• Diagnosis is by clinical assessment, detailed history and examination.
• The use of hand diagrams of symptoms ^[6,7] has been shown to assist diagnosis.
• The symptoms can be prominent at night, when waking in the morning or with relevant ergonomic activity.
• CTS is also associated with pain and discomfort in the wrist with possible radiation into the hand or arm. Sensory changes can also occur with numbness, pins and needles, and the sensation of swelling. In a classic presentation these occur over the lateral (thumb or radial side) three and a half fingers.
• In severe cases changes in the median nerve causes muscle wasting as well as motor and sensory loss.
• A number of provocative tests can also be undertaken:
• Phalen’s sign ^[8,9]
• Carpal tunnel compression test ^[9]
• Tinel’s sign ^[9]
• In addition the following tests could be undertaken to confirm or support a CTS diagnosis especially if uncertainty exists or surgery is planned:
• Nerve conduction study – however the issue of false/negative rates must be considered ^[10]
• Ultrasound – for evidence of nerve enlargement ^[11,12]
• MRI – for evidence of nerve enlargement ^[11,12]

• Consider any underlying medical conditions such as diabetes, thyroid disease, pregnancy or arthritis as this may be central to the management of CTS.
• Avoid aggravating activities of work, home and in recreation.
• Splinting ^[13,14].
• Medication, especially non-steroidal anti-inflammatory drugs ^[4,16] when they are not contraindicated.
• Injection therapy especially corticosteroid ^{[15,16,17,18,4]}.
• The use of hand therapists should be considered to assist with early and sustained return to function. 
• The issue of psychosocial and occupational risk factors (Yellow Flags) should also be considered. These factors increase the likelihood of a delayed or poorer than expected recovery including the condition developing into a chronic condition or an associated sequelae injury such as depression. These issues must be considered especially when the condition fails to improve beyond the expected timeframes.

• Prior to surgical intervention a nerve conduction study test should be undertaken.
• Decompression of the medial nerve can be either endoscopic or open.  However there can be a complication rate of 2–15% including failure to relieve symptoms, incomplete release and late recurrence  due to tight scaring occurring as the transverse carpal ligament heals ^[19].
• The use of hand therapists should be considered to assist with early and sustained return to function.  
• The issue of psychosocial and occupational risk factors (Yellow Flags) should also be considered. These factors increase the likelihood of a delayed or poorer than expected recovery including the condition developing into a chronic condition or an associated sequelae injury such as depression. These issues must be considered especially when the condition fails to improve beyond the expected timeframes.

1. Bernard BP, ed. Musculoskeletal disorders and workplace factors: a critical review of epidemiological evidence for work-related musculoskeletal disorders of the neck, upper extremity and low back. Cincinnati: National Institute for Occupational Safety and Health, July 1997 (DHHS(NIOSH) publication no 97-141.)
2. National Institute for Occupational Safety and Health. National occupational research agenda. Cincinnati: Department of Health and Human Services Publication 96-115.
3. Palmer KT, Harris EC, Coggon D. Carpal tunnel syndrome and its relation to occupation: a systematic  literature review Occ Med (Lond) 2007;57(1) 57-66.
4. Katz JN, Simmons BP Carpal tunnel syndrome. NEJM 2002 346(23) 1807-92.
5. Bland, J. D. P. (2005). Carpal tunnel syndrome. Curr Opin Neurol, 18(5), 581-585.
6. Katz JN, Stirrat CR. A self-administered hand diagram for the diagnosis of carpal tunnel syndrome. J Hand Surg (Am 1990;15:360-363.)
7. Kamath V, Stothard J A clinical questionnaire for the diagnosis of carpal tunnel syndrome. J Hand Surg (Br) 2003;28:455-459.
8. Phalen GS The carpal-tunnel syndrome. Seventeen years' experience in diagnosis and treatment of six hundred fifty-four hands J Bone Joint Surg Am. 1966 Mar;48(2):211-28.
9. MacDermid JC, Wessel J. Clinical Diagnosis of Carpal Tunnel Syndrome: A Systematic Review. Journal of Hand Therapy 2004 April-June 309-319.
10. Jablecki CK, Andary MT, Floeter MK et al. Practice parameter:electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Neurology and the American Academy
11. Sarria, L., Cabada , T., Cozcolluela,R., Martinez-Berganza, T., Garcia,S. (2000). Carpal Tunnel Syndrome: usefulness of sonography. Eur Radiol. 10(12):1920-5.
12. Ziswiler, H. R., Reichenbach, S., Vogelin, E., Bachmann, L. M., Viliger, P. M. & Juni, P. (2005). Diagnostic value of sonography in patients with suspected carpal tunnel syndrome: a prospective study. Arthritis Rheum, 52(1), 304-11.
13. Burke DT, Burke MM, Steward GW, Cambre A. Splinting for carpal tunnel syndrome: in search of the optimal angle. Arch Phys Med Rehabil 1994; 75: 1241-4.
14. O’Connor D, Marshall S, Massey-Westtropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cocharane Database Syst Rev 2003:CD003219
15. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev, 2003: CD0015B4.
16. Girlanda  P, Dattola R, Venuto C, Mangiapane R, Nicolosi C, Messina C. Local sterois treatment in idiopathic carpal tunnel syndrome: short- and long-term efficacy. J Neurol 1993;240:187-90.
17. Dammers JW’HH, Veering MM, Vermeulen M. Injection with methylprednisolone proximal to the carpal tunnel: randomized double blind trial BMJ 1999;319:884-6.
18. Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: one year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum 2005,52 (2):612-9.
19. Erdil M, Dickerson OB, Glackin E. Cumulative Trauma Disorders of the Upper Extremity. In Zenz C, Dickerson OB, Howarth GP (eds.) Occupational Medicine. Mosby St Louis, Missouri 1994; 48-64.

Carpal tunnel syndrome – Non-surgical treatment
Not applicable. Consider avoiding aggravating activities, job rotation and appropriate rest breaks.

Carpal tunnel syndrome - Surgical treatment
For uncomplicated cases approx 64–90% should return to work within usual recovery times ^[1,2]. In non-compensable injury this is expected to be two to six weeks. Attention to the non-surgical issues above may also be necessary.

References

1. Shin AY, Perlman M, Shin PA, Garay AA. Disability outcomes in a worker's compensation population: surgical versus nonsurgical treatment of carpal tunnel syndrome. Am J Orthop. 2000 29(3); 179-84.
2. Schmelzer RE, Della Rocca GL, Caplin DA. Endoscopic carpal tunnel release: a review of 753 cases in 486 patients. Plast Reconstr Surg 2006; 117(1); 177-85.

A clinician's guide to carpal tunnel syndrome incorporating workers compensation aspects