A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- General physical examination – including blood pressure, pulse, body weight, height; further:
- Inspection (viewing).
- Skin and mucous membranes
- Hand [atrophy (tissue atrophy) of the thenar musculature/thumb pad muscles and sensory disturbances (of the palm and fingers 1-3 including the radial side of the 4th finger) skin/nail changes (rare)]
- Inspection (viewing).
- Functional testing:
- Bottle sign – abduction of the thumb weakened, i.e. there is an inability of the hand to enclose a bottle (without a space between the thumb-index finger interdigital fold and the bottle).
- Hoffman-Tinel sign – elicitation of paresthesias (patient reports electrifying nerve pain) when tapping the median nerve at the level of the wrist, i.e., the volar (internal) side of the wrist
- Phalen’s test (palmar flexion test; hand flexion test) – prolonged (30 to 120 s) terminal hand flexion (hand flexion) results in dysesthesias (sensory disturbances) in the supply area of the median nerve [unreliable as a screening method of incipient median nerve compression].
- Compression test with the wrist flexed – applying pressure to the median nerve by means of two fingers and simultaneously flexing the wrist by 60°, while the elbow is extended and the forearm is held in supination (outward rotation of the hand by rotation of the forearm): if the test is positive, paresthesias in the innervation area of the median nerve are indicated; sensitivity (percentage of diseased patients in whom the disease is detected by the use of the method, i. e. That is, a positive finding occurs) 82%, specificity (probability that actually healthy people who do not suffer from the disease in question, are also detected as healthy in the test) 99%.
- Neurological examination [due topossible secondary diseases: Paresis (paralysis)/paresthesia (sensory disturbances) of the hand; in the early stages usually unremarkable]
“Carpal Tunnel Syndrome 6” (CTS-6) [gold standard in clinical diagnosis]
| Symptoms | Points |
| Paresthesias (numbness) predominantly in the median nerve area | 3,5 |
| Atrophy (tissue atrophy) and/or weakness of the thenar (ball of the thumb). | 5 |
| Nocturnal numbness | 4 |
| Positive Phalen sign (see above). | 5 |
| Loss of discrimination/perception in fingers innervated by median nerve, with inability to distinguish between two point stimuli 5 mm apart | 4,5 |
| Positive Hoffmann-Tinel sign (see above). | 4 |
Assessment: a CTS-6 score of 12 is considered the threshold for diagnosing carpal tunnel syndrome. Caveat: the CTS-6 may be falsely positive in the presence of cervical radiculopathy (irritation or damage to the nerve roots (radiculopathy) in the cervical spine) or peripheral neuropathy (nerve disease of the peripheral nervous system).