CTS CLINICAL PRESENTATION

Primary features of CTS include pain in the hand,
unpleasant tingling, pain or numbness in the distal
distribution of the median nerve (thumb, index, middle
finger and the radial side of the ring finger) [25]), and a
reduction of the grip strength and function of the affected
hand [26]. Symptoms tend to be worse at night, and
clumsiness is reported during the day with activities
requiring wrist flexion [27]). Patients often describe a
phenomenon termed the “flick sign”, in which shaking or
flicking their wrists relieves symptoms [28].
 Many patients report symptoms outside the distribution
of the median nerve as well, which has been confirmed by a
systematic study conducted by Stevens et al., [29]. In 159
hands of patients with electrodiagnostically confirmed CTS,
symptoms were most commonly reported in both the median
and ulnar digits more frequently than the median digits
alone. They also report location of symptoms in areas other
than the digits. 21% of patients had forearm paraesthesias
and pain; 13.8% reported elbow pain; 7.5% reported arm
pain; 6.3% reported shoulder pain; and 0.6% reported neck
pain [29]. Interestingly, trigger digit presentation
accompanies idiopathic CTS in approximately 20% of
patients [30].
 A large multicentre study has confirmed that patients
with mild to moderate CTS are more likely to report
substantial symptoms and mild functional limitations,
whereas patients with more severe disease may report less
severe symptoms, but have more severe functional
limitations of the hand [31]. This appears to be a
contradiction, but in fact it relates to the fact that severe
compromise of the median nerve may impair sensory
functioning to the extent that the profound numbness
minimizes the experience of tingling and pain. However,
profound functional limitations will ensue as a result of such
a level of numbness and motor impairment [32].
 Patients suffering from CTS often report subjective
feelings of swelling in their hands or wrists, but no apparent
swelling can be observed. However, some clinicians find that
this symptom has some diagnostic value attached to it [33].
In study of over 8000 patients with suspected CTS,
symptoms on the radial part of the hand and nocturnal
exacerbation of symptoms were most strongly predictive of
positive NCS [34]. In a retrospective study of 1039 patients
with a neurophysiological diagnosis of CTS, Nora et al., [35]
found that the most characteristic manifestation of the
syndrome was parasthesia in the median nerve distribution,
frequently extending to the whole hand. Pain was very
common but less specific, and weakness was rare [35].