What is the appropriate treatment plan for a patient with a diagnosis of carpal tunnel syndrome and a positive Phalen's test?

Management of Carpal Tunnel Syndrome with Positive Phalen's Test

For a patient with carpal tunnel syndrome and positive Phalen's test, night splinting with a rigid wrist brace in neutral position combined with physical therapy is the most appropriate first-line treatment approach. 1

Initial Conservative Management

Splinting

• Use a rigid immobilization brace positioning the wrist in neutral to slight extension
• Instruct patient to wear primarily at night and during aggravating activities 1
• Night-only splinting is as effective as continuous wear 2
• A neutral wrist position splint may be more effective than an extension splint 2

Physical Therapy

• Include exercises to improve median nerve mobility and reduce pressure in the carpal tunnel
• Therapeutic ultrasound may be beneficial as an adjunctive treatment 3
• Yoga has shown some benefit in symptom management 3

Additional Conservative Measures

• Rest and activity modification to prevent ongoing damage 1
• Ice therapy for 10-minute periods through a wet towel for symptom relief 1

Medication Considerations

• NSAIDs have not shown significant benefit specifically for carpal tunnel syndrome 1, 2
• Local corticosteroid injection can be considered if symptoms persist despite splinting
  • Can resolve symptoms in approximately 61% of cases after a single injection 1
  • Provides greater improvement of symptoms compared to splinting at 6 weeks 2
  • Can delay the need for surgery for up to one year 3

Follow-up and Monitoring

• Schedule follow-up in 8 weeks to assess response to treatment (as planned)
• Monitor for:
  • Changes in symptom severity
  • Development of thenar muscle weakness or atrophy (late finding) 2
  • Range of motion limitations

When to Consider Surgical Referral

• If symptoms do not improve after 4-6 months of conservative therapy 3
• If there is evidence of:
  • Severe carpal tunnel syndrome
  • Objective weakness or sensory deficits
  • Thenar muscle atrophy 2, 4

Important Considerations

• Conservative management should be the first-line approach for mild to moderate cases 1
• Surgical decompression is more effective than non-surgical treatments for long-term symptom relief, but should be reserved for severe cases or after failed conservative management 1
• Ultrasound can be useful for confirming the diagnosis in atypical cases, with high specificity (80-94%) 1
• Electrodiagnostic studies may be necessary if symptoms persist despite treatment to determine severity and surgical prognosis 3

This 33-year-old patient with a positive Phalen's test is an appropriate candidate for conservative management with night splinting and physical therapy, with follow-up in 8 weeks to assess treatment response.