Differential Diagnosis of Carpal Tunnel Syndrome

  • Cameron W. Schick
  • F. Thomas D. KaplanEmail author


Carpal tunnel syndrome is the most commonly diagnosed compressive neuropathy and the third most common procedure performed by orthopedic surgeons. The majority of carpal tunnel syndrome is idiopathic with classic symptoms of nocturnal paresthesias and activity-related symptoms with prolonged grip. Carpal tunnel syndrome can be idiopathic or caused by a variety of conditions such as space-occupying disorders or endocrinopathies. As with many disorders, other conditions can cause symptoms mimicking carpal tunnel syndrome, whose pathologies do not involve the median nerve at the carpal tunnel. These diagnoses include neurologic and non-neurologic conditions and should always be considered when evaluating patients with carpal tunnel symptoms, especially in those who present with atypical complaints and an abnormal physical examination. This chapter focuses on those conditions providing clinicians with a broad differential diagnosis for patients with paresthesias of the hand.


Neurologic Non-neurologic Cervical Vascular Inflammatory Tumor Neuropathy Arthritis Infection Tenosynovitis 


  1. 1.
    Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Garrett WE Jr, Swiontkowski MF, Weinstein JN, Callaghan J, Rosier RN, Berry DJ, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic surgeon: part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88(3):660–7.CrossRefPubMedGoogle Scholar
  3. 3.
    Luchetti R, Schoenhuber R, De Cicco G, Alfarano M, Deluca S, Landi A. Carpal-tunnel pressure. Acta Orthop Scand. 1989;60(4):397–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Rempel D, Evanoff B, Amadio PC, de Krom M, Franklin G, Franzblau A, et al. Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies. Am J Public Health. 1998;88(10):1447–51.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Keith MW, Masear V, Chung K, Maupin K, Andary M, Amadio PC, et al. Diagnosis of carpal tunnel syndrome. J Am Acad Orthop Surg. 2009;17(6):389–96.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Dunkow PD, Bhutta A, Pena MA. "Life" above the neck: brain tumour presenting as carpal tunnel syndrome. Hand Surg. 2004;9(2):233–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Yasuoka S, Okazaki H, Daube JR, MacCarty CS. Foramen magnum tumors. Analysis of 57 cases of benign extramedullary tumors. J Neurosurg. 1978;49(6):828–38.CrossRefPubMedGoogle Scholar
  8. 8.
    Meyer FB, Ebersold MJ, Reese DF. Benign tumors of the foramen magnum. J Neurosurg. 1984;61(1):136–42.CrossRefPubMedGoogle Scholar
  9. 9.
    Spinner RJ, Bachman JW, Amadio PC. The many faces of carpal tunnel syndrome. Mayo Clin Proc. 1989;64(7):829–36.CrossRefPubMedGoogle Scholar
  10. 10.
    Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast's syndrome. N Engl J Med. 1997;337(19):1370–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Gundes H, Tosun B, Muezzinoglu B, Alici T. A very large Schwannoma originating from the median nerve in carpal tunnel. J Peripher Nerv Syst. 2004;9(3):190–2.CrossRefPubMedGoogle Scholar
  12. 12.
    Wood MK, Erdmann MW, Davies DM. Malignant Schwannoma mistakenly diagnosed as carpal tunnel syndrome. J Hand Surg Br. 1993;18(2):187–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Padua L, Pazzaglia C, Insola A, Aprile I, Caliandro P, Rampoldi M, et al. Schwannoma of the median nerve (even outside the wrist) may mimic carpal tunnel syndrome. Neurol Sci. 2006;26(6):430–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Lee MJ, LaStayo PC. Pronator syndrome and other nerve compressions that mimic carpal tunnel syndrome. J Orthop Sports Phys Ther. 2004;34(10):601–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Thomas PK. Classification, differential diagnosis, and staging of diabetic peripheral neuropathy. Diabetes. 1997;46(Suppl 2):S54–7.CrossRefPubMedGoogle Scholar
  16. 16.
    England JD, Gronseth GS, Franklin G, Miller RG, Asbury AK, Carter GT, et al. Distal symmetric polyneuropathy: a definition for clinical research: report of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2005;64(2):199–207.CrossRefPubMedGoogle Scholar
  17. 17.
    Witt JC, Stevens JC. Neurologic disorders masquerading as carpal tunnel syndrome: 12 cases of failed carpal tunnel release. Mayo Clin Proc. 2000;75(4):409–13.CrossRefPubMedGoogle Scholar
  18. 18.
    Miller DH, Weinshenker BG, Filippi M, Banwell BL, Cohen JA, Freedman MS, et al. Differential diagnosis of suspected multiple sclerosis: a consensus approach. Mult Scler. 2008;14(9):1157–74.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Al-Araji AH, Oger J. Reappraisal of Lhermitte's sign in multiple sclerosis. Mult Scler. 2005;11(4):398–402.CrossRefPubMedGoogle Scholar
  20. 20.
    Tjoumakaris FP, Anakwenze OA, Kancherla V, Pulos N. Neuralgic amyotrophy (Parsonage-Turner syndrome). J Am Acad Orthop Surg. 2012;20(7):443–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24(6):783–92.CrossRefPubMedGoogle Scholar
  22. 22.
    Micev AJ, Ivy AD, Aggarwal SK, Hsu WK, Kalainov DM. Cervical radiculopathy and myelopathy: presentations in the hand. J Hand Surg Am. 2013;38(12):2478–81. quiz 81CrossRefPubMedGoogle Scholar
  23. 23.
    Chow CS, Hung LK, Chiu CP, Lai KL, Lam LN, Ng ML, et al. Is symptomatology useful in distinguishing between carpal tunnel syndrome and cervical spondylosis? Hand Surg. 2005;10(1):1–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Crandall PH, Batzdorf U. Cervical spondylotic myelopathy. J Neurosurg. 1966;25(1):57–66.CrossRefPubMedGoogle Scholar
  25. 25.
    Ono K, Ebara S, Fuji T, Yonenobu K, Fujiwara K, Yamashita K. Myelopathy hand. New clinical signs of cervical cord damage. J Bone Joint Surg Br. 1987;69(2):215–9.PubMedGoogle Scholar
  26. 26.
    Ziadeh MJ, Richardson JK. Arnold-Chiari malformation with syrinx presenting as carpal tunnel syndrome: a case report. Arch Phys Med Rehabil. 2004;85(1):158–61.CrossRefPubMedGoogle Scholar
  27. 27.
    Sethi N, Torgovnick J, Martin C, Arsura E. Churg-Strauss syndrome (CSS) manifesting with Mononeuritis multiplex due to the use of botanical solution—a case report. Indiana J Allergy Asthma Immunol. 2005;19(2):97–8.Google Scholar
  28. 28.
    Salvarani C, Cantini F, Macchioni P, Olivieri I, Niccoli L, Padula A, et al. Distal musculoskeletal manifestations in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum. 1998;41(7):1221–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Browett JP, Fiddian NJ. Delayed median nerve injury due to retained glass fragments. A report of two cases. J Bone Joint Surg Br. 1985;67(3):382–4.PubMedGoogle Scholar
  30. 30.
    Rosenbaum RB, Ochoa JL. Differential diagnosis of carpal tunnel syndrome. In: Carpal tunnel syndrome and other disorders of the median nerve. 2nd ed. Boston, MA: Butterworth Heinemann; 2002. p. 55–65.Google Scholar
  31. 31.
    Miller RF, William HL, Maldonado G, Mandel JS. An epidemiologic study of carpal tunnel syndrome and hand-arm vibration syndrome in relation to vibration exposure. J Hand Surg. 1994;19A(1):99–105.CrossRefGoogle Scholar
  32. 32.
    Chung MS, Gong HS, Baek GH. Prevalence of Raynaud's phenomenon in patients with idiopathic carpal tunnel syndrome. J Bone Joint Surg Br. 1999;81(6):1017–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Pelmear PL, Taylor W. Carpal tunnel syndrome and hand-arm vibration syndrome. A diagnostic enigma. Arch Neurol. 1994;51(4):416–20.CrossRefPubMedGoogle Scholar
  34. 34.
    Mancusi Ungaro A, Corres JJ, Di Spaltro F. Median carpal tunnel syndrome following a vascular shunt procedure in the forearm. Plast Reconstr Surg. 1976;57(1):96–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Seifert V, Zumkeller M, Stolke D, Dietz H. Carpal tunnel syndrome following arteriovenous forearm shunt in chronic dialysis patients—a review of 24 surgically treated patients. Z Orthop Ihre Grenzgeb. 1987;125(1):85–90.CrossRefPubMedGoogle Scholar
  36. 36.
    Thermann F, Ukkat J, Wollert U, Dralle H, Brauckhoff M. Dialysis shunt-associated steal syndrome (DASS) following brachial accesses: the value of fistula banding under blood flow control. Langenbeck's Arch Surg. 2007;392(6):731–7.CrossRefGoogle Scholar
  37. 37.
    Monsivais JJ, Shawna S. Rotary subluxation of the scaphoid resulting in persistent carpal tunnel syndrome. J Hand Surg. 1992;17A(4):642–4.CrossRefGoogle Scholar
  38. 38.
    Harris AR, McNamara TR, Brault JS, Rizzo M. An unusual presentation of acute calcific tendinitis in the hand. Hand (N Y). 2009;4(1):81–3.CrossRefGoogle Scholar
  39. 39.
    Lacerda EM, Nacul LC, Augusto LG, Olinto MT, Rocha DC, Wanderley DC. Prevalence and associations of symptoms of upper extremities, repetitive strain injuries (RSI) and 'RSI-like condition'. A cross sectional study of bank workers in Northeast Brazil. BMC Public Health. 2005;5:107.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Marinus J, Van Hilten JJ. Clinical expression profiles of complex regional pain syndrome, fibromyalgia and a-specific repetitive strain injury: more common denominators than pain? Disabil Rehabil. 2006;28(6):351–62.CrossRefPubMedGoogle Scholar
  41. 41.
    Laoopugsin N, Laoopugsin S. The study of work behaviours and risks for occupational overuse syndrome. Hand Surg. 2012;17(2):205–12.CrossRefPubMedGoogle Scholar
  42. 42.
    Gellman H, Gelberman RH, Tan AM, Botte MJ. Carpal tunnel syndrome. An evaluation of the provocative diagnostic tests. J Bone Joint Surg Am. 1986;68(5):735–7.CrossRefPubMedGoogle Scholar
  43. 43.
    DeHertogh D, Ritland D, Green R. Carpal tunnel syndrome due to gonococcal tenosynovitis. Orthopedics. 1988;11(1):199–200.PubMedGoogle Scholar
  44. 44.
    Hassanpour SE, Gousheh J. Mycobacterium tuberculosis-induced carpal tunnel syndrome: management and follow-up evaluation. J Hand Surg Am. 2006;31(4):575–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Moores CD, Grewal R. Radical surgical debridement alone for treatment of carpal tunnel syndrome caused by mycobacterium avium complex flexor tenosynovitis: case report. J Hand Surg Am. 2011;36(6):1047–51.CrossRefPubMedGoogle Scholar
  46. 46.
    Koss SD, Reardon TF, Groves RJ. Recurrent carpal tunnel syndrome due to tuberculoid leprosy in an Asian immigrant. J Hand Surg. 1993;18A(4):740–2.CrossRefGoogle Scholar
  47. 47.
    Bekler H, Alper G, Beyzadeoglu T. Presentation of Varicella-Zoster mimicking carpal tunnel syndrome. J Hand Surg Eur. 2007;32(2):233.CrossRefGoogle Scholar
  48. 48.
    Janssen T, Rayan GM. Gouty tenosynovitis and compression neuropathy of the median nerve. Clin Orthop Relat Res. 1987;216:203–6.Google Scholar
  49. 49.
    Yamazaki H, Uchiyama S, Kato H. Median nerve and ulnar nerve palsy caused by calcium pyrophosphate dihydrate crystal deposition disease: case report. J Hand Surg Am. 2008;33(8):1325–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Verfaille S, Luc DS, Leemans A, Van Damme B, Fabry G. Acute carpal tunnel syndrome caused by hydroxyapatite crystals—a case report. J Hand Surg. 1996;21A(3):360–2.CrossRefGoogle Scholar
  51. 51.
    Patil VS, Chopra A. Watch out for 'pins and needles' in hands–it may be a case of gout. Clin Rheumatol. 2007;26(12):2185–7.CrossRefPubMedGoogle Scholar
  52. 52.
    Sonoda H, Takasita M, Taira H, Higashi T, Tsumura H. Carpal tunnel syndrome and trigger wrist caused by a lipoma arising from flexor tenosynovium: a case report. J Hand Surg Am. 2002;27(6):1056–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Ho YY, Choueka J. Synovial chondromatosis of the upper extremity. J Hand Surg Am. 2013;38(4):804–10.CrossRefPubMedGoogle Scholar
  54. 54.
    Ward CM, Lueck NE, Steyers CM. Acute carpal tunnel syndrome caused by diffuse giant cell tumor of tendon sheath: a case report. Iowa Orthop J. 2007;27:99–103.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Dailiana ZH, Bougioukli S, Varitimidis S, Kontogeorgakos V, Togia E, Vlychou M, et al. Tumors and tumor-like lesions mimicking carpal tunnel syndrome. Arch Orthop Trauma Surg. 2014;134(1):139–44.CrossRefPubMedGoogle Scholar
  56. 56.
    Batra S, Batra M, Sakamuri R, Sinha AK, Kanvinde R. High-grade infiltrative myxofibrosarcoma in the forearm presenting as acute carpal tunnel syndrome. J Hand Surg Am. 2008;33(2):269–72.CrossRefPubMedGoogle Scholar
  57. 57.
    Weiss ACS, James B. Synovial sarcoma causing carpal tunnel syndrome. J Hand Surg. 1992;17A(6):1024–5.CrossRefGoogle Scholar
  58. 58.
    Patel MR, Desai SS, Gordon SL. Functional limb salvage with multimodality treatment in epithelioid sarcoma of the hand: a report of two cases. J Hand Surg Am. 1986;11(2):265–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Mackay IR, Barua JM. Perineural tumour spread: an unusual cause of carpal tunnel syndrome. J Hand Surg Br. 1990;15(1):104–5.CrossRefPubMedGoogle Scholar
  60. 60.
    De Vos J, Mulliez A, De Loore G. Melorheostosis of the humerus: a rare differential diagnosis of carpal tunnel syndrome. Chir Main. 2010;29(2):125–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Indiana Hand to Shoulder CenterIndianapolisUSA

Personalised recommendations