What is the initial management for carpal tunnel syndrome?

Initial Management of Carpal Tunnel Syndrome

For patients with mild to moderate carpal tunnel syndrome, initial management should consist of wrist splinting in a neutral position, which is as effective as continuous wear when used at night only. 1, 2

Diagnosis and Assessment

• Carpal tunnel syndrome is diagnosed primarily through clinical evaluation, with characteristic symptoms including pain and paresthesias in the distribution of the median nerve (palmar aspect of thumb, index and middle fingers, and radial half of ring finger) 1, 2
• Provocative maneuvers such as the Phalen test (wrist flexion) and Tinel sign (tapping over the median nerve) have varying sensitivity and specificity but can support the diagnosis 1
• Thenar atrophy is a late finding and highly specific for carpal tunnel syndrome, indicating more severe disease 1
• Ultrasound may be used to measure median nerve size in patients with clinical symptoms when the diagnosis is unclear 3
• Electrodiagnostic studies can confirm the diagnosis in atypical cases, exclude other causes, and gauge severity for surgical prognosis 1, 2

Initial Conservative Management

• Wrist splinting in a neutral position is a first-line treatment for mild to moderate carpal tunnel syndrome 1, 2
  • Night-only splinting is as effective as continuous wear 1
  • A neutral wrist splint may be more effective than an extension splint 1
• Activity modification to reduce movements that exacerbate symptoms should be recommended 4
• Local corticosteroid injections can be considered for short-term symptom relief 1, 2
  • Corticosteroid injections provide slightly greater improvement of symptoms compared to splinting at 6 weeks, with similar outcomes at 6 months 1
  • Injections are especially effective if there is no loss of sensibility or thenar-muscle atrophy and weakness, and if symptoms are intermittent rather than constant 4

Ineffective Treatments to Avoid

• Over-the-counter analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen have not shown benefit for carpal tunnel syndrome 1, 5
• Pyridoxine (vitamin B6) and diuretics are no more effective than placebo in relieving symptoms 4, 5

When to Consider Surgical Management

• Surgical decompression should be offered to patients with severe carpal tunnel syndrome, including those with objective weakness or sensory deficits 1
• Surgery should also be considered if symptoms are refractory to conservative measures after 4-6 months 2
• Both open carpal tunnel release and endoscopic carpal tunnel release are equally effective for symptom relief 3, 2
• Endoscopic repair allows patients to return to work approximately one week earlier than open release 3, 2

Special Considerations

• Carpal tunnel syndrome should be treated conservatively in pregnant women because spontaneous postpartum resolution is common 5
• Patients with diabetes mellitus, hypothyroidism, obesity, arthritis, or those on hemodialysis have increased risk of carpal tunnel syndrome and may require more careful monitoring 6