The November/December 1996 issue of The Guides Newsletter included an article regarding the challenges faced by those who evaluate carpal tunnel syndrome (CTS) impairment. A recent case highlights some of these challenges: Ms Kirby presented for an independent medical evaluation to address two issues, the work-relatedness of her left CTS and the percentage of anatomic impairment due to her surgically treated left CTS. Relevant clinical records noted nonspecific complaints of left-hand pain and paresthesia but no abnormalities of the peripheral neuromusculoskeletal system. Motor nerve conduction velocities were normal and showed relative prolonged latencies in the left vs right median nerve at the wrist. Left carpal tunnel release surgery was recommended and performed, but Ms Kirby reported no improvement in her symptoms and had a self-perception of substantial occupational incapacity. The evaluating physician determined that Ms Kirby had neither the specific hand/wrist symptoms nor the median nerve slowing necessary to establish a diagnosis of CTS and, therefore, could not have work-related CTS according to the criteria in the AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition. The parties involved could not reach a settlement, and the case went to trial; the trial court relied on the testimony of the treating surgeon in finding that Ms Kirby's CTS was caused by her work and awarded her a substantial percentage of occupational disability.