Download PDF
J Hand Microsurg 2017; 09(02): 067-073
DOI: 10.1055/s-0037-1603346
Original Article
Thieme Medical and Scientific Publishers Private Ltd.

Motor Examination in the Diagnosis of Carpal Tunnel Syndrome

Mithun Neral
1   Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, United States
2   Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Joseph E. Imbriglia
2   Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
,
Lois Carlson
3   The Hand Center, University of Connecticut School of Medicine, Glastonbury, Connecticut, United States
,
Ronit Wollstein
1   Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, United States
4   Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Technion School of Medicine, Haifa, Israel
› Author Affiliations
Further Information

Publication History

23 January 2017

21 April 2017

Publication Date:
25 May 2017 (online)

    Permissions and Reprints

Abstract

The relative importance and use of motor evaluation to diagnose carpal tunnel syndrome (CTS) is not clear. Because the ulnar nerve is not affected in CTS, we evaluated comparing the strength of the median-nerve innervated muscles to the ulnar innervated muscles in the same patient, through manual muscle testing (MMT) and a handheld dynamometer. Our purpose was to evaluate whether this method, which takes into account patient-dependent factors that would affect both groups of muscles equally, can provide better assessment of CTS. A retrospective case-control review of MMT and dynamometer-measured strength for CTS was performed. The study was performed retrospectively but prior to surgery or other treatment. There were 28 cases (CTS) and 14 controls (without CTS). Positive nerve conduction tests defined cases. MMT of the thenar musculature was found to be unreliable as a test for CTS. Comparisons to ulnar nerve innervated muscle strength did not improve sensitivity or specificity of the MMT examination. Use of the dynamometer improved sensitivity and specificity of motor testing in CTS over MMT. Motor evaluation is important for the diagnosis of CTS, but further study is warranted, specifically to define the method of motor evaluation and delineate the subgroup of patients (predominantly thenar motor presentation) that would benefit most from motor testing and motor-focused treatment.

Keywords

carpal tunnel syndrome - diagnosis - dynamometer - motor examination - ulnar
 

  • References

  • 1 Foresti C, Quadri S, Rasella M, Tironi F, Viscardi M, Ubiali E. Carpal tunnel syndrome: which electrodiagnostic path should we follow? A prospective study of 100 consecutive patients. Electromyogr Clin Neurophysiol 1996; 36 (06) 377-384
    PubMedGoogle Scholar
  • 2 Shimizu S, Tachibana S, Fujii K. Difficulty of pinching behind the back: an atypical symptom of carpal tunnel syndrome related to a specific wrist position. Two case reports. Neurol Med Chir (Tokyo) 2012; 52 (04) 229-230
    CrossrefPubMedGoogle Scholar
  • 3 Spindler HA, Dellon AL. Nerve conduction studies and sensibility testing in carpal tunnel syndrome. J Hand Surg Am 1982; 7 (03) 260-263
    CrossrefPubMedGoogle Scholar
  • 4 Sohn MW, Whittle J, Pezzin LE, Miao H, Dillingham TR. Electrodiagnostic consultation and identification of neuromuscular conditions in persons with diabetes. Muscle Nerve 2011; 43 (06) 812-817
    CrossrefPubMedGoogle Scholar
  • 5 Visser LH, Smidt MH, Lee ML. High-resolution sonography versus EMG in the diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 2008; 79 (01) 63-67
    CrossrefPubMedGoogle Scholar
  • 6 Fowler JR, Munsch M, Huang Y, Hagberg WC, Imbriglia JE. Pre-operative electrodiagnostic testing predicts time to resolution of symptoms after carpal tunnel release. J Hand Surg Eur Vol 2016; 41 (02) 137-142
    CrossrefPubMedGoogle Scholar
  • 7 Rozmaryn LM, Bartko JJ, Isler ML. The Ab-Adductometer: a new device for measuring the muscle strength and function of the thumb. J Hand Ther 2007; 20 (04) 311-324 , quiz 325
    CrossrefPubMedGoogle Scholar
  • 8 Geere J, Chester R, Kale S, Jerosch-Herold C. Power grip, pinch grip, manual muscle testing or thenar atrophy—which should be assessed as a motor outcome after carpal tunnel decompression? A systematic review. BMC Musculoskelet Disord 2007; 8: 114 . Doi: 10.1186/1471-2474-8-114
    CrossrefPubMedGoogle Scholar
  • 9 Keith MW, Masear V, Chung K. , et al. Diagnosis of carpal tunnel syndrome. J Am Acad Orthop Surg 2009; 17 (06) 389-396
    CrossrefPubMedGoogle Scholar
  • 10 Mondelli M, Aretini A, Ginanneschi F, Padua L. Thenar motor neuropathy electrophysiological study of 28 cases. J Clin Neurophysiol 2010; 27 (05) 344-349
    CrossrefPubMedGoogle Scholar
  • 11 Inukai T, Uchida K, Kubota C, Takamura T, Nakajima H, Baba H. Second lumbrical-interossei nerve test predicts clinical severity and surgical outcome of carpal tunnel syndrome. J Clin Neurosci 2013; 20 (09) 1224-1227
    CrossrefPubMedGoogle Scholar
  • 12 Danoff JR, Birman MV, Rosenwasser MP. Transfer of the flexor carpi radialis to the abductor pollicis brevis tendon for the restoration of tip-pinch in severe carpal tunnel syndrome. J Hand Surg Eur Vol 2014; 39 (02) 175-180
    CrossrefPubMedGoogle Scholar
  • 13 de Krom MC, Knipschild PG, Kester AD, Spaans F. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. Lancet 1990; 335 (8686): 393-395
    CrossrefPubMedGoogle Scholar
  • 14 Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening test?. Clin Rehabil 2005; 19 (06) 662-667
    CrossrefPubMedGoogle Scholar
  • 15 Bohannon RW. Internal consistency of manual muscle testing scores. Percept Mot Skills 1997; 85 (02) 736-738
    CrossrefPubMedGoogle Scholar
  • 16 Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am 1984; 9 (02) 222-226
    CrossrefPubMedGoogle Scholar
  • 17 Bohannon RW. Hand-held compared with isokinetic dynamometry for measurement of static knee extension torque (parallel reliability of dynamometers). Clin Phys Physiol Meas 1990; 11 (03) 217-222
    CrossrefPubMedGoogle Scholar
  • 18 Bohannon RW, Andrews AW. Interrater reliability of hand-held dynamometry. Phys Ther 1987; 67 (06) 931-933
    CrossrefPubMedGoogle Scholar
  • 19 Brandsma JW, Schreuders TA, Birke JA, Piefer A, Oostendorp R. Manual muscle strength testing: intraobserver and interobserver reliabilities for the intrinsic muscles of the hand. J Hand Ther 1995; 8 (03) 185-190
    CrossrefPubMedGoogle Scholar
  • 20 Brandsma JW, Schreuders TA. Sensible manual muscle strength testing to evaluate and monitor strength of the intrinsic muscles of the hand: a commentary. J Hand Ther 2001; 14 (04) 273-278
    CrossrefPubMedGoogle Scholar
  • 21 Liu F, Carlson L, Watson HK. Quantitative abductor pollicis brevis strength testing: reliability and normative values. J Hand Surg Am 2000; 25 (04) 752-759
    CrossrefPubMedGoogle Scholar
  • 22 Liu CW, Chen TW, Wang MC, Chen CH, Lee CL, Huang MH. Relationship between carpal tunnel syndrome and wrist angle in computer workers. Kaohsiung J Med Sci 2003; 19 (12) 617-623
    CrossrefPubMedGoogle Scholar
  • 23 Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson AE. Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures. J Hand Surg Am 2017; 42 (03) e139-e147
    CrossrefPubMedGoogle Scholar
  • 24 Ren YM, Wang XS, Wei ZJ. , et al. Efficacy, safety, and cost of surgical versus nonsurgical treatment for carpal tunnel syndrome: a systematic review and meta-analysis. Medicine (Baltimore) 2016; 95 (40) e4857 . Doi: 10.1097/MD.0000000000004857
    CrossrefPubMedGoogle Scholar
  • 25 Zhang S, Vora M, Harris AH, Baker L, Curtin C, Kamal RN. Cost-minimization analysis of open and endoscopic carpal tunnel release. J Bone Joint Surg Am 2016; 98 (23) 1970-1977
    CrossrefPubMedGoogle Scholar
  • 26 Conlon C, Asch S, Hanson M. , et al. Assessing the value of high-quality care for work-associated carpal tunnel syndrome in a large integrated health care system: study design. Perm J 2016; 20 (04) 87-95
    PubMedGoogle Scholar
  • 27 Vahdatpour B, Khosrawi S, Chatraei M. The role of median nerve terminal latency index in the diagnosis of carpal tunnel syndrome in comparison with other electrodiagnostic parameters. Adv Biomed Res 2016; 5: 110 . Doi: 10.4103/2277-9175.183671
    CrossrefPubMedGoogle Scholar
  • 28 Ten Cate DF, Glaser N, Luime JJ. , et al. A comparison between ultrasonographic, surgical and histological assessment of tenosynovits in a cohort of idiopathic carpal tunnel syndrome patients. Clin Rheumatol 2016; 35 (03) 775-780
    CrossrefPubMedGoogle Scholar
  • 29 Yagci I, Gunduz OH, Sancak S, Agirman M, Mesci E, Akyuz G. Comparative electrophysiological techniques in the diagnosis of carpal tunnel syndrome in patients with diabetic polyneuropathy. Diabetes Res Clin Pract 2010; 88 (02) 157-163
    CrossrefPubMedGoogle Scholar
  • 30 Zalaffi A, Mariottini A, Carangelo B. , et al. Wrist median nerve motor conduction after end range repeated flexion and extension passive movements in carpal tunnel syndrome. Pilot study. Acta Neurochir Suppl (Wien) 2005; 92: 47-52
    PubMedGoogle Scholar
  • 31 Yildiz N, Atalay NS, Gungen GO, Sanal E, Akkaya N, Topuz O. Comparison of ultrasound and ketoprofen phonophoresis in the treatment of carpal tunnel syndrome. J Back Musculoskeletal Rehabil 2011; 24 (01) 39-47
    CrossrefPubMedGoogle Scholar
  • 32 Watanabe T, Ito H, Morita A. , et al. Sonographic evaluation of the median nerve in diabetic patients: comparison with nerve conduction studies. J Ultrasound Med 2009; 28 (06) 727-734
    CrossrefPubMedGoogle Scholar
  • 33 Lee KM, Kim HJ. Relationship between electrodiagnosis and various ultrasonographic findings for diagnosis of carpal tunnel syndrome. Ann Rehabil Med 2016; 40 (06) 1040-1047
    CrossrefPubMedGoogle Scholar
  • 34 Kolovos S, Tsiotas D. Ultrasonographic diagnosis of carpal tunnel syndrome: introducing a new approach. Eur J Orthop Surg Traumatol 2016; 26 (02) 167-175
    CrossrefPubMedGoogle Scholar
  • 35 Makanji HS, Becker SJ, Mudgal CS, Jupiter JB, Ring D. Evaluation of the scratch collapse test for the diagnosis of carpal tunnel syndrome. J Hand Surg Eur Vol 2014; 39 (02) 181-186
    CrossrefPubMedGoogle Scholar
  • 36 Boland RA, Kiernan MC. Assessing the accuracy of a combination of clinical tests for identifying carpal tunnel syndrome. J Clin Neurosci 2009; 16 (07) 929-933
    CrossrefPubMedGoogle Scholar
  • 37 Brown WF. Thenar motor unit count estimates in the carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 1973; 36 (02) 194-198
    CrossrefPubMedGoogle Scholar
  • 38 Mondelli M, Baldasseroni A, Aretini A, Ginanneschi F, Padua L. Prevalent involvement of thenar motor fibres in vineyard workers with carpal tunnel syndrome. Clin Neurophysiol 2010; 121 (08) 1251-1255
    CrossrefPubMedGoogle Scholar
  • 39 Cobb TK, An KN, Cooney WP, Berger RA. Lumbrical muscle incursion into the carpal tunnel during finger flexion. J Hand Surg [Br] 1994; 19 (04) 434-438
    CrossrefPubMedGoogle Scholar
  • 40 Baker NA, Moehling KK, Rubinstein EN, Wollstein R, Gustafson NP, Baratz M. The comparative effectiveness of combined lumbrical muscle splints and stretches on symptoms and function in carpal tunnel syndrome. Arch Phys Med Rehabil 2012; 93 (01) 1-10
    CrossrefPubMedGoogle Scholar
  • 41 Liu F, Watson HK, Carlson L, Lown I, Wollstein R. Use of quantitative abductor pollicis brevis strength testing in patients with carpal tunnel syndrome. Plast Reconstr Surg 2007; 119 (04) 1277-1283
    CrossrefPubMedGoogle Scholar
  • 42 Schrama PP, Stenneberg MS, Lucas C, van Trijffel E. Intraexaminer reliability of hand-held dynamometry in the upper extremity: a systematic review. Arch Phys Med Rehabil 2014; 95 (12) 2444-2469
    CrossrefPubMedGoogle Scholar
  • 43 Molenaar HM, Selles RW, Schreuders TA, Hovius SE, Stam HJ. Reliability of hand strength measurements using the Rotterdam Intrinsic Hand Myometer in children. J Hand Surg Am 2008; 33 (10) 1796-1801
    CrossrefPubMedGoogle Scholar
  • 44 Molenaar HM, Selles RW, de Kraker M, Stam HJ, Hovius SE. The added value of measuring thumb and finger strength when comparing strength measurements in hypoplastic thumb patients. Clin Biomech (Bristol, Avon) 2013; 28 (08) 879-885
    CrossrefPubMedGoogle Scholar
  • 45 Jenkins PJ, Srikantharajah D, Duckworth AD, Watts AC, McEachan JE. Carpal tunnel syndrome: the association with occupation at a population level. J Hand Surg Eur Vol 2013; 38 (01) 67-72
    CrossrefPubMedGoogle Scholar
  • 46 Raman SR, Al-Halabi B, Hamdan E, Landry MD. Prevalence and risk factors associated with self-reported carpal tunnel syndrome (CTS) among office workers in Kuwait. BMC Res Notes 2012; 5: 289 . Doi: 10.1186/1756-0500-5-289
    CrossrefPubMedGoogle Scholar
  • 47 Abumunaser LA. Demographic pattern of carpal tunnel syndrome in western Saudi Arabia. Neurosciences (Riyadh) 2012; 17 (01) 44-47
    PubMedGoogle Scholar
  • 48 Mondelli M, Giannini F, Giacchi M. Carpal tunnel syndrome incidence in a general population. Neurology 2002; 58 (02) 289-294
    CrossrefPubMedGoogle Scholar
  • 49 Goyal V, Bhatia M, Padma MV, Jain S, Maheshwari MC. Electrophysiological evaluation of 140 hands with carpal tunnel syndrome. J Assoc Physicians India 2001; 49: 1070-1073
    PubMedGoogle Scholar
  • 50 Padua L, Padua R, Nazzaro M, Tonali P. Incidence of bilateral symptoms in carpal tunnel syndrome. J Hand Surg [Br] 1998; 23 (05) 603-606
    Google Scholar