Suggested Variations on Standard Carpal Tunnel Syndrome Assessment Tests


Mention carpal tunnel syndrome (CTS), and most think of it as the leading upper extremity nerve entrapment issue. It is prevalent, especially among women and in certain professions involving extensive upper extremity use. Jobs with high-velocity, high-force labor, vibrating tools, or repetitive motions, like assembly-line work, increase CTS risks. Massage therapists are also particularly prone to CTS because of extensive hand and finger use.

Many seek to avoid surgery for this condition as surgical stats show a high degree of recurrence or failed surgery. Consequently, massage therapists are in an excellent position for assessing and treating nerve conditions like CTS.

Physical examinations are crucial to identify nerve-related injuries. This article focuses on the biomechanics and physiology behind CTS and introduces innovative methods to enhance standard physical assessments for better recognition of potential issues.

Physiological effects of nerve compression

CTS and similar neuropathies arise from several factors, such as muscle pressure, swelling-induced fluid buildup, fibrosis, external compression, and reduced blood flow to nerves (neural ischemia). These elements often interact, exacerbating each other. For example, nerve pressure can impede blood flow, potentially triggering inflammation that further compresses the nerve, creating a worsening cycle.

CTS involves median nerve compression and is usually considered a chronic condition. However, CTS can also cause damage within a short timeframe. The duration and intensity of pressure are critical; even minimal pressure over a long period can be harmful.

CTS symptoms vary due to the structure of the affected nerve. Median nerve impairment usually shows sensory symptoms (pain, numbness, tingling) before motor symptoms (weakness, atrophy). Sensory symptoms usually appear first because sensory fibers are more peripheral in the nerve and therefore more susceptible to external pressure. If significant grip strength loss accompanies sensory symptoms, it may indicate a more advanced stage because both motor and sensory fibers are affected.

Variations on Common Evaluation Methods

CTS, despite its frequency, lacks a highly accurate means of recognition. Nerve conduction velocity tests, commonly used to identify median nerve impairment, may not show changes, even when there is some nerve compression involved. Thus, physical examinations play a crucial role in early detection of neural involvement.

Massage therapists can provide valuable treatment to address carpal tunnel syndrome, as well as other nerve compression pathologies. Accurate recognition of the potential compression site is helpful for proper treatment and client education to reduce offending forces on the nerve. Effective evaluation requires skilled clinical reasoning and refined physical examination skills. Relying solely on palpation without formal assessment limits the ability to detect nerve compression pathologies, often deviating from simple guidelines.

Practitioners frequently rely on special orthopedic tests to confirm suspicions of median nerve compression in the carpal tunnel. Orthopedic tests for CTS vary in accuracy, assessed by their sensitivity (identifying those with the problem) and specificity (excluding those without the problem). Many standard tests lack sensitivity in early CTS stages. Modifying these tests can enhance their sensitivity to better evaluate nerve compression issues.

When performing these varied tests, consider that exaggerated neural sensations might indicate not just mechanical compression neuropathy but also factors like neural tension or systemic disorders like diabetes. Evaluation results should inform treatment decisions and help consider appropriate contraindications.


Phalen’s Test

The Phalen’s test, a standard method for evaluating carpal tunnel syndrome, involves the client pressing their hands together with wrists flexed at nearly 90 degrees (Image 1). A positive result, indicating median nerve compression in the carpal tunnel, occurs if symptoms like pain, tingling, or numbness in the median nerve area appear within about 60 seconds.

image of the Phalen's test

Image 1
The standard Phalen’s test

The test works because wrist flexion increases carpal tunnel compression. However, the standard method, using both hands simultaneously with flexed elbows, lessens tension on the remainder of the median nerve. That means there is potentially less stress on the median nerve in the carpal tunnel, and therefore, the test might not pick up a milder case.

Enhancing this test’s sensitivity involves maintaining the wrist in the Phalen’s position while adding tension to the rest of the median nerve. Additional positioning includes neck lateral flexion away from the test side, raising the shoulder, straightening the elbow, and flexing the wrist (Image 2). Unlike the standard test, this modified version is performed one side at a time.


image of a modified version of the Phalen's test

Image 2
Modification of the Phalen’s test

Pressure Provocative Test

The carpal compression test, applying moderate pressure on the median nerve at the carpal tunnel, suggests nerve compression if symptoms appear within 20-30 seconds (Image 3).


Image of the pressure provocation test

Image 3
The pressure provocation test

A variation of the pressure provocative test involves extending the elbow, supinating the forearm, and flexing the wrist at about 60 degrees while applying pressure to the carpal tunnel. This test can be further refined by incorporating the upper extremity median nerve stretch position used in the Phalen’s test. This includes flexing the neck laterally away from the tested side, abducting the shoulder, extending the elbow, supinating the forearm, and partially flexing the wrist. While in this position, the practitioner applies moderate pressure to the carpal tunnel (Image 4).


Image of a variation on the pressure provocation test

Image 4
Variation on the pressure provocation test

Hand Elevation Test

The hand elevation test is a newer and more accurate method than the Phalen’s test. It involves the client raising their hand overhead as high as comfortable (Image 5). If median nerve-related neurological symptoms appear in the hand within one minute, the test is considered positive.


Image of the hand elevation test

Image 5
The hand elevation test

You can increase the sensitivity of this test by adding tension to the median nerve. With the arm raised, laterally flex the neck to the opposite side and extend or flex the wrist, like the Phalen’s test position (Image 6). Both variations add further tension to the median nerve.


Image of a modification of the hand elevation test

Image 6
Modification of the hand elevation test


Tethered Median Nerve Stress Test

The tethered median nerve stress test, increasingly used for evaluation, inherently involves some neural tension. It is performed by extending and supinating the wrist, then hyperextending the index finger as far as possible, either by the practitioner or the client. A positive result, indicating neural issues, occurs if neurological symptoms manifest within about a minute.

You can apply additional tension to the proximal upper extremity to increase the test’s sensitivity. Movement variation includes laterally flexing the neck away from the test side, abducting the shoulder, extending the elbow, and supinating the forearm (Image 7).


Image of modification of the tethered median nerve stress test

Image 7
Modification of the tethered median nerve stress test


Not all these movements are necessary; sometimes adding just one can exacerbate symptoms. This variation helps pinpoint other potential median nerve entrapment sites, such as increased symptoms with elbow extension suggesting nerve issues around the elbow or forearm.


Massage therapists are seeing more clients for conditions like carpal tunnel syndrome. Since high-tech diagnostics are often not reliable, our physical examination methods gain importance. Familiarity with standard evaluations is good, but adapting them for greater sensitivity enhances their usefulness, leading to more accurate assessments. Understanding the precise location of nerve pathology allows for targeted, effective treatments.

If you want to see some further explanations of these procedures, check out this YouTube video on the topic.

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