BACKGROUND: Carpal tunnel syndrome (CTS) is by far the most common entrapment 
neuropathy (Adams et al. Am J Ind Med 25:527-536, 1994; Cheadle et al. Am J 
Public Health 84:190-196, 1994; Stevens et al. Neurology 38:134-138, 1988). A 
combination of described symptoms, clinical findings and electrophysiological 
testing is used to confirm the diagnosis. Several studies have suggested that in 
patients with a clinical diagnosis of CTS, the accuracy of nerve sonography is 
similar to that for electromyography (Chen et al. BMC Med Imaging 11:22, 2011; 
Guan et al. Neurol Res 33:970-953, 2011; Kele et al. Neurology 61:389-391, 2003; 
Tai et al. Ultrasound Med Biol 38:1121-1128, 2012). In special cases though, the 
nerve sonography can reveal the cause of the median entrapment neuropathy 
(Fumière et al. JBR-BTR 85:1-3, 2002; Kele et al. J Neurosurg 97:471-473, 2002; 
Kele et al. Neurology 61:389-391, 2003; Zamora et al. J Clin Ultrasound 
39:44-47, 2011).
METHODS: A 43-year-old farmer was admitted to our department with 1 year of 
intermittent pain in the left hand and numbness of the thumb, index and middle 
finger. The pain and the numbness could be reproduced by extension of the wrist 
and fingers. The electrophysiological testing revealed signs of an entrapment 
median neuropathy in carpal tunnel.
RESULTS: The high-resolution sonography (18 MHz) revealed signs of entrapment 
neuropathy with increased cross-sectional area, disturbed echostructure of the 
nerve and pathological wrist-to-forearm ratio, confirming the results from a 
similar study (Kele et al. Neurology 61:389-391, 2003). In addition, an 
elongated muscle belly of the flexor digitorum superficialis in the carpal 
tunnel could be identified. During the extension of the wrist and fingers, a 
greater protrusion of the muscle belly could be demonstrated causing compression 
of the median nerve.
CONCLUSIONS: We present a video case report of the sonographic findings of a 
patient diagnosed with carpal tunnel syndrome due to an elongated muscle belly 
of the flexor digitorum superficialis in the carpal tunnel. Our case highlights 
the importance of nerve sonography in the differential diagnosis of the cause of 
a carpal tunnel syndrome. With the aid of ultrasonography, it is possible to 
obtain very important information concerning different aspects of this case. 
First, in showing the presence of the elongated muscle belly of the flexor 
digitorum superficialis, the cause of the symptoms could be explained. Second, 
it was possible through the ultrasound study to explain the atypical clinical 
appearance in this case, demonstrating the compression neuropathy only after 
extension of the wrist and fingers. There have been no previous reports in which 
authors described an elongated muscle belly as cause of a CTS. Third, and 
perhaps most important, ultrasonography had a direct influence on our selection 
of therapeutical strategy and approach. As a result, we recommended in this 
patient a surgical therapy to completely solve the problem, but the patient 
declined this option and preferred a conservative therapy with a hand orthosis 
to prevent wrist extension. In conclusion we recommend ultrasonography as a very 
useful method in the diagnostic evaluation of carpal tunnel syndrome. We have 
clearly demonstrated that ultrasonography can be used to discover the cause of 
median nerve compression, especially in cases with an atypical clinical 
presentation.