To which specialist should I refer a patient with suspected carpal tunnel syndrome for evaluation and management?

Specialist Referral for Suspected Carpal Tunnel Syndrome

For suspected carpal tunnel syndrome, refer to a hand surgeon or orthopedic surgeon specializing in hand surgery, as surgical decompression provides the most effective treatment and these specialists manage both conservative and surgical care pathways. 1

Primary Referral Pathway

Hand Surgeon or Orthopedic Hand Specialist

• Hand surgeons are the primary specialists for CTS evaluation and management, as they can provide the full spectrum of care from conservative treatment through surgical decompression 1, 2
• These specialists perform both open and endoscopic carpal tunnel release procedures, which are equally effective for symptom relief, with endoscopic repair allowing return to work approximately one week earlier 1
• Surgical decompression is the most effective treatment for moderate to severe CTS and provides significantly better symptom relief than non-surgical options 1

Alternative Specialist Considerations

Neurologist or Physiatrist (PM&R)

• Consider referral to neurology or physical medicine and rehabilitation when electrodiagnostic confirmation is needed before proceeding with surgical consultation 3
• The American Academy of Neurology recommends obtaining electrodiagnostic testing when clinical examination is positive and surgical management is being considered, to determine severity and surgical prognosis 1
• These specialists can also evaluate for differential diagnoses including cervical radiculopathy, diabetic peripheral neuropathy, or polyneuropathy that may mimic or coexist with CTS 1

Rheumatologist

• Refer to rheumatology when bilateral CTS presents without clear etiology, as unexplained bilateral CTS (without rheumatoid arthritis or known trauma) may be associated with systemic conditions including cardiac amyloidosis 4
• Consider rheumatology consultation when signs suggest systemic disease requiring laboratory evaluation (ANA, ESR, CRP, ANCA) 1

When Imaging Specialists Are Involved

Radiologist (for Ultrasound or MRI)

• Radiologists perform and interpret imaging when clinical diagnosis is unclear, though routine imaging is not indicated for typical CTS presentations 4, 1
• Ultrasound is highly sensitive and specific for CTS diagnosis and can identify anatomic variants (bifid median nerve, persistent median artery) or space-occupying lesions 4
• The American College of Radiology recommends ultrasound as first-line imaging when imaging is needed, as it is more cost-effective and widely available than MRI 4

Clinical Decision Algorithm

For typical CTS presentation with positive clinical signs:

1. Refer directly to hand surgeon/orthopedic hand specialist for comprehensive management 1, 2
2. The surgeon will determine need for electrodiagnostic studies and conservative versus surgical management 3

For atypical presentations or diagnostic uncertainty:

1. Consider neurology/PM&R referral first for electrodiagnostic confirmation and exclusion of alternative diagnoses 1, 3
2. Then refer to hand surgeon if CTS is confirmed 1

For bilateral CTS without clear cause:

1. Consider rheumatology evaluation to exclude systemic disease before surgical referral 4, 1

Critical Pitfalls to Avoid

• Do not delay surgical referral for patients with moderate to severe symptoms or thenar weakness, as surgical outcomes are better with shorter symptom duration (<1 year) 1
• Avoid referring to general surgery unless the surgeon has specific hand surgery expertise, as CTS management requires specialized knowledge of hand anatomy and surgical techniques 2, 5
• Do not refer for imaging before specialist consultation unless there is suspicion of space-occupying lesion or systemic disease, as routine imaging is not indicated 4, 1
• Recognize that some healthcare systems allow specially trained general practitioners (GPwSI) to perform carpal tunnel decompression, though this is system-dependent 1