Several key comorbidities and/or human factors are associated with an increased incidence of carpal tunnel syndrome. These include pregnancy, advancing age, female gender, specific occupations, hand-related repetitive motions, strong family history, and specific medical disorders such as hypothyroidism, diabetes, autoimmune diseases, rheumatological diseases, arthritis, obesity, renal disease, trauma, anatomic predisposition in the wrist and hand due to shape and size, infectious diseases, and substance abuse. In many cases, there is no identifiable comorbidity or causal relationship. These are “idiopathic CTS cases” [1].

It is essential to ask the right questions in obtaining the history for a patient who is suspected of carpal tunnel syndrome. This is particularly important since the patient may have their own ideas of what the etiology of the problem is, which might be correct or incorrect. The index of suspicion must reside with the clinician in terms of asking the right questions.

The way I like to approach this is to ask the typical questions in obtaining information in any investigation, modified for carpal tunnel syndrome. Very simply these are who, how, what, when, and where.

What is the pattern up until now? What might the pattern be going forward? Often patients would like the clinician to “predict the future,” in terms of progression of their symptoms based on their current situation. In order to get a complete history, you have to know what the pattern up until the present has been.

In terms of the future pattern or “natural history” of this or any other disorder, there are always three choices: it gets better, it gets worse, or it stays the same. Yes, this is absurdly simplistic, but it is important to try to elicit the past pattern and get more detail on the progression of symptom etiology that has brought the patient to the physician’s office.

In terms of the present, and the future, there are two key things to try to consider. One is the duration of symptoms, and the second is the severity of the symptoms. The duration can be ascertained to some degree with the patient’s cooperation and if the patient is a reasonable historian. On the other hand, severity cannot be easily determined by history or physical exam, but this can be inferred by the careful conducting of the history and support of physical exam. Electrodiagnostic testing may give some indication of this severity, but not the likelihood of progression or rate. Confirmation of CTS can be obtained in the diagnostic testing which will be discussed in the sections to follow.

Inspection of the involved upper extremity should start with the neck and shoulder girdle exam. The contralateral side should always be inspected in unilateral cases. The neck should be tested for range of motion in terms of rotation, flexion and extension, and lateral bend. Nerve compressive signs should be observed, and compression testing performed. Any tenderness should be noted, either locally or especially if there is any radiating pain.

In terms of the shoulder girdle, palpation of the trapezius, the paracervical area , the supraclavicular area, the area around the clavicle, and the infraclavicular area of the upper chest should be carefully and sequentially palpated to elicit tenderness or irritation symptoms. The axilla should be palpated, and any radiating pain should be noted. The shoulder girdle should be tested for range of motion, instability, and impingement. Any pain should be noted.

Provocative tests for the thoracic outlet syndrome (TOS) such as Wright’s maneuver, Adson’s maneuver, and overhead fisting should be performed. Thoracic outlet syndrome is a very commonly diagnosed condition in my clinical practice. Because of the lack of good diagnostic tests for this condition, I find that the condition of TOS is often overlooked. TOS is the cause for many patients to have arm and hand symptoms that can mimic or exist in conjunction with carpal tunnel syndrome.

The elbow exam is extremely important in these patients. There are many conditions about the elbow that cause pain and disability that can mimic carpal tunnel syndrome. Direct palpation of the elbow with particular attention to the biceps insertion anteriorly, the medial epicondyle, the lateral epicondyle, and posteriorly the olecranon should be performed. Tenderness about the elbow with epicondylitis is another common clinical scenario seen in my practice.

Nerve compression about the elbow and forearm that does not involve the median nerve can cause significant symptoms. The cubital tunnel is located between the medial epicondyle and the olecranon tip, on the posteromedial side of the elbow. It is a common site of compression and in fact is the no. 2 upper extremity compressive diagnosis. A positive Tinel’s sign , or sensitivity to palpation, or nerve subluxation with elbow flexion and extension, or increase in symptoms with elbow flexion, is a maneuver that should be performed by the clinician. The medial epicondyle may be tender to palpation either on the bony prominence or slightly distally at the muscle belly of the flexor-pronator mass. As the ulnar nerve enters the forearm between the heads of the flexor carpi ulnaris, provocative or resistive testing of the flexor pronator muscles including the flexor carpi ulnaris is recommended.

On the lateral side, lateral epicondylitis is a common condition that may or may not be related to sports activities or repetitive use. The tenderness may be on the lateral epicondylar ridge itself or more distally in the supination/extension muscle group.

On the lateral side, the radial nerve courses around the head and neck of the radius bone and between the heads of the supinator muscle. Compression of the radial nerve should always be evaluated. Radial tunnel syndrome is another condition that should be carefully assessed by the clinician. Tenderness several centimeters distal to the lateral upper condyle to deep palpation and/or a positive Tinel’s test is an indicator of this condition. Provocative testing of wrist extension against resistance can be positive with radial tunnel syndrome. More fulminant radial nerve compression can result in motor weakness in the radial nerve-supplied muscles. These two entities, lateral epicondylitis and radial tunnel syndrome, can exist together.

In terms of the forearm, the volar forearm should not be neglected. Tenderness of the flexor pronator muscles either coming off the medial upper condyle on the medial side of the elbow or in the midline of the volar aspect of the forearm in supination and the proximal one third can be associated with pronator syndrome. This is a compressive neuropathy of the median nerve proximal to the wrist. This can exist alone or in conjunction with traditional carpal tunnel syndrome at the wrist.

At the wrist itself, all flexor tendons and all extensor tendons should be inspected and palpated in their compartments for tenderness or crepitus or swelling. Any of these structures can have a tenosynovitis associated with them. Of course the most common is the first dorsal compartment, or de Quervain’s tendinitis , but flexor carpi ulnaris and flexor carpi radialis tendinitis are common. Extensor carpi ulnaris, flexor digitorum communis, and extensor carpi radialis brevis and longus tendinitis are all additional clinical entities that can cause pain and require treatment including surgery.