












































Journal of Enam Medical College
Vol 11 No 2 May 2021

78

Original Article

Association of Carpal Tunnel Syndrome with Diabetic Polyneuropathy
Sayeda Shabnam Malik1, Mohammad Rezaul Karim Khan2, MA Hannan3, SK Mahbub Alam 4

Received: 17 February 2021        Accepted: 30 March 2021
doi: https://doi.org/10.3329/jemc.v11i2.65189

Abstract

Background: Common thought is that diabetic neuropathy is a predisposing factor to entrapment 
syndromes. Carpal tunnel syndrome (CTS) is the most frequent entrapment neuropathy. Objectives: 
To find out association of carpal tunnel syndrome with diabetic polyneuropathy. Materials and 
Methods: During the period of March 2013 to September 2015, this cross-sectional study was 
carried out in the Department of Neurology, Bangabandhu Sheikh Mujib Medical University, 
Dhaka. A total of 100 adult patients having symptoms and signs of polyneuropathy were recruited 
as study population. Of them 50 patients grouped into diabetic polyneuropathy (DPN) and the 
rest 50 patients in non-diabetic neuropathy due to other causes. Results: Out of all patients, the 
mean age was found 49.60 (13.53) years with 42% female in diabetic neuropathy patients and 
mean age was 44.64 (15.72) years with 46% female in non-diabetic neuropathy patients. The 
duration of diabetes was found 8.44 (7.79) years.  According to development of Carpal tunnel 
syndrome (CTS), in diabetic neuropathy patients, about 58% patients developed CTS while in 
non-diabetic neuropathy patients, that of 14% (p=0.0001). We found diabetic neuropathy patients 
have 8.48 times higher possibility of development of CTS than non-diabetic neuropathy patients. 
On adjusted model, age as confounding variable, diabetic neuropathy and female sex were 
found significantly associated with development of CTS with adjusted odd ratio 10.92 and 3.78 
respectfully (p<0.0001). Conclusion: In conclusion, we revealed the higher frequency of CTS 
in diabetics with DPN. As well we also found DPN and female sex were strongly associated 
with development of CTS. As DPN is a risk factor for CTS, priority should also be given to the 
treatment of DPN.

Key words: Diabetic neuropathy; Carpal tunnel syndrome

J Enam Med Col 2021; 11(2): 78−85

1. Assistant Professor, Department of Neurology, Enam Medical College, Savar, Dhaka
2. Professor, Department of Neurology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
3. Department of Neurology Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
4. Associate Professor, Department of Neurology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka
Correspondence Sayeda Shabnam Malik, Email: sayedashabnam.malik@gmail.com

Introduction

Diabetes mellitus is the most common chronic 
non communicable disease now-a-days. Peripheral 
neuropathy has been considered as the most 
troublesome complication of DM. Diabetes affects 
382 million people worldwide and its prevalence is 
expected to increase to 592 million by the year 2035.1 

Diabetes mellitus is a clinical syndrome characterized 
by hyperglycemia caused by absolute or relative 
deficiency of insulin.2  Diabetic neuropathy, a well-
known long term complication of diabetes, can 
affect almost half of the diabetic population3 and is 
associated with higher mortality and morbidity.4 The 



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overall prevalence of neuropathy is 66% for type 1 and 
59% for type 2 diabetes.5 Prevalence of neuropathic 
symptoms increases at the time of diagnosis, the 
incidence increases to about 50% after 20−25 years 
of diabetic life.6

Painful diabetic neuropathy (PDN) is a common 
type of diabetic neuropathy and the most common 
cause of neuropathic pain.7 Neuropathic pain can be 
a prominent presenting symptom in a great number 
of peripheral neuropathy.8 DPN is insidious in onset 
and patient complains of tingling, pricking, burning 
sensation and numbness of mild to moderate severity.9 
PDN is caused by the involvement of small nerve 
fibers, which may affect without objective clinical 
findings. The diagnosis of DPNP does not require 
evidence of a large-fiber abnormality.10 Other common 
causes of neuropathy, e.g., Guillaine Barre syndrome, 
CIDP, toxins and metabolic and nutritional diseases.5

Carpal tunnel syndrome (CTS) is a compressive 
neuropathy which is defined as a mononeuropathy 
or radiculopathy caused by mechanical distortion 
produced by a compressive force11 and a symptomatic 
compression neuropathy of the median nerve at the 
level of the wrist.12

CTS is the most well-known and frequent form of 
median nerve entrapment, and accounts for 90% of 
all entrapment neuropathies13 and the second most 
important cause of diabetic neuropathy after distal 
symmetric sensory motor polyneuropathy.9 CTS 
is  caused by entrapment of the median nerve at the 
level of the carpal tunnel, and delimitated by the 
carpal bones and by the transverse carpal ligament.12 
Physiological evidence indicates increased pressure 
within the carpal tunnel, and therefore decreased 
function of the median nerve at that level.12 The 
prevalence of CTS is 15−25% in patients with DPN.14

The most typical symptoms are pain and paresthesia 
in the thumb, index, middle finger and the radial 
side of ring finger, occurring especially at night.14 
The main conditions associated with carpal tunnel 
syndrome are diabetes, hypothyroidism, rheumatoid 
arthritis, osteoarthritis, obesity and pregnancy.15 
Carpal tunnel syndrome and diabetic polyneuropathy 
are common conditions in patients with diabetes and 

therefore frequently occur concomitantly. Carpal 
tunnel syndrome has been reported in up to 20% of 
people with diabetes. The diabetic link is possibly due 
to the fact that when blood glucose levels are high the 
proteins in the tendons of the carpal tunnel become 
glycosylated, inflaming them and forming a sort of 
biological superglue that makes the tendon less able 
to slide freely.15

The two provocative tests most commonly used in 
the clinical settings are Phalen’s and Tinel’s tests. The 
sensitivity of Phalen’s test is 67−83% and specificity 
is 40−98%. Tinnel’s test has sensitivity of 48−73% 
and specificity is 30−94%.16

Nerve conduction study is considered to be gold 
standard in the diagnosis of CTS. This is the most 
sensitive and accurate technique, with a sensitivity 
of 80−92% and specificity of 80−99%.17 NCS criteria 
is used to diagnose CTS in diabetic subjects without 
distal peripheral neuropathy in the same manner as 
in the non-diabetic population. The standard method 
of diagnosis is comparing the latency and amplitude 
of a median nerve segment across the carpal tunnel 
to another nerve segment that does not go through 
the carpal tunnel, such as the radial or ulnar nerve.17 
Prolonged motor and sensory latencies of the median 
nerve and reduced sensory and motor conduction 
velocities are accepted as diagnostic criteria for 
carpal tunnel syndrome.14 When CTS occurs due to 
entrapment then only distal latency is increased in 
both motor and sensory parts. If two stimuli are given 
in both proximal and distal to the wrist, entrapment 
can be identified. In diabetic mononeuropathy usually 
homogenous involvement of nerve (axonal and 
demyelinating) may occur both proximal and distal 
to wrist joint. It is important to determine whether 
median neuropathy is due to entrapment or it results 
from diabetic polyneuropathy. For future treatment 
planning it is important to determine whether CTS 
is an entrapment of the median nerve under the 
transverse carpal ligament or it results from diabetic 
polyneuropathy.

Materials and Methods

This cross-sectional analytical study was carried out in 
the inpatient and outpatient departments of neurology 



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including neuropathy clinic of Bangabandhu Sheikh 
Mujib Medical University (BSMMU), Dhaka from 
March 2013 to September 2015. Study population 
was adult patients having symptoms and signs of 
polyneuropathy. Then these patients were grouped 
into diabetic polyneuropathy and non-diabetic 
polyneuropathy due to other causes. Patients having 
symptoms of CTS were included in both groups by 
random sampling method 107 adult patients who 
were having symptoms and signs of polyneuropathy 
undergo meticulous history and physical examination. 
Then these patients were divided into diabetic 
polyneuropathy and non-diabetic polyneuropathy 
(due to other cause). 50 patients were in diabetic 
polyneuropathy group and 50 were in nondiabetic 
polyneuropathy group (due to other cause). Rest 7 
patients did not give consent to take part in the study 
and had other diseases like hypothyroidism.

•	 The diagnosis of CTS was done by the presence of 
nocturnal and activity related pain or dyseshesia 
limited to hand. Patients having symptoms of CTS 
were included in both groups. 

•	 Height and weight were measured and BMI was 
calculated as weight (kg)/height (m)2.

•	 2015 American Diabetes Association (ADA) 
diabetes guidelines criteria used for diabetes 
diagnosis, the values were HBA1c ≥6.5%, FPG 
≥126 mg/dL (7.0 mmol/L), two-hr PG ≥200 mg/dL 
(11.1 mmol/L) during OGTT (75g).

•	 The diabetic and non-diabetic patients with a 
history and signs of polyneuropathy were evaluated 
by some routine investigations (CBC, ESR, FBS, 
PPBS, HBA1C, serum creatinine, RA Test, TSH) 
for exclusion of other diseases.

•	 For evaluation for presence of CTS distal latency, 
conduction velocity of sensory and motor 
component of medial nerve was measured.

•	 If the median motor latency exceed 4.4 ms or the 
difference between distal motor latency of median 
and ulnar nerve exceed 1.1 ms or the difference 
between distal sensory latency of median and 

ulnar nerve exceed 0.2ms used as a parameter for 
diagnosis of CTS.

Data were collected by face to face interview or history 
taking of the patient. Clinical examination, laboratory 
investigations were collected by using structured data 
information sheet.

Data were analyzed by computer with the help 
of SPSS version 21.0 Software package. All data 
were recorded systematically in a preformed data 
collection sheet. Quantative variables are expressed 
as mean ± SD. Analysis of the variables was done 
by using Chi square test and independent t-test. For 
all statistical tests, we considered p value <0.05 as 
statistically significant. Binary logistic regression was 
seen to reveal the association of CTS with diabetic 
polyneuropathy and nondiabetic polyneuropathy.

Results

This cross-sectional analytical study was carried out 
in the Department of Neurology, Bangabandhu Sheikh 
Mujib Medical University, Dhaka from March 2013 
to September 2015. By random sampling method 107 
adult patients who were having symptoms and signs 
of polyneuropathy were enrolled in this study. Seven 
patients who did not give consent to take part in the 
study and had other diseases like hypothyroidism 
were excluded. Finally, a total of 100 adult patients 
having symptoms and signs of polyneuropathy were 
recruited as study population. Out of these patients, 
58% were male and 42% female. Fifty patients had 
diabetic polyneuropathy and 50 patients non-diabetic 
neuropathy due to other causes. All diabetics had type 
2 DM and mean (SD) duration was 8.44 years. Table I 
shows the distribution of the patients by gender.

Table II shows comparison of patients according 
to nerve conduction velocity. In context of median 
nerve and ulnar nerve, all the parameters showed 
statistically significant difference between diabetic 
and non-diabetic neuropathy patients except the distal 
latency of ulnar nerve which was found statistically 
nonsignificant. Other nerve shows non-significant 
difference.



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Table I: Distribution of the patients by gender (N=100)

Gender
       Type of Patients

Chi-square value  
(df)

p value*Diabetic Neuropathy 
(n=50)

Non-Diabetic 
Neuropathy (n=50)

Male 29 (58.0%) 27 (54.0%)
0.041 (1) 0.840ns

Female 21 (42.0%) 23 (46.0%)

ns=non significant; *Chi square test was done to measure level of significance 
#Figure within parenthesis denoted corresponding column percentage

Table II: Comparison of patients according to nerve conduction velocity (N=100)

Diabetic neuropathy 
(n=50) Mean (SD)

Non-diabetic neuropathy 
(n=50) Mean (SD)

p values*

Median nerve

Distal motor latency (ms) 5.02 (1.50) 3.84 (1.21) <0.0001s

Motor amplitude (mv) 8.29 (4.12) 5.13 (4.61) <0.0001s

Sensory  amplitude (µv) 11.40 (8.86) 29.22 (25.69) <0.0001s

NCV (m/s) 32.96 (13.41) 40.22 (10.17) 0.003s

Ulnar nerve

Distal latency (ms) 2.84 (0.64) 3.21 (1.20) 0.067ns

Motor amplitude (mv) 9.80 (6.10) 7.61 (5.24) 0.060s

Sensory amplitude (µv) 12.85 (9.30) 30.63 (25.48) <0.0001s

NCV (m/s) 36.72 (12.82) 31.04 (12.27) 0.027s

NCV (m/s) tibial nerve 31.79 (9.36) 32.88 (8.88) >0.05ns

NCV (m/s) peroneal nerve 33.33 (5.14) 33.75 (7.40) >0.05ns

NCV (m/s) sural nerve 39.09 (7.20) 42.03 (9.03) >0.05ns

ns=non significant; s=significant; *Independent sample t test was done to measure the level of significance

Table III shows distribution of patients according to development of carpal tunnel syndrome (CTS). In diabetic 
neuropathy patients, about 58% patients developed CTS while in non-diabetic neuropathy patients CTS was 
14%. There was statistically highly significant difference between these groups in terms of CTS development.

Table III: Distribution of patients according to development of carpal tunnel syndrome (CTS) (N=100)

CTS
Diabeteic neuropathy 

(n=50)
Non-diabetic neuropa-

thy (n=50)
p value*

Present 29 (58.0) 7 (14.0)
<0.0001s

Absent 21 (42.0) 43 (86.0)

*Chi square test was done to measure the level of significance. Figure within parenthesis indicates percentage.  
s= significant



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Binary logistic regression was seen in enter method to 
reveal the association of carpal tunnel syndrome with 
diabetic neuropathy (Table IV). Here we found diabetic 
neuropathy patients have 8.48 times higher possibility 
of development of CTS than non-diabetic neuropathy 
patients which is statistically highly significant (p 
<0.0001). Table V shows multiple logistic regression 
model done in Forward conditional method. Here age 
was act as confounding variable. Diabetic neuropathy 
and female sex were found significantly associated 
with development of CTS with adjusted Odd Ratio 
10.92 and 3.78 respectfully. 

Table IV: Binary logistic regression model to see the association of carpal tunnel syndrome with diabetic 
neuropathy patients (Enter method)

unadjOR p value
95% CI

Lower value Upper value
Non-diabetic neuropathy (Ref) 1
Diabetic neuropathy 8.48 <0.0001 3.195 22.523

unadjOR= unadjusted odd ratio

Table V:  Multiple logistic regression model to see the association of Carpal tunnel syndrome with age, sex and 
diabetic neuropathy (Forward conditional method)

adjOR p value
95% CI

Lower value Upper value
Group
Non-diabetic neuropathy (Ref) 1
Diabetic Neuropathy 10.92 < 0.0001 3.76 31.74
Sex
Male (Ref) 1
Female 3.78 0.010 1.370 10.417

adjOR= adjusted odd ratio

Discussion

Carpal tunnel syndrome (CTS) which is the most well-
known and frequent form of median nerve entrapment 
accounting for 90% of all entrapment neuropathies, 
remains a puzzling and disabling condition.13,18 One 
in every five subjects who complain of symptoms 
such as pain, numbness and a tingling sensation in 
the hands is expected to have CTS based on clinical 
examination and electrophysiological testing.18 An 
epidemiological study in UK reported that median 
number of days away from work due to CTS is 

amongst the highest in the UK at 27 days.19 Therefore, 
the underlying cause of CTS is necessary to detect for 
its better management.

The prevalence of diabetic polyneuropathy (DPN) 
has been reported as 5 to 60%.20 It occurs thrice as 
frequently in a diabetic population compared with 
a normal healthy population.21,22 The increased 
prevalence in diabetes may be related to repeated 
undetected trauma, metabolic changes, accumulation 
of fluid or edema within the confined space of the 
carpal tunnel, and diabetic cheiroarthropathy.23 CTS 
is found in up to one-third of patients with diabetes, 
when demonstrated electrophysiologically, but may 
only be symptomatic in 5.8%.24 

This cross-sectional study was carried out in the 
department of neurology, Bangabandhu Sheikh 
Mujib Medical University, Dhaka from March 2013 
to September 2015. A total of 100 adult patients 
having symptoms and signs of polyneuropathy were 
recruited as study population. Of them 50 patients 
were diabetic polyneuropathy and 50 patients non-
diabetic neuropathy due to other causes.

There are substantial numbers of publications 



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83

demonstrating the prevalence and association of CTS 
with diabetic neuropathy patients. We compared our 
study findings with result of some other published 
articles elsewhere in the world to verify our results.25−27 

Analysis of gender distribution showed that out of all 
patients, 58% were male and 42% female in diabetic 
neuropathy diagnosed patients and in non-diabetic 
neuropathy patients, 54% were male and 46% female. 
But in unadjusted odd ratio model, we found female 
were 2.5 times more prone to develop CTS than male 
and that was statistically significant (p<0.05).  Our 
study findings are consistent to some other studies 
done in the world. Aybin et al28 studied on 100 patients, 
16 patients developed CTS and among them 11 were 
female and 5 were male. 

According to development of Carpal Tunnel Syndrome 
(CTS), in diabetic neuropathy patients, about 58% 
patients developed CTS while in non-diabetic 
neuropathy patients it was 14% which is statistically 
highly significant (p<0.0001). CTS was present in 16% 
of all diabetic patients and of these 93% were found 
to have DPN (p<0.001). A review was done Comi et 
al29 on carpal tunnel syndrome (CTS) in patients with 
diabetes mellitus. The prevalence of CTS is higher 
in diabetic patients with peripheral polyneuropathy 
compared to patients with diabetes, who do not have 
diabetes-related late complications (30% vs. 14%). 
One of the study observed the prevalence of carpal 
tunnel syndrome (CTS) in diabetic polyneuropathy 
(DPN) patients in a cross-sectional design in a total 
of 478 subjects.25 On the basis of nerve conduction 
study, the prevalence of clinical CTS was 2% in the 
reference population, 14% in diabetic subjects without 
DPN, and 30% in those with DPN. Moreover reported 
the prevalence of symptomatic CTS in those with 
diabetes as 11 and 6% in type 1 and type 2 diabetic 
patients, respectively.25 

On the measuring of distal motor latency of median 
nerve, the mean (SD) of non-diabetic neuropathic 
patients with CTS was found 6.29 (1.54) m/sec which 
was statistically significant than NDPN without 
CTS, 3.45 (0.47). Meanwhile, statistical significant 
difference was also found in distal motor latency 
of median nerve between diabetic neuropathy with 

CTS and without CTS [6.03 (1.21) vs. 3.64 (0.11), 
p<0.0001].

Binary logistic regression was seen in enter method to 
reveal the association of Carpal tunnel syndrome with 
diabetic neuropathy patients. Here we found diabetic 
neuropathy patients have 8.48 times higher possibility 
of development of CTS than non-diabetic neuropathy 
patients which was statistically highly significant 
(p<0.0001). We also found age is not associated with 
development of CTS. But in case of female gender, we 
found female were 2.5 times more prone to develop 
CTS than male and that was statistically significant 
(p<0.05). Diabetic neuropathy and female sex were 
found significantly associated with development 
of CTS with adjusted Odd Ratio 10.92 and 3.78 
respectfully (p<0.0001). A similar study done by 
Galer et al30 evaluated the prevalence of Carpal tunnel 
syndrome (CTS) in diabetics and associated risk 
factors. The strongest risk factors for CTS, in order of 
importance, were: female sex, older age and presence 
of neuropathy which is in accordance of our study 
findings, found that there were more CTS patients than 
control subjects who had diabetes (p=0.03; odds ratio, 
3.02) which is in agreement of our study findings.27  In 
other studies, DPN is found to be a major risk factor 
for developing CTS.21,22,31,32

In our study, we recorded 58% patients developed 
carpal tunnel syndrome (CTS) in diabetic neuropathy 
patients while in non-diabetic neuropathy patients, 
that of 14% which was statistically highly significant. 
We also found diabetic neuropathy patients have 8.48 
times higher possibility of development of CTS than 
non-diabetic neuropathy patients (p<0.0001). Diabetic 
neuropathy and female sex were found significantly 
associated with development of CTS with adjusted odd 
ratio 10.92 and 3.78 respectfully (p<0.05). Therefore, 
on our study findings CTS development is common in 
diabetic neuropathy patients in our country context.  
Examination of the hands and shoulders should be 
included in the evaluation of patients with diabetes. 
So, proper monitoring and advice may reduce the 
frequency of development of CTS in DPN patients. 

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