Variation in Interpretation of Provocative Tests for Carpal Tunnel Syndrome

Purpose: We studied variation in interpretation of specific symptoms during clinical tests for carpal tunnel syndrome to estimate the degree to which surgeons consider pain without paresthesia characteristic of median neuropathy. Methods: We invited all upper-extremity surgeon members of the Science of Variation Group to complete a scenario-based experiment. Surgeons read 5–10 clinical vignettes of patients with variation in patient demographics and random variation in symptoms and signs as follows: primary symptoms (nighttime numbness and tingling, constant numbness and loss of sensibility, pain with activity), symptoms elicited by a provocative test (Phalen, Durkan, or Tinel) (tingling, pain), and location of symptoms elicited by the provocative test (index and middle fingers, thumb and index fingers, little and ring fingers, entire hand). Results: Patient factors associated with surgeon interpretation of provocative tests as negative included pain rather than paresthesia during the Phalen, Durkan, or Tinel test and location of symptoms in the entire hand rather than the median nerve distribution. Conclusions: Specialists do not consider pain without paresthesia or a noncharacteristic symptom distribution as characteristic of carpal tunnel syndrome. Clinical relevance: Awareness that elicitation of pain with Phalen, Durkan, and Tinel tests is regarded by specialists as relatively uncharacteristic of median neuropathy can help limit the potential for both overdiagnosis and overtreatment of median neuropathy as well as underdiagnosis and undertreatment of mental and social health contributions to illness (notable correlates of the intensity and distribution of pain).