Wrist Position for Carpal Tunnel Splinting
For patients with mild to moderate carpal tunnel syndrome, the wrist should be splinted in a neutral position (0 degrees) rather than in extension, as this position provides superior symptom relief and minimizes carpal tunnel pressure. 1
Optimal Splint Position
- Neutral position (0 degrees) is the evidence-based recommendation for wrist immobilization in carpal tunnel syndrome, as it demonstrates superior symptom relief compared to extension splinting 1
- A neutral position or slight extension of 0-15 degrees (most commonly 0-5 degrees) is recommended in clinical practice 2
- Extension splinting at 20 degrees has been directly compared to neutral positioning and found to be inferior for symptom relief 1
The rationale is straightforward: carpal tunnel pressure measurements demonstrate that the neutral position generates less pressure within the carpal tunnel compared to extension or flexion positions, thereby reducing compression on the median nerve 1
Splint Design Considerations
Standard Wrist Immobilization
- A basic wrist splint maintaining neutral position is effective for most patients with mild to moderate carpal tunnel syndrome 2, 1
- Both rigid and soft orthoses show no statistically significant differences in treatment outcomes 2
Enhanced Splint Design for Specific Patients
- A splint immobilizing both the wrist AND the metacarpophalangeal joints (2-5) should be used in patients with a positive Berger test 2
- Dorsal lock wrist-hand orthoses that maintain the wrist in neutral position while incorporating distal joint stabilization provide significantly better pain relief compared to standard volar cock-up splints 3
- Wrist splints with an additional metacarpophalangeal unit demonstrate significantly greater pain reduction (P = 0.022) and functional improvement (P = 0.027) compared to classic thermoplastic wrist splints alone 4
Wearing Schedule
- Night-time splinting is the primary recommendation, worn for several weeks 2
- During symptom exacerbations, the splint can also be worn during daytime activities that provoke symptoms 2
- Symptom relief typically occurs within 2 weeks and does not substantially improve between 2 weeks and 2 months of wear 1
- Treatment duration of 3-6 weeks is standard in most protocols 2, 3, 4
Clinical Pitfalls to Avoid
- Avoid excessive immobilization, as prolonged splinting can lead to muscle deconditioning and potentially worsen functional outcomes 5
- Do not rely on electromyography/nerve conduction study results to predict response to splinting, as EMG/NCS findings do not correlate with likelihood of symptom improvement from splinting 1
- Extension splinting should be avoided, as it increases carpal tunnel pressure and provides inferior symptom relief 1
Treatment Context
- Splinting should be attempted before proceeding to surgical decompression, as 48-63% of patients with mild carpal tunnel syndrome respond to conservative measures 5
- Night-time splinting more than triples the likelihood of overall improvement at 4 weeks compared to no treatment (RR 3.86,95% CI 2.29 to 6.51) 6
- Splinting is effective across all stages of carpal tunnel syndrome severity, though surgical decompression remains the most effective treatment for moderate to severe cases 5, 2