Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

clinical diagnosis of carpal tunnel syndrome (CTS) without electromyogram (EMG) confirmation, or pregnant women

1st line – wrist splint

Back
ACUTE
|
clinical diagnosis of carpal tunnel syndrome (CTS) without electromyogram (EMG) confirmation, or pregnant women
1st line – 

wrist splint

Low certainty evidence suggests that night-time splinting may improve symptoms of CTS, compared with no treatment.[38]​ Wrist splints (neutral or 20° extension) worn every night for 1 month. Uncommonly, splints can exacerbate CTS symptoms and/or cause additional pain and discomfort.

The patient should be referred to an occupational therapist or orthotist for custom-made splints if they have a hand/wrist deformity, or are unable to find a splint that is comfortable.

Activities that particularly provoke symptoms should be limited or modified.

If further treatment is required, patients should be referred for EMG to classify the severity of CTS and guide management. Based on EMG findings, patients are usually classified as having mild, moderate, or severe CTS.

In pregnancy, symptoms can appear rapidly and worsen rapidly, which may require aggressive intervention and close monitoring (both clinically and electrophysiologically).

Typically, it is recommended to persevere with a wrist splint given that after delivery, symptoms usually quickly dissipate within several weeks.

mild or moderate based on EMG findings (non-pregnant)

1st line – wrist splint

Back
ACUTE
|
mild or moderate based on EMG findings (non-pregnant)
1st line – 

wrist splint

Low certainty evidence suggests that night-time splinting may improve symptoms of CTS, compared with no treatment.[38]​ Wrist splints (neutral or 20° extension) worn every night for a trial of 1 to 2 months (mild 1-2 months; moderate up to 1 month). Uncommonly, splints can exacerbate CTS symptoms and/or cause additional pain and discomfort.

The patient should be referred to an occupational therapist or orthotist for custom-made splints if they have a hand/wrist deformity, or are unable to find a splint that is comfortable.

Activities that particularly provoke symptoms should be limited or modified.

2nd line – corticosteroid injection + wrist splint

Back
ACUTE
|
mild or moderate based on EMG findings (non-pregnant)
2nd line – 

corticosteroid injection + wrist splint

If response to splinting is unsatisfactory, offer an injection of corticosteroid into the carpal tunnel, in addition to splinting. Corticosteroid injections are associated with an improvement in hand function at 6 months, and a reduction in the need for surgery at 12 months compared with placebo.[46]​ There is no clear consensus on type or dose, which is often administered with a local anaesthetic (e.g., 0.5 to 1 mL of 2% lidocaine). 

Most patients respond to corticosteroid injections in the first month, and the benefit may last for several months in some individuals.

If the patient requires more than 2 injections in 12 months, they should be considered for referral for surgical release.[53]

Primary options

methylprednisolone acetate: single doses of 20-80 mg intracarpally with or without a local anaesthetic have been reported; however, consult a specialist for further guidance on dose

OR

dexamethasone: single doses of 4 mg intracarpally with or without a local anaesthetic have been reported; however, consult a specialist for further guidance on dose

OR

hydrocortisone: single doses of 25-100 mg intracarpally (as hydrocortisone succinate) have been reported; however, consult a specialist for further guidance on dose

severe based on EMG findings (non-pregnant)

1st line – surgical release

Back
ACUTE
|
severe based on EMG findings (non-pregnant)
1st line – 

surgical release

Patients should be referred for surgical release as soon as possible, as the risk of permanent nerve damage is a possibility. It is unclear whether any specific rehabilitation after surgery is helpful.[55]

ONGOING

moderate based on EMG findings + failed splint and corticosteroid injection(s)

1st line – surgical release

Back
ONGOING
|
moderate based on EMG findings + failed splint and corticosteroid injection(s)
1st line – 

surgical release

Splints should be trialled for up to 1 month before considering corticosteroid injection. If the patient requires more than 2 injections in addition to splinting in 12 months, they should be considered for referral for surgical release.[53]​ It is unclear whether any specific rehabilitation after surgery is helpful.[55]

One Cochrane review reported moderate quality evidence that surgery may result in a higher rate of clinical improvement, compared with splinting for >3 months.[54]

refractory to surgery

1st line – review diagnosis + repeat conservative management and/or repeat surgical release

Back
ONGOING
|
refractory to surgery
1st line – 

review diagnosis + repeat conservative management and/or repeat surgical release

Conservative therapy is started with wrist splints and corticosteroid injection while awaiting repeat EMG studies.

The original diagnosis should be re-confirmed and consideration given to whether an additional diagnosis is also present (e.g., polyneuropathy, radiculopathy). Repeat surgical release may be offered.

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer