Treatment of Carpal Tunnel Syndrome
The recommended treatment for carpal tunnel syndrome should follow a stepwise approach, beginning with conservative measures for mild to moderate cases, progressing to corticosteroid injections if symptoms persist, and ultimately surgical decompression for severe cases or those that fail conservative management. 1
Initial Diagnosis
- Diagnosis is primarily clinical, based on:
- Pain and paresthesias in the median nerve distribution (palmar aspect of thumb, index, middle fingers, and radial half of ring finger)
- Positive physical examination findings: flick sign, Phalen maneuver, median nerve compression test
- Electrodiagnostic studies and ultrasonography are not needed for typical presentations but useful for atypical cases 2, 1
Conservative Management (First-Line for Mild to Moderate CTS)
Wrist Splinting
- Most effective initial conservative treatment 3
- Immobilize wrist in neutral position or slight extension (0-15°)
- Wear at night initially; during day for symptom exacerbations
- Continue for at least 3-9 weeks 4, 3
- Advantages: available, low cost, good patient tolerance, minimal complications 3
Corticosteroid Injections
- Effective for symptom relief beyond one month
- Can delay need for surgery at one year
- Consider after failed splinting or for moderate symptoms 1, 4
- May be combined with splinting for better results 4
Additional Conservative Options
- Physical therapy including eccentric strengthening exercises and tendon gliding exercises
- Therapeutic ultrasound
- Yoga
- Activity modification (avoiding repetitive wrist movements)
- Ergonomic education 5, 1
Ineffective Treatments (Not Recommended)
When to Consider Surgery
Indications for Surgical Referral
- Severe carpal tunnel syndrome
- Symptoms persisting after 4-6 months of conservative therapy
- Development of thenar muscle atrophy
- Severe functional limitations 5, 1
Surgical Options
- Both endoscopic and open carpal tunnel release techniques are equally effective
- Endoscopic repair allows patients to return to work approximately one week earlier
- Surgical decompression provides better symptom relief than non-surgical treatments for severe CTS 5, 1
Prognostic Factors
Favorable Response to Conservative Treatment
- Symptom duration less than 3 months
- Absence of sensory impairment at presentation
- Approximately 10% of patients may have long-term relief with conservative measures alone 4
Monitoring
- Regular assessment of symptoms and range of motion
- Early detection and intervention are crucial to prevent complications
- Consider electrodiagnostic studies before surgery to determine severity and prognosis 5, 1
Special Considerations
- Pregnant women should be treated conservatively as spontaneous postpartum resolution is common 6
- For CTS associated with systemic conditions (e.g., rheumatoid arthritis), treatment should address the underlying condition 5
By following this treatment algorithm and selecting the appropriate intervention based on symptom severity and duration, most patients with carpal tunnel syndrome can achieve significant improvement in symptoms and function.