Carpal Tunnel Syndrome: Assessment Insights for Physios

Approximately 14.4% of the population is affected by Carpal Tunnel Syndrome (CTS), making it a common condition seen by physios.

While it’s often approached as a straightforward compression of the median nerve, both the clinical presentation and its management are rarely that simple. Differences in pain mechanisms, symptom behaviour, and contributing factors mean that effective management relies on thorough assessment.

When you look more closely at the underlying mechanisms, treatment becomes less about a single intervention and more about combining approaches that target the nerve, the person, and the broader context.

If you want a deep dive into the assessment and management of CTS, watch expert Dr Colette Ridehalgh’s full Masterclass here.

Understand what you’re treating

CTS is defined as compression of the median nerve within the carpal tunnel. But not all symptoms are explained by compression alone. Changes within the nerve itself also contribute.

Increased intraneural pressure, oedema, and neuroinflammatory processes can affect nerve function. Even relatively small increases in pressure can disrupt axonal transport, which is essential for maintaining nerve health.

Understanding the type of pain you’re treating is also key. Patients experiencing neuropathic pain may present with pain outside the region supplied by the nerve, as well as spontaneous or evoked symptoms. Common descriptors include burning or electric shock sensations, paraesthesia, and dysaesthesia (an unpleasant abnormal sensation), as well as features such as allodynia or hyperalgesia.

Recognising these features helps you interpret the presentation more accurately and informs your assessment and management. See Colette describe a framework for identifying neuropathic pain in this video from her Masterclass:

Objective assessment

Your objective assessment should build from simple to more specific testing, rather than jumping straight to special tests. The tests you prioritise should also reflect the patient’s irritability.

Start with observation and function. Thenar wasting may indicate more advanced involvement, and swelling around the carpal tunnel can also be present. From there, explore movement:

• What activities reproduce symptoms?
• How do wrist, thumb and finger movements behave?
• Do combinations of movement change the response?

This gives you an early sense of irritability and functional impact, which helps guide how far to progress your assessment.

A full neurological assessment is important. This should extend beyond the wrist and hand to the entire upper limb, including sensation (light touch, pinprick, temperature), motor function and reflexes.

This broader approach helps rule out more proximal or even central contributors. Distal symptoms can originate from cervical or central sources, so it’s important not to narrow your focus too early and risk missing something important!

You can then move into tests of neural mechanosensitivity. These help you understand how sensitive the median nerve is to movement and loading, rather than simply whether it is compressed. See Colette explain what constitutes a positive test in this clip from her Masterclass:

Special tests

Phalen’s, Tinel’s and carpal compression (Durkan’s) tests are commonly used, but they should support your reasoning rather than drive it.

Colette highlights that none of these tests are particularly strong on their own. Phdurkan’s (combined Phalen’s and Durkan’s tests) and Durkan’s test can be useful for ruling out CTS, but results should always be interpreted alongside your broader clinical findings.

Diagnostic questionnaires can also support your assessment. The 6-item CTS symptom scale, for example, has been shown to have high sensitivity and specificity.

Management guided by your assessment

Once you have a clear picture of the presentation, management becomes more targeted. The NICE guidelines (updated 2022) provide a useful framework. Across all patients, this includes:

• Providing advice about information and support available
• Providing advice on relevant lifestyle factors
• Optimising management of underlying conditions (e.g., diabetes)

For mild to moderate symptoms, a six-week trial of conservative management is recommended, including one or more of: night splinting in a neutral position, a single corticosteroid injection, hand exercises and median nerve mobilisation.

Corticosteroid injections may not improve long-term outcomes, but can provide short-term symptom relief, which can still be meaningful for patients.

In practice, your assessment findings should guide what you prioritise. If symptoms are easily provoked and movement-related, addressing neural mechanosensitivity with neurodynamic approaches may be helpful. Manual therapy can also contribute to pain modulation and influence the interface between the nerve and surrounding structures.

Night splinting is often useful, particularly for those patients reporting night and/or morning pain.

There is also a role for broader approaches. General and cardiovascular exercise may support nerve health and address contributing factors such as reduced circulation or higher body weight.

Wrapping up

CTS may be a local condition anatomically, but in practice it requires a broader approach.

A structured assessment helps you understand how the nerve is behaving, identify neuropathic features, and rule out other contributors. From there, management becomes about selecting and combining the right strategies for the patient in front of you.

If you want to learn from an expert on the assessment and management of CTS, watch Dr Colette Ridehalgh’s full Masterclass here.