Initial Treatment for Carpal Tunnel Syndrome
Begin with nighttime wrist splinting in a neutral position as first-line therapy for mild to moderate carpal tunnel syndrome, reserving corticosteroid injections for patients who fail splinting after 4-6 weeks. 1
Conservative Treatment Algorithm
First-Line Therapy: Wrist Splinting
- Initiate nighttime wrist splinting in a neutral position for all patients with mild to moderate symptoms 1, 2
- Night-only splinting is as effective as continuous wear, making it more practical for patients 2
- A neutral wrist splint may be more effective than an extension splint 2
- Continue splinting for 4-6 weeks before escalating therapy 1, 3
Second-Line Therapy: Corticosteroid Injections
- Offer local corticosteroid injection if splinting fails after 4-6 weeks 1, 3
- Corticosteroid injections provide relief for more than one month and can delay surgery at one year 3
- In patients with recent onset CTS, injections provide slightly greater symptom improvement compared with splinting at 6 weeks, with similar outcomes at 6 months 2
Additional Conservative Options
- Oral corticosteroids can be effective for short-term management (2-4 weeks) 4, 5
- Physical therapy, therapeutic ultrasound, and yoga may be considered as adjunctive therapies 3
Critical Pitfalls to Avoid
Ineffective Medications
- Discontinue NSAIDs, acetaminophen, diuretics, and vitamin B6 immediately—these are no more effective than placebo 3, 4, 5, 2
- NSAIDs have limited efficacy for nerve compression and do not address the underlying pathophysiology 1
Timing Considerations
- Do not inject corticosteroids within 3 months of planned surgery, as this increases infection risk 1
- Avoid proceeding directly to surgery in patients with very mild electrodiagnostic findings without attempting conservative treatment, as 48-63% will respond to conservative measures 1
When to Escalate to Surgery
Indications for Surgical Referral
- Severe CTS with objective weakness or sensory deficits requires immediate surgical evaluation 2
- Symptoms persisting after 4-6 months of conservative therapy 3, 4
- Moderate to severe disease on electrodiagnostic studies 4
Surgical Outcomes
- Surgical decompression is the most effective treatment, providing significantly better symptom relief than non-surgical options for moderate to severe cases 1
- Open and endoscopic carpal tunnel release are equally effective, with endoscopic repair allowing return to work approximately one week earlier 1, 3