Phalen test (Fig. 12-1): The patient’s wrist is held in a flexed position for up to 1 minute or until onset of symptoms. A positive test consists of the onset of numbness or paraesthesia in the median nerve distribution. Care must be taken to avoid direct pressure or flexion at the elbow when performing this examination, in order to avoid inducing ulnar nerve symptoms.

Carpal tunnel compression test (Fig. 12-2): The examiner applies direct pressure to the carpal tunnel with his or her thumb for up to 1 minute or until onset of symptoms. A positive test consists of the onset of numbness or paresthesia in the median nerve distribution. As with Phalen test, care is taken to avoid direct pressure or flexion at the elbow when performing this examination.

Tinel sign (Fig. 12-3): The examiner taps directly over the carpal tunnel with his or her long and index fingers. A positive test consists of paresthesia or pain in a median nerve distribution.

Two-point discrimination (tests innervation density; abnormal test is a late finding)

Semmes-Weinstein monofilament test (tests pressure threshold; more sensitive)

Three-view radiographs of the wrist (posteroanterior, lateral, oblique) plus carpal tunnel view: obtained when there is antecedent wrist trauma that may narrow the carpal tunnel. Otherwise, routine wrist x-rays are unnecessary.

Nerve conduction studies (NCS) and electromyelogram (EMG)