Initial Treatment for Carpal Tunnel Syndrome
For mild to moderate carpal tunnel syndrome, begin with wrist splinting in a neutral position, which should be the first-line conservative therapy. 1, 2, 3
Conservative Management Approach
First-Line Therapy: Splinting
- Neutral wrist splinting is the primary initial treatment, with night-only splinting being as effective as continuous wear 3
- A neutral wrist splint may be more effective than an extension splint 3
- Splinting should be continued for 4-6 weeks before considering other interventions 2, 4
Second-Line Therapy: Corticosteroid Injections
- Local corticosteroid injections provide superior symptom relief compared to splinting alone, particularly for patients with recent onset of symptoms 2, 3
- Injections provide slightly greater improvement at 6 weeks compared to splinting, with similar outcomes at 6 months 3
- Corticosteroid injections can provide relief for more than one month and delay the need for surgery at one year 1, 2
- Injections are especially effective when there is no loss of sensibility, no thenar muscle atrophy or weakness, and symptoms are intermittent rather than constant 5
Oral Corticosteroids
- Oral corticosteroids can be effective for short-term management (2-4 weeks) but are less effective than local injections for longer-term relief 6, 5, 4
Therapies to AVOID
The following treatments have been proven ineffective and should not be used:
- NSAIDs (nonsteroidal anti-inflammatory drugs) - no more effective than placebo 6, 2, 3, 4
- Pyridoxine (vitamin B6) - no more effective than placebo 6, 2, 5, 4
- Diuretics - no more effective than placebo 6, 5, 4
- Acetaminophen - has not shown benefit 3
When to Proceed to Surgery
Surgical decompression should be offered in the following circumstances:
- Severe carpal tunnel syndrome with objective weakness or sensory deficits 3
- Symptoms refractory to 4-6 months of conservative therapy 2, 4
- Moderate to severe disease on nerve conduction studies 1, 4
Surgical Options
- Both open and endoscopic carpal tunnel release are equally effective for symptom relief, with endoscopic repair allowing patients to return to work approximately one week earlier 1, 2, 4
Clinical Pitfalls
- Do not routinely order laboratory tests (HbA1c, TSH, vitamin B12) in patients with typical carpal tunnel syndrome, as this generates more false positives than true positives 1
- Avoid excessive or prolonged immobilization, which can lead to muscle deconditioning and worsening symptoms 1
- In pregnant women, treat conservatively as spontaneous postpartum resolution is common 6