The physician treating carpal tunnel syndrome needs to be aware of the possible concomitant occurrence of thoracic outlet syndrome, the so-called double crush syndrome. Palpation is used to differentiate carpal tunnel syndrome from thoracic outlet syndrome. Such palpatory examination assists the physician in planning the initial treatment, including osteopathic manipulation and self-stretching maneuvers, targeted specifically at the most clinically significant pathologic region. Supplemental physical medicine modalities such as ultrasound may enhance the treatment response. Some illustrative cases are reported.