Editor's Choice| Volume 48, ISSUE 1, P19-27, January 2023

Has the Use of Electrodiagnostic Studies for Carpal Tunnel Syndrome Changed After the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline?

Published:November 29, 2022DOI:


      A 2016 American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline (CPG) de-emphasized the need for electrodiagnostic studies (EDS) for carpal tunnel syndrome (CTS). We tested the hypothesis that use of EDS decreased after the AAOS CPG.


      Using a national administrative claims database, we measured the proportion of patients with a diagnosis of CTS who underwent EDS within 1 year after diagnosis between 2011 and 2019. Using an interrupted time series design, we defined 2 time periods (pre-CPG and post-CPG) and compared EDS usage between the periods using segmented regression analysis. We conducted a subgroup analysis of preoperative EDS usage in patients who underwent carpal tunnel release.


      Of 2,081,829 patients with CTS, 315,449 (15.2%) underwent EDS within 1 year after diagnosis. The segmented regression analysis showed a decrease in the level of EDS usage after publication of the AAOS CPG (−11.50 per 1,000 patients [95% CI, −1.47 to −0.95 per 1,000 patients]); however, the rate of EDS usage increased in the post-CPG period (+1.75 per 1,000 patients per quarter [95% CI, 0.97–2.54 per 1,000 patients per quarter]). Of 473,753 eligible patients who underwent carpal tunnel release, 139,186 (29.4%) underwent EDS within 6 months before surgery. After publication of the AAOS CPG, preoperative EDS usage decreased by −23.57 per 1,000 patients (95% CI, −37.72 to −9.42 per 1,000 patients). However, these decreasing trends in EDS usage predated the 2016 AAOS CPG.


      The overall and preoperative EDS usage for CTS has been decreasing since at least 2014, predating the 2016 AAOS CPG, reflecting the rapid implementation of evidence into practice. However, EDS usage has increased in the post-CPG period, and a considerable proportion of patients who underwent carpal tunnel release still received EDS.

      Clinical relevance

      Given its high costs and disputed value, routine EDS usage should be considered for further deimplementation initiatives.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mudumbai S.C.
        • Pershing S.
        • Bowe T.
        • et al.
        Variability and costs of low-value preoperative testing for cataract surgery within the veterans health administration.
        JAMA Netw Open. 2021; 4e217470
        • Ganguli I.
        • Lupo C.
        • Mainor A.J.
        • et al.
        Prevalence and cost of care cascades after low-value preoperative electrocardiogram for cataract surgery in fee-for-service Medicare beneficiaries.
        JAMA Intern Med. 2019; 179: 1211-1219
        • Harris A.H.S.
        • Meerwijk E.L.
        • Kamal R.N.
        • et al.
        Variability and costs of low-value preoperative testing for carpal tunnel release surgery.
        Anesth Analg. 2019; 129: 804-811
        • Anderson T.S.
        • Lin G.A.
        Testing Cascades—a call to move from descriptive research to deimplementation science.
        JAMA Intern Med. 2020; 180: 984-985
        • Ubel P.A.
        • Asch D.A.
        Creating value in health by understanding and overcoming resistance to de-innovation.
        Health Aff (Millwood). 2015; 34: 239-244
        • Davidoff F.
        On the undiffusion of established practices.
        JAMA Intern Med. 2015; 175: 809-811
        • Fowler J.R.
        Nerve conduction studies for carpal tunnel syndrome: gold standard or unnecessary evil?.
        Orthopedics. 2017; 40: 141-142
        • Wang M.T.M.
        • Gamble G.
        • Grey A.
        Responses of specialist societies to evidence for reversal of practice.
        JAMA Intern Med. 2015; 175: 845-848
        • Graham B.
        • Peljovich A.E.
        • Afra R.
        • et al.
        The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on: management of carpal tunnel syndrome.
        J Bone Joint Surg Am. 2016; 98: 1750-1754
        • Tulipan J.E.
        • Ilyas A.M.
        Carpal tunnel syndrome surgery: what you should know.
        Plast Reconstr Surg Glob Open. 2020; 8e2692
        • Graham B.
        The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome.
        J Bone Joint Surg Am. 2008; 90: 2587-2593
        • Becker S.J.E.
        • Makanji H.S.
        • Ring D.
        Changes in treatment plan for carpal tunnel syndrome based on electrodiagnostic test results.
        J Hand Surg Eur Vol. 2014; 39: 187-193
        • Greenfield P.T.
        • Spencer C.C.
        • Dawes A.
        • Wagner E.R.
        • Gottschalk M.B.
        • Daly C.A.
        The preoperative cost of carpal tunnel syndrome.
        J Hand Surg Am. 2022; 47: 752-761.e1
        • Sears E.D.
        • Swiatek P.R.
        • Hou H.
        • Chung K.C.
        Utilization of preoperative electrodiagnostic studies for carpal tunnel syndrome: an analysis of national practice patterns.
        J Hand Surg Am. 2016; 41: 665-672.e1
        • Keith M.W.
        • Masear V.
        • Chung K.C.
        • et al.
        American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the treatment of carpal tunnel syndrome.
        J Bone Joint Surg Am. 2010; 92: 218-219
        • Billig J.I.
        • Sears E.D.
        Utilization of diagnostic testing for carpal tunnel syndrome: a survey of the American Society for Surgery of the Hand.
        J Hand Surg Am. 2022; 47: 11-18
        • Sears E.D.
        • Lu Y.T.
        • Wood S.M.
        • et al.
        Diagnostic testing requested before surgical evaluation for carpal tunnel syndrome.
        J Hand Surg Am. 2017; 42: 623-629.e1
        • Parker G.
        • Kastner M.
        • Born K.
        • Shahid N.
        • Berta W.
        Understanding low-value care and associated de-implementation processes: a qualitative study of Choosing Wisely interventions across Canadian hospitals.
        BMC Health Serv Res. 2022; 22: 1-92
        • Augustsson H.
        • Ingvarsson S.
        • Nilsen P.
        • et al.
        Determinants for the use and de-implementation of low-value care in health care: a scoping review.
        Implement Sci Commun. 2021; 2: 13
        • Prasad V.
        • Ioannidis J.P.
        Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices.
        Implement Sci. 2014; 9: 1
        • Grimshaw J.M.
        • Patey A.M.
        • Kirkham K.R.
        • et al.
        De-implementing wisely: developing the evidence base to reduce low-value care.
        BMJ Qual Saf. 2020; 29: 409-417
        • Voorn V.M.A.
        • Marang-van de Mheen P.J.
        • van der Hout A.
        • et al.
        The effectiveness of a de-implementation strategy to reduce low-value blood management techniques in primary hip and knee arthroplasty: a pragmatic cluster-randomized controlled trial.
        Implement Sci. 2017; 12: 72
        • Kamal R.N.
        • Behal R.
        Clinical care redesign to improve value in carpal tunnel syndrome: a before-and-after implementation study.
        J Hand Surg Am. 2019; 44: 1-8
        • Lo J.K.
        • Finestone H.M.
        • Gilbert K.
        • Woodbury M.G.
        Community-based referrals for electrodiagnostic studies in patients with possible carpal tunnel syndrome: what is the diagnosis?.
        Arch Phys Med Rehabil. 2002; 83: 598-603
        • Grandizio L.C.
        • Boualam B.
        • Shea P.
        • et al.
        The reliability of the cts-6 for examiners with varying levels of clinical experience.
        J Hand Surg Am. 2022; 47: 501-506
        • Cassel C.K.
        • Guest J.A.
        Choosing Wisely: helping physicians and patients make smart decisions about their care.
        JAMA. 2012; 307: 1801-1802
        • Levinson W.
        • Born K.
        • Wolfson D.
        Choosing wisely campaigns: a work in progress.
        JAMA. 2018; 319: 1975-1976
        • Henderson J.
        • Bouck Z.
        • Holleman R.
        • et al.
        Comparison of payment changes and choosing wisely recommendations for use of low-value laboratory tests in the United States and Canada.
        JAMA Intern Med. 2020; 180: 524-531
        • Barnett M.L.
        • Wilcock A.
        • McWilliams J.M.
        • et al.
        Two-year evaluation of mandatory bundled payments for joint replacement.
        N Engl J Med. 2019; 380: 252-262
        • Kamal R.N.
        • Ring D.
        • Akelman E.
        • et al.
        Quality measures in upper limb surgery.
        J Bone Joint Surg Am. 2016; 98: 505-510
        • Hand Surgery Quality Consortium
        Candidate quality measures for hand surgery.
        J Hand Surg Am. 2017; 42 (e3): 859-866
        • Harris A.H.S.
        • Meerwijk E.L.
        • Ding Q.
        • et al.
        Testing proposed quality measures for treatment of carpal tunnel syndrome: feasibility, magnitude of quality gaps, and reliability.
        BMC Health Serv Res. 2020; 20: 861
        • Sarrazin M.S.V.
        • Rosenthal G.E.
        Finding pure and simple truths with administrative data.
        JAMA. 2012; 307: 1433-1435
        • Harris A.H.S.
        • Ding Q.
        • Trickey A.W.
        • et al.
        Do proposed quality measures for carpal tunnel release reveal important quality gaps and are they reliable?.
        Clin Orthop Relat Res. 2022; 480: 1743-1750
        • Sears E.D.
        • Swiatek P.R.
        • Hou H.
        • Chung K.C.
        The influence of insurance type on management of carpal tunnel syndrome: an analysis of nationwide practice trends.
        Plast Reconstr Surg. 2016; 138: 1041-1049