy. They were gathered from those attending the outpatient hospital staff. They were subjected to full musculoskeletalclinic with a history suggestive of median nerve entrapment. and neurological examination to verify their normality. AllAll patients had both hands examined clinically, sonographi- patients showed negative results on the self-administered ques-cally and electrophysiologically. The limit for age matching tionnaire. In addition, they were subjected to the same labora-was a 5-year interval for both men and women. tory investigations as the patient group. Nerve conduction studies and ultrasonography examination of both wrists were2.2. Deﬁnition of cases and data collection at initial carried out for all subjects included in the control group.evaluation 2.5. Patient-oriented data Sociodemographic data, clinical and work related data wereobtained for every subject included in this study. Diagnosis of Each subject included in this study completed a self-CTS was based on the American Academy of Neurology clin- administered questionnaire for clinical assessment as well asical diagnostic criteria (1993)  summarized as: paraesthesia; severity of carpal tunnel syndrome. This includes 11 questionspain; swelling; weakness or clumsiness of the hand provoked to identify 5 main presenting symptoms: paraesthesia, nocturnalor worsened by sleep, sustained hand or arm position; repeti- pain, diurnal pain, weakness/clumsiness and pain. Severity of alltive action of the hand or wrist that is mitigated by changing patients’ symptoms was assessed by the carpal tunnel severity
Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457 453index . The main symptoms were identiﬁed based on the Y.M.), 12 MHz linear array transducer. To ensure unbiased ex-American Academy of Neurology clinical diagnostic criteria amination, the examiner was requested not to inquire about. symptoms and the patients were asked not to speak about their In addition, each subject completed the modiﬁed Boston problem during the examination. Sonographic examination wasCarpal Tunnel Questionnaire (BCTQ) . The mBCTQ eval- done either on the same day or within 3 days of the electrophys-uates ‘‘functional status’’ assessed with a ten-item scale (writ- iological study. The sonographic examination was performeding, buttoning, holding, gripping, bathing, dressing, computer with the patient seated in a comfortable position facing the so-work/typing and driving). The questionnaire was presented in nographer with the forearm resting on the table and the palmmultiple-choice format and scores were assigned from 1 point facing up in the neutral position. The volar wrist crease was(mildest) to 5 points (most severe). Each score was calculated used an initial external reference point with subsequent modiﬁ-as the mean of the responses of the individual items. Patients cations during scanning. The median nerve was located superﬁ-were divided into 5 groups according to their mean score: cial to the echogenic ﬂexor tendons and its size, shape,extreme (4.1e5 points), severe (3.1e4 points), moderate echogenicity and relationship to the surrounding structures(2.1e3 points), mild (1.1e2 points) and minimal (0.1e1 and overlying retinaculum were noted. The amount of synovialpoint). The patients had to answer the questions for each ﬂuid and the presence of masses within the carpal tunnel werehand separately. In order to avoid any inﬂuence of the physi- noted. Measurement of the anteroeposterior dimensions ofcian or the neurophysiologic data on the patient-oriented re- the carpal tunnel was also assessed at the midpoint of the carpalsults, the mBCTQ was always completed in the waiting room. tunnel at the level of the distal margin of pisiform bone. The main hallmark of tenosynovitis is irregularities of tendon mar-2.6. Electrodiagnostic evaluation gins and presence of ﬂuid in the tendon’s sheath. Doppler tech- niques were carried out to detect ﬂow signals within and around Electrodiagnostic studies were carried out for all subjects in- the involved tendon(s). Colour Doppler was also used to distin-cluded in this study according to the protocol inspired by the guish the hypoechoic pannus in patients with arthritis from theAmerican Association of Electrodiagnostic Medicine recom- effusion based on the presence or absence of ﬂow signals.mendations [8,25,26] using a Dantec Keypoint. All testing In order to assess the reliability, every seventh subject waswas done in the same room and in similar temperature condi- asked to return within 24 h for a repeat US. A total of 33 CTStions. When standard tests (median sensory nerve conduction patients and 26 control subjects were assessed for this purpose.velocity in two-digit/wrist segment and median distal motor la- Inter-observer reliability was also assessed.tency from the wrist to the thenar eminence) yielded normal re- The local protocols for the study approval were followed.sults, further segmental tests over a short distance of 7e8 cm The nature of the work was explained to all patients andwere performed [27,28] or comparative median/ulnar studies healthy subjects included in the study. All subjects who shared[29,30]. F-wave testing was done for all patients. Measurements in this work signed information consent written according toperformed and cut-off points or normal values used in our study the Declaration of Helsinki.were as follows: (1) median nerve distal sensory latency, upperlimit of normal 3.6 ms; (2) difference between the median and 2.8. Statistical analysisulnar nerve distal sensory latencies, upper limit of normal0.4 ms; (3) distal motor latency over the thenar, upper limit of For statistical analysis we used SPSS for windows, Releasenormal 4.3 ms; (4) median motor nerve conduction velocity, 11 (statistical package for Social Sciences Inc. Chicago, IL,lower limit of normal 49 m/s; (5) median sensory nerve conduc- USA). Chi square (c2) test was used for categorical variables.tion velocity, lower limit of normal 49 m/s . The severity of Student t-test and one-way analysis of variance (ANOVA) withelectrophysiological CTS impairment was assessed according Tukey were used for quantitative variables. Epicalc 2000 pro-to the classiﬁcation reported by Padua et al. . CTS hands gram was used to calculate the conﬁdence intervals of sensitiv-were divided into 6 groups based on their neurophysiological ity and speciﬁcity of clinical tests. Sensitivity was calculatedﬁndings: negative, normal ﬁndings on all tests; minimal, abnor- as the number of true positive divided by the total diseasedmal segmental or comparative tests only; mild, abnormal digit/ persons. Speciﬁcity was calculated as the number of true neg-wrist sensory nerve conduction velocity and normal distal motor ative divided by the total disease-free persons by the goldenlatency; moderate, abnormal digit/wrist sensory nerve conduc- standard test. Nerve conduction testing and ultrasonographytion velocity and abnormal distal motor latency; severe, absence were considered the golden standard tests. The correlations be-of sensory response and abnormal distal motor latency; ex- tween distal sensory latency and distal motor sensory latencytreme, absence of motor and sensory response. with age and score of severity of symptoms were calculated using Pearson’s correlation coefﬁcient. Level of signiﬁcance2.7. Sonography was set at p less than or equal to 0.05. All patients and control subjects underwent high-resolution 3. Resultsreal-time sonography of the carpal tunnels of both hands usinga Diasonic Gateway machine (examination was carried out by The study included 232 patients with CTS. The patientsAM)/Mylab 50 Esoate (Italy) (examination carried out by group was 69 male and 163 female aged between 20 and
454 Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e45791 years. For patients with bilateral symptoms, the moreaffected hand was used for analysis. Tenosynovitis symptoms conﬁrmed by US examination(Figs. 1 and 2) were found in 54% of cases. Table 1 shows so-cio-demographic and clinical data of the patient group in-cluded in this study. A positive history of forearm symptomswas given by 54.3% of the patients (126/232). The diagnosisof tenosynovitis was conﬁrmed by US in 94% of these patients(119/126). No signiﬁcant difference was found (Table 2) be-tween different anthropometric measures in the affected hands(197 patients) in comparison to the control group hands (pa-tients with past history of carpal tunnel decompression opera-tion were excluded). In patients with postoperative recurrenceof symptoms (35 subjects), US assessment revealed that inter-stitial oedema was present in 9/35 patients, focal swelling in 3/35 patients, synovitis in 4/35 patients, biﬁd median nerve in 1/35 patient, and tenosynovitis in 18 patients. Fig. 2. Transverse scan showing tenosynovitis of the ﬂexor tendons: the Table 3 shows the association between the positivity of the tendons appear swollen and indenting the compressed median nerve (MN).clinical provocative tests and both socio-demographic factorsas well as the diagnostic tests applied in this study (nerve con-duction testing and US). The prevalence of positive Tinel, Pha- Reverse Phalen’s and CT compression than those with abnor-len’s, Reverse Phalen’s and CT compression were signiﬁcantly mal conduction but with no tenosynovitis.higher in patients in the age category 65 years in comparison The sensitivity and speciﬁcity with 95% conﬁdence intervalto those >65 years (37.4, 69.9, 56.1 and 66.1% versus 13.1, of clinical tests for the diagnosis of carpal tunnel syndrome13.1, 19.7 and 11.5% respectively). and tenosynovitis are shown in Table 5. Sensitivity of Tinel, Association between tenosynovitis and clinical tests in pa- Phalen’s, Reverse Phalen’s and CT compression tests wastients with normal and abnormal nerve conduction is described higher for the diagnosis of tenosynovitis than for the diagnosisin Table 4. Signiﬁcantly higher percentages of positive Pha- of CTS (46 vs. 30 in Tinel; 92 vs. 47 in Phalen’s; 75 vs. 42 inlen’s, Reverse Phalen’s and CT compression tests were found Reverse Phalen’s; 95 vs. 46 in carpal tunnel compression).in patients with normal conduction but with tenosynovitis than Similarly, higher speciﬁcity of these tests was found with teno-in those who had normal conduction without tenosynovitis. synovitis than CTS.Similarly, patients with abnormal conduction and having teno-synovitis had a higher prevalence of positive Tinel, Phalen’s, Table 1 Sociodemographic and clinical history of patients with carpal tunnel syndrome Number (%) (N ¼ 232) Age categories 65-years old 65 (28) >65-years old 167 (72) Sex Male 69 (29.7) Female 163 (70.3) Forearm symptoms No 106 (45.7) Yes 126 (54.3) Tenosynovitis (detected by US) No 113 (48.7) Yes 119 (51.3) Nocturnal dysaesthesia No 0 (0) Yes 232 (100) Diurnal pain No 120 (51.7) Yes 112 (48.3)Fig. 1. Transverse scan showing tenosynovitis of the ﬂexor policis longus: the Improvement of symptoms on shaking the handstendon appears swollen and surrounded by hypoechoic hallo of oedema (ar- No 117 (50.4)rowheads), median nerve (MN). The tendon could be identiﬁed by asking Yes 115 (49.6)the patient to move the thumb during scanning.
Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457 455Table 2 Table 4Anthropometric measures in the symptomatic hands (197 patients) in compar- Association between tenosynovitis and clinical tests in patients with normalison to the control group (182 patients) and abnormal nerve conduction Affected hands Control group Signiﬁcance Positive N (%) Total mean Æ SD mean Æ SD Tinel Phalen’s Reverse Carpal N (%)BMI 29.01 Æ 4.75 28.93 Æ 5.25 NS Phalen’s tunnelForearm length (cm) 19.35 Æ 1.54 19.19 Æ 1.73 NS compressionFlexor retinaculum (mm) 1.065 Æ 0.37 1.012 Æ 0.16 NS Normal nerve conductionAntero-posterior of carpal 11.75 Æ 0.90 11.71 Æ 0.64 NS No 4 (40.0) 3 (30.0) 2 (20.0) 0 10 (20.8) tunnel (mm) tenosynovitisBMI, body mass index. Tenosynovitis 13 37 29 27 38 (34.2) (97.4)*** (76.3)** (71.1)*** (79.2) Total 48 Studies for the reproducibility of the radiographic assess- Abnormal nerve conductionment showed high inter-observer reproducibility (K ¼ 0.89 No 13 (12.6) 14 (13.6) 16(15.5) 6 (5.8) 103 (56)and 0.93), whereas, kappa values for intra-observer reproduc- tenosynovitisibility were 0.91 and 0.93 indicating high reproducibility. Tenosynovitis 42 73 61 72 81 (51.9)*** (90.1)*** (75.3)*** (88.9)*** (44) Total 1844. Discussion *p < 0.05, **p < 0.01, ***p < 0.001. The diagnosis of carpal tunnel syndrome (CTS) continues tobe neurophysiologically and clinically controversial. Earlier compression test), the results of this study revealed that thedata highlighted the possibility of having patients with symp- prevalence of positive clinical tests in patients with CTS diag-toms suggestive of CTS but without evidence of median mono- nosed by nerve conduction testing as the gold standard was:neuropathy and revealed the need for a better understanding of 29.9%, 47.3%, 41.8% and 42.4% respectively. Sensitivitiesthe underlying pathophysiology and natural history of CTS. of the 4 test were 30%, 47%, 42% and 46% respectively,This study was carried out to examine the relationship between whereas their speciﬁcities were 65%, 17%, 35% and 25% re-the clinical symptoms of CTS (and the possible related forearm spectively. These ﬁgures are in agreement with the earlier dataconditions) with the outcome of assessment using the diagnostic published. Ghavanini and Haghighat  carried out a study totools (nerve conduction testing and US) in patients presenting reappraise the value of these clinical tests in CTS patients.with carpal tunnel syndrome manifestations. They found that, in patients with CTS diagnosed by nerve con- On examining the prevalence of the 4 clinical tests exam- duction testing as the gold standard, Tinel’s test was the mostined (Tinel’s, Phalen’s, Reverse Phalen’s and carpal tunnel speciﬁc and the least sensitive; carpal compression test was less sensitive and speciﬁc. There was no correlation betweenTable 3 Phalen time, Reverse Phalen time, carpal compression time,Association between clinical provocative tests and both socio-demographic and nerve conduction measurements. In another study Buchfactors as well as the diagnostic tests applied in this study (nerve conduction and Foucher  found that when correlation between 11 clin-testing and US) ical signs and tests (isolated or associated) was performed in Positive N (%) patients with CTS manifestations with nerve conduction test- Tinel Phalen’s Reverse Carpal tunnel ing used as ‘‘standard’’, none of the signs or tests reached Phalen’s compression an acceptable level of sensitivity, speciﬁcity or predictiveAge categories value. Furthermore, in the study carried out by Homan et al. 65-years 64 (37.4)*** 119 (69.9)*** 96 (56.1)*** 113 (66.1)***  to evaluate the concordance between various clinical>65-years 8 (13.1) 8 (13.1) 12 (19.7) 7 (11.5) screening procedures for carpal tunnel syndrome, there wasSexMale 18 (26.1) 32 (46.4) 29 (42.0) 32 (46.4) Table 5Female 54 (33.1) 95 (58.4) 79 (48.5) 88 (54.0) Sensitivity and speciﬁcity and 95% conﬁdence interval of clinical tests in di-Diagnosis of carpel tunnel syndrome by nerve conduction test agnosis of carpal tunnel syndrome and tenosynovitisNormal 17 (35.4) 40 (83.3) 31 (64.6) 36 (75.0) Carpal tunnel syndrome TenosynovitisMild 17 (36.2) 31 (66.0)* 23 (48.9) 24 (51.1)* Sensitivity Speciﬁcity Sensitivity SpeciﬁcityModerate 24 (31.2) 37 (48.1)*** 40 (51.9) 37 (48.1) ** (95% CI) (95% CI) (95% CI) (95% CI)Severe 14 (23.3) 19 (31.7)*** 14 (23.3)*** 23 (38.3)*** Tinel 30 65 46 85Forearm symptoms (24.3e36.4) (58.4e71.1) (40.5e53.6) (79.6e89.2)No 16 (15.1) 11 (10.4) 13 (12.3) 0 Phalen’s 47 17 92 87Yes 56 (44.4)*** 116 (92.1)*** 95 (75.4)*** 120 (95.2)*** (40.5e53.6) (12.5e22.6) (35.6e48.7) (81.8e90.9)Tenosynovitis by US Reverse Phalen’s 42 35 75 85No 16 (14.7) 14 (12.8) 16 (14.7) 3 (2.8) (35.6e48.7) (29.0e41.6) (68.8e80.3) (79.6e89.2)Yes 56 (45.5)*** 113 (91.9)*** 92 (74.8)*** 117 (95.1)*** Carpal tunnel 46 25 95 97 compression (39.5e52.6) (19.7e31.2) (91.1e97.3) (93.7e98.7)*p < 0.05, **p < 0.01, ***p < 0.001.
456 Y. El Miedany et al. / Joint Bone Spine 75 (2008) 451e457relatively poor overlap between the reported symptoms, the reported that most people with positive physical ﬁndings con-physical examination ﬁndings, and the electrodiagnostic re- sistent with CTS do not have electrodiagnostic abnormalities,sults consistent with CTS. Overall, only 23 out of 449 subjects and vice versa.(5%) with at least 1 positive ﬁnding met all 3 criteria (symp- This work also has its therapeutic implications. A 1987 sur-toms, physical examination ﬁndings, and electrophysiological vey of hand surgeons found that many did not have electro-results consistent with carpal tunnel syndrome) for the domi- diagnostic studies performed for patients with suspectednant hand. The screening procedures showed poor or no agree- CTS  implying that these clinicians based their diagnosisment with kappa values ranging between 0.00 and 0.18 for all and treatment on history and physical examination ﬁndings.the case deﬁnitions evaluated for carpal tunnel syndrome. Jen- The results of this study suggest that some of these patientssen et al.  reported that these tests represent ‘‘objective ev- might have beneﬁted from medical therapy rather than surgicalidence’’, and have only a limited relationship with the typical option. Earlier studies revealed that short-term oral predniso-clinical features of CTS. This situation is analogous to the lone or local steroid injections are effective treatment for car-weak relationship between ﬁndings on magnetic resonance im- pal tunnel syndrome [40,41].aging (MRI) of the lower back and low back pain. Further- To answer the question, why tenosynovitis has been missedmore, in agreement with our results, De Krom et al.  in the assessment of patients with CTS despite it being wellsuggested that there is little evidence to support the notion known to be a work related disorder, the diagnosis of CTSthat provocative tests are useful for the diagnosis of CTS. has been based only on symptoms and/or signs suggestive ofMore recently, Wainner et al.  suggested that additional the disease, but does not include in its assessment other com-studies of provocative tests items such as the Phalen test and mon disorders such as tendonitis and cervical radiculopathyTinel sign, whose values have yet to be clearly demonstrated, which can give similar manifestations . Second, the ques-are likely to yield more of the same unfruitful results. They tionnaire that has been developed by Levine et al. (1999) torecommended that future studies should assess and report assess the severity of CTS symptoms, did not include full as-the inﬂuence of the disease spectrum on test item performance. sessment of tenosynovitis and was never designed as a diagnos-This was one of the main targets of this study. tic tool. In fact, studies have shown insigniﬁcant correlation The results of this work revealed that the prevalence of the 4 between the overall severity scale for all symptoms and nerveclinical tests assessed was higher among the younger age group conduction studies . Hence, it was important to assess forof patients (<65 years). Similarly, tenosynovitis was signiﬁ- tenosynovitis. You  recommended CTS symptoms be clas-cantly more prevalent among the same group of the patients. siﬁed into 2 groups to provide better interpretation of theThird, in the group of patients who had normal nerve conduc- symptoms. The ﬁrst group includes typical symptoms fortion studies, but had tenosynovitis, the prevalence of positive nerve damage. The second group includes pain, and symptomsPhalen’s, Reverse Phalen’s and carpal tunnel compression tests, suggestive of affection of body tissues including tendon, mus-was signiﬁcantly higher than the patient subgroup who had nor- cle and nerve. The results of this study are in agreement withmal nerve conduction studies and did not suffer from tenosyn- such a hypothesis.ovitis. Lastly, the speciﬁcity and sensitivity of these tests in The results of this study revealed that Phalen, Reverse Pha-patients with tenosynovitis were signiﬁcantly higher when com- len and carpal tunnel compression tests are more sensitive, aspared to the speciﬁcity and sensitivity of the same tests among well as being speciﬁc tests for the diagnosis of tenosynovitis ofpatients diagnosed to have CTS by the NCS as the gold stan- the ﬂexor muscles of the hand rather than being speciﬁc testsdard. These data give the conclusion that such provocative tests for carpal tunnel syndrome and can be used as an indicator forare more sensitive and speciﬁc for tenosynovitis rather than medical management of the condition.being valid clinical tests for carpal tunnel syndrome. Britzet al. , correlating the clinical, electrodiagnostic, intra-operative, and magnetic resonance imaging (MRI) ﬁndings, re- Referencesported that increased signal of the median nerve was seen in 41of 43 (95%) wrists, increased signal of the ﬂexor tendon sheath  Stevens JC, Sun S, Beard CM, et al. Carpal tunnel syndrome in Roches- ter, Minnesota, 1961 to 1980. Mayo Clin Proc 1988;38:134e8.in 41 of 43 (95%), volar bowing of the ﬂexor retinaculum in 39  Quality standards subcommittee of the American Academy of Neurol-of 43 (91%), increased distance between the ﬂexor tendons in ogy. Practice parameter for carpal tunnel syndrome. Neurology37 of 43 (86%), and abnormal nerve conﬁguration in 28 of 43 1993;43:2406e9.(65%). In another study Mesgarzadeh et al. , studying the  Hanrahan LP, Higgins D, Anderson H, et al. Project SENSOR: Wisconsin sur-MRI images of patients with CTS, found CTS could be caused veillance of occupational carpal tunnel syndrome. WMJ 1991;90:82e3.  Bureau of Labour Statistics. Occupational injuries and illness in theby tendon sheath oedema in traumatic tenosynovitis, synovial United States by industry. Washington DC: US Department of Labour,hypertrophy in rheumatoid tenosynovitis, a ganglion cyst, and Bureau of Labour Statistics; 1995.excessive amount of fat within the carpal tunnel, a persistent  de Krom MC, Knipschild PG, Kester AD, et al. Carpal tunnel syndrome.median artery, and a large adductor pollicis muscle. J Clin Epidemiol 1992;45:373e6. In our work tenosynovitis was more prevalent among pa-  Atroshi I, Gummesson C, Johnsson R, et al. Diagnostic properties of nerve conduction tests in population based carpal tunnel syndrome.tients who had either normal nerve conduction tests or mild BMC Musculoskelet Disord 2003;4:9e16.compression of the median nerve (Table 4). These ﬁndings  Fisher B, Gorsche R, Leake P. 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