What are the treatment options for carpal tunnel syndrome?

Treatment Options for Carpal Tunnel Syndrome

For carpal tunnel syndrome, initial treatment should consist of conservative measures like splinting and corticosteroid injections, progressing to surgical decompression for severe cases or those failing conservative management after 4-6 months. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis through:

• Clinical evaluation with provocative tests (Phalen maneuver, median nerve compression test)
• Electrodiagnostic studies for atypical presentations or to determine severity before surgery
• Ultrasound in selected cases to visualize median nerve compression

Treatment Algorithm

First-Line Conservative Management (Mild to Moderate CTS)

1. Wrist Splinting

   • Neutral wrist position splinting (more effective than extension splint)
   • Night-only splinting is as effective as continuous wear 2
   • Avoid continuous daytime splinting unless specifically indicated, as this can lead to muscle deconditioning 1

2. Corticosteroid Injections

   • Local corticosteroid injections provide relief for more than one month
   • Can delay the need for surgery at one year 3
   • More effective than splinting at 6 weeks, with similar outcomes at 6 months 2
   • Should be performed with ultrasound guidance when possible 1

3. Physical Therapy Options

   • Therapeutic ultrasound
   • Yoga
   • Eccentric strengthening exercises
   • Tendon gliding exercises
   • Ergonomic education 1

4. Activity Modification

   • Relative rest
   • Avoiding repetitive thumb and wrist movements
   • Cryotherapy (ice application for 10-minute periods through a wet towel) 1

Ineffective Treatments (Avoid These)

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Diuretics
• Vitamin B6 (pyridoxine)
• Over-the-counter analgesics 3, 2

Second-Line Treatment (Surgical Intervention)

Surgical decompression is indicated for:

• Severe CTS (including objective weakness or sensory deficits)
• Symptoms that persist beyond 4-6 months of conservative therapy
• Development of thenar muscle atrophy
• Continued severe symptoms or functional limitations 1, 2

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 than open repair 3

Special Considerations

• Pregnancy: CTS should be treated conservatively in pregnant women as spontaneous postpartum resolution is common 4
• Occupational CTS: Important to exclude intrinsic factors such as obesity before attributing CTS to occupation 5
• Regular monitoring: Essential to track symptoms and range of motion to prevent long-term complications 1

Treatment Effectiveness

Surgical treatment relieves symptoms significantly better than non-surgical treatment for severe CTS or cases that fail conservative management 1. However, conservative management should always be the first approach for mild to moderate cases before considering surgical intervention.