Carpal tunnel syndrome guide
Welcome to Carpal tunnel syndrome guide
Your doctor says you have carpal tunnel syndrome. Will nonsurgical treatments ease the pain, numbness and weakness in your hand? Or will you need an operation?
This guide is designed for those who have already been diagnosed with carpal tunnel syndrome and are deciding how to treat it. The guide explains your treatment options, including the pros and cons of each.
Review the guide in sequence by following the links at the right or at the bottom of each page. Treatments are listed in the order most people typically try them — from nonsurgical options to surgical options.
Carpal tunnel syndrome treatment options
All traditional treatments for carpal tunnel syndrome attempt to relieve pressure on the median nerve as it passes through the carpal tunnel in your wrist. No single treatment choice is right for everyone. What you and your doctor decide to do depends on the following factors:
- How severe your symptoms are and what's causing them
- How long you've had your symptoms
- How much your symptoms affect your life at work and at home
Treatments fall into two general categories: surgical and nonsurgical. Both have potential risks and benefits.
Nonsurgical treatment of carpal tunnel syndrome
Nonsurgical treatments include a sequence of options, starting with simple steps you can take, such as activity modification, and moving on to more involved treatments, such as splints and corticosteroid injections.
Most people with carpal tunnel syndrome should at least give nonsurgical treatments a try. These treatments work best if you're under 50 and your symptoms:
- Are mild to moderate
- Are not constant
- Began less than 10 months ago
Activity modification to treat carpal tunnel syndrome
Wrist position is key to controlling your carpal tunnel syndrome symptoms. The carpal tunnel is most narrow when your wrist is either bent down or cocked back all the way. It is largest when the wrist is straight. For this reason, changing how you do repetitive hand activities or avoiding those activities altogether can help. The more your wrist is bent, the more pressure is put on your median nerve. To protect your hands, take these precautions:
- Reduce wrist bending. Avoid bending your wrist all the way up or down. A relaxed middle position is best. Often, it's possible to do the same task and avoid extreme wrist positions, simply by changing your position or that of the object you're holding.
- Relax your grip. Avoid gripping too hard when driving, writing or using hand tools. Most people use more force than necessary when doing hand tasks.
- Choose tools wisely. When writing, use a thick pen with an oversized, soft grip adapter and free-flowing ink. Modify your hand tools — going from a straight handle to a pistol grip. Avoid vibrating tools, if possible.
- Take breaks. When doing activities that require repetitive, forceful motion with your wrists bent, stop every 15 to 20 minutes and gently stretch and bend your hands and fingers. If possible, change activities for several minutes every hour.
- Use proper posture. Poor posture causes your shoulders to roll forward, shortening your neck and shoulder muscles and compressing nerves in your neck. Nerve impulses from your wrists, fingers and hands must travel through your neck to reach your spinal cord and brain.
- Keep your hands warm. Pain and stiffness are more likely to occur if your hands are cold. Adjust the room temperature or wear fingerless gloves.
Splinting for carpal tunnel syndrome
Splints (braces) are the most commonly used nonsurgical treatment for carpal tunnel syndrome. Splints that immobilize the wrist in a neutral (unbent) position are most likely to relieve discomfort. An unbent wrist maximizes the size of the carpal tunnel, which reduces pressure on the median nerve, relieving your symptoms.
You can buy ready-made splints at a medical-supplies store. Or you can ask your doctor to prescribe custom-made splints. Both are equally effective, although many people find custom-made splints more comfortable to wear. In either case, you may find splints make certain hand movements difficult to do.
You may need to wear a splint for a few weeks before noticing definite improvement. Some studies show that continuous splinting — wearing a splint both day and night — is more effective than wearing a splint just at night. Others, however, show little or no added benefit from 24-hour splinting. Many people find that a splint restricts their hand and wrist movements too much to be worthwhile at work and around the house, so night wear alone is a good option.
Splints are safe and relatively inexpensive, and they give many people with carpal tunnel syndrome excellent short-term relief from their symptoms. Besides relieving discomfort, splints can sometimes improve conduction of nerve impulses along the median nerve, which can improve strength, dexterity and sensation.
Splints are most likely to work for you if you've had mild to moderate carpal tunnel syndrome symptoms for one year or less. Splints may be a good choice for pregnant women if water retention is causing temporary carpal tunnel syndrome symptoms.
Physical therapy to treat carpal tunnel syndrome
Sometimes, physical therapy or special hand exercises relieve mild to moderate symptoms of carpal tunnel syndrome. These therapies include:
- Gliding exercises. Moving your fingers in a specified pattern of exercises may help your tendons and nerves glide more smoothly through your carpal tunnel. While there's some evidence that gliding exercises can help relieve carpal tunnel syndrome symptoms when used alone, these exercises appear to work better in combination with other treatments — such as splinting.
- Contrast baths. Alternating between warm water and cold water soaks helps reduce carpal tunnel symptoms in some people.
- Ultrasound. Deep, pulsed ultrasound directed at the carpal tunnel can reduce pain and numbness, and improve hand strength. Continuous superficial ultrasound doesn't help.
- Traction. Some people obtain relief from carpal tunnel symptoms by using a hand traction device, called C-Trac. You might try this device, which can be purchased for home use, if other conservative treatment options have failed.
Drug therapy for carpal tunnel syndrome
If you don't get adequate relief from splints or activity modification, your doctor may suggest trying medications to improve your carpal tunnel symptoms.
Corticosteroids
Although a short course of oral corticosteroids, such as prednisone, may help relieve some of your symptoms, the most effective drug treatment for carpal tunnel syndrome is delivered with a needle.
Injecting a corticosteroid, such as cortisone, directly into the carpal tunnel sometimes provides immediate relief from pain, tingling and numbness. In most cases, relief peaks about one month after injection. The length of time an injection is effective varies greatly — from several weeks to more than a year.
You may get renewed relief from a second injection. Most doctors limit the number of injections you can receive to three a year, because of the potential for side effects such as nerve injury and tendon rupture.
Nonsurgical treatment of carpal tunnel syndrome: Pros and cons
For most people with carpal tunnel syndrome, doctors try nonsurgical treatments before opting for surgery. However, the decision is a personal one influenced by the cause and severity of your symptoms and your feelings about surgery. When deciding whether to try nonsurgical options or to skip them, keep these points in mind:
Pros
- Nonsurgical techniques are less invasive than surgery, which means fewer lost workdays or time away from routine activities. You also don't face the rare, but possible, risks of surgery, such as infection, nerve damage or a bad reaction to the anesthetic.
- Most people get at least short-term relief from one or a combination of nonsurgical treatments. Many get long-term relief.
- You can try nonsurgical options first. Then you can have surgery, if the nonsurgical treatments don't work.
Cons
- Nonsurgical techniques are usually effective only in cases of mild to moderate carpal tunnel syndrome.
- They're less likely than surgery to provide permanent symptom relief. They may provide only temporary relief to a long-term problem that may worsen without surgery.
- Nonsurgical treatments may lead you to postpone an operation you'll eventually have to get. If you wait too long to decide on surgery, you may reduce your chance of a completely successful operation.
Surgery for carpal tunnel syndrome
Your doctor may suggest surgery for your carpal tunnel symptoms if you experience:
- Persistent numbness and pain
- Diminished strength in gripping and pinching
- Muscle wasting in your hand
Carpal tunnel surgery cuts the transverse carpal ligament. Severing the ligament is like cutting a rubber band wrapped over a rolled-up newspaper. It allows the carpal tunnel to expand, relieving pressure on the median nerve and thereby reducing or eliminating carpal tunnel syndrome symptoms.
Two main types of carpal tunnel surgery are widely available. One variety, called open-release, uses an incision large enough to expose the carpal tunnel anatomy for direct viewing and surgical adjustment. The other variety, called endoscopic or arthroscopic surgery, uses one or two very small incisions to insert instruments and a tiny camera. Surgeons watch what they're doing on a video monitor.
Open-release surgery for carpal tunnel syndrome
Open-release operations allow the surgeon to view the carpal tunnel directly, without the aid of a camera. Many surgeons prefer this approach because it is technically simple, safe and effective. Open-release surgery can be done for anybody with carpal tunnel syndrome.
Open-release surgery may have some particular advantages if your doctor wishes to directly inspect the contents of the carpal tunnel. Your surgeon might wish to inspect or remove some of the carpal tunnel contents if:
- Your carpal tunnel or median nerve has unusual characteristics
- You also have rheumatoid arthritis or diabetes
- Your physical examination and imaging studies strongly suggest that a tumor is compressing your median nerve
- You've had previous wrist surgery
How is it done?
While general anesthesia isn't necessary for carpal tunnel surgery, you may be sedated during the procedure if you wish or if your surgeon is planning to do a more extensive operation than usual. Your doctor will numb the area with an injection. Some doctors inject the numbing medicine in your palm, while others target a bundle of nerves near your collarbone. A tourniquet may be placed on your arm to reduce the amount of blood flow to your hand. The entire procedure usually takes about 10 minutes.
Most open-release incisions are about 2 inches (5 centimeters) long. The standard incision starts in the middle of your palm and sometimes extends into your wrist. Some surgeons use a mini-incision about an inch (2.5 centimeters) long, in an effort to avoid scar tenderness, which tends to be worse in incisions that cross the wrist.
Recovery
Open-release carpal tunnel surgery is an out-patient procedure, so you should be able to go home later that same day. Some people need prescription pain medication for a few days, but then can switch to over-the-counter drugs such as ibuprofen (Advil, Motrin) and acetaminophen (Tylenol, others).
Your doctor may want you to wear a splint on the hand at night or for certain activities for the first two weeks after surgery, to protect your wrist while it heals. Unless your doctor tells you differently, don't lift anything heavier than 11 pounds (5 kilograms) for two months after surgery. For reference, a gallon of milk weighs roughly 8.5 pounds (4 kilograms).
Finger and wrist exercises typically begin immediately after surgery, to help prevent the nerve tissue and tendons from getting stuck in one position. The amount of rehabilitation you may need will vary, depending on the size of your incision and the severity of your symptoms. Most people won't need any formal physical or occupational therapy.
Results
Many people continue to have some carpal tunnel symptoms after surgery, but most report that the operation reduced their symptoms significantly. Grip strength is often reduced immediately after surgery, but usually rebounds within a few months. Your scar, however, may feel tender for up to a year. Massaging your scar can help desensitize it.
The time off work after carpal tunnel surgery depends on many factors. A right-handed factory worker with open-release surgery on the right hand and no option for light-duty work might be off work six weeks or more, while a left-handed executive with a right open-release surgery may not miss any time from work. Most people are off work for at least a month after open-release surgery.
At least 10 percent of the people who have either variety of carpal tunnel surgery never return to their original line of work — especially if their jobs involved heavy manual labor. Be sure to discuss return to work with your surgeon before surgery.
Endoscopic surgery for carpal tunnel syndrome
Endoscopic carpal tunnel surgery uses special tools and a tiny video camera inserted through one or two small incisions in your palm or wrist. You may not be a good candidate for this procedure if:
- Your carpal tunnel or median nerve is anatomically abnormal
- You have rheumatoid arthritis or diabetes
- Your physical examination and imaging studies strongly suggest that a tumor is compressing your median nerve
- You've had wrist surgery before
How is it done?
General anesthesia isn't necessary for endoscopic carpal tunnel surgery, but you may be sedated during the procedure. Your doctor will inject a numbing agent into your palm. A tourniquet may be placed on your arm to reduce the amount of blood flow to your hand.
Your surgeon makes one or two small incisions called portals. Many surgeons consider it safer to make two incisions — one in the palm and one in the wrist. With two portals, it may be easier for your surgeon to be sure that the carpal ligament has been completely cut. Each incision is about 1/2 inch (1.3 centimeters) long.
Specialized surgical instruments and a miniature video camera (endoscope) are passed into your wrist via the portals. Your surgeon manipulates the tools by watching the surgery's progress on a video monitor. The entire procedure usually takes less than 10 minutes.
Recovery
Endoscopic carpal tunnel surgery is an out-patient procedure, so you should be able to go home later that same day. You may need prescription pain medication for a few days, but many people only need over-the-counter drugs such as ibuprofen (Advil, Motrin) and acetaminophen (Tylenol, others).
Your doctor may want you to wear a splint on the hand for the first two weeks after surgery, to protect your wrist while it heals. Some doctors don't require a splint after endoscopic carpal tunnel surgery. But most agree that you shouldn't lift anything heavier than 11 pounds (5 kilograms) for two months after surgery.
Finger and wrist exercises typically begin immediately after surgery, to help prevent the nerves, tendons and supporting tissue from getting stuck in one position. You may also be instructed to begin carefully using your hand for daily activities as soon as possible.
Results
Some studies indicate that endoscopic procedures have a slightly higher risk of surgical complications — such as damage to the median nerve or incomplete division of the carpal ligament — than do open-release procedures. Other studies, however, show no difference in these risks between the two types of operations.
Because there is less pain after endoscopic procedures, recovery is often faster than after open-release surgeries. Depending on the type of work you do, you may be able to go back to work on light duty just a few days or a few weeks after surgery.
Some people have experienced both varieties of carpal tunnel surgery, typically having one type of surgery on one hand and then the other variety of surgery some years later on the other hand. More than 85 percent prefer the endoscopic technique to the open-release procedure.
Surgery for carpal tunnel syndrome: Pros and cons
Which type of carpal tunnel release surgery you have — open or endoscopic — largely depends on your surgeon's experience and your preference. Both procedures share similar outcomes, providing:
- Excellent long-term success rates
- Low complication rates
- Restored muscle strength, manual dexterity and sensation in most cases
Comparing open and endoscopic procedures
Some surgeons strongly prefer endoscopic procedures while other surgeons just as strongly prefer open-release surgeries.
Proponents of open-release procedures believe there is less risk of accidentally damaging nerve tissue or tendons because they have a better view of the anatomical structures within your wrist. But among experienced surgeons, the complication rates between endoscopic and open-release procedures are now very similar.
Endoscopic procedures cost more than open-release procedures because they require more complex surgical instruments. This extra cost may be offset if you have less post-operative pain and can return to work more quickly. But if your return to work is accelerated by only a few days, the extra cost may not be worth it.
Also, there is always a chance that your surgeon will have to switch from an endoscopic approach to an open-release procedure if unforeseen problems arise during surgery.
Doing both hands at once
If you have carpal tunnel symptoms in both hands, you may consider having both hands operated on at the same time, to reduce the number of days you'll have to take off work. This can also lower the cost of treatment, since you're using the operating room just once instead of twice.
Although it seems logical to assume that you'd have less temporary disability after endoscopic carpal tunnel surgery on one hand than on both, there's not much difference.
Still, if you're considering having both hands operated on at once, you may want to make sure you have someone available to assist you with normal daily activities for the first two weeks after surgery.
Surgery compared with other treatments
Arguments in favor of surgery include:
- For long-term symptom relief, surgery is more effective than splinting, injection or any other nonsurgical treatment.
- Even if some symptoms remain after surgery, they tend to be less severe than those persisting or recurring after other types of therapies.
- In many cases, pain, tingling and numbness are gone immediately after surgery.
Arguments against surgery include:
- There is a slight risk of nerve damage or infection.
- Hand strength may be slow to return to normal, or not return to normal.
- Surgery may not help if another medical condition — such as obesity, arthritis or thyroid disease — is contributing to your carpal tunnel symptoms.
- You may not be able to perform your job or do other routine activities for more than a month.
Alternative therapies for carpal tunnel syndrome
You may find alternative treatments for carpal tunnel syndrome on the Internet and in books and magazines. In some cases, researchers haven't studied these treatments adequately using widely accepted scientific methods. In other cases, however, a growing body of evidence indicates that some alternative treatments may help relieve carpal tunnel symptoms.
Acupuncture
According to the National Center for Complementary and Alternative Medicine, acupuncture may be useful for treating carpal tunnel symptoms. Its effectiveness, however, hasn't been adequately proved by research.
Yoga
Yoga appears to relieve carpal tunnel symptoms in some people. Yoga postures designed to strengthen, stretch and balance joints in the upper body can sometimes reduce pain and increase grip strength. These conclusions are based on a study of people with carpal tunnel syndrome who practiced 11 yoga postures twice weekly for eight weeks.
Chiropractic
Some experts suggest that chiropractic treatment may be as effective as splinting for relief of carpal tunnel symptoms, but reliable scientific evidence is lacking.
Things to consider about carpal tunnel syndrome treatment
Carpal tunnel syndrome has no standard treatment program. The treatment path you take is up to you and your doctor. Most people begin by trying a sequence of conservative, nonsurgical treatments. If none of these works, you can move on to surgery.
As you mull over your treatment options, it may help to consider these key decision points and discuss them with your doctor.
How severe are your symptoms?
Carpal tunnel syndrome symptoms usually worsen gradually, which often gives you time to try nonsurgical treatments to see if you can avoid surgery. That's one reason it's important to get diagnosed and treated as early as possible.
Will nonsurgical treatments help your symptoms?
You're more likely to get relief from nonsurgical treatments if:
- You have mild to moderate symptoms that you've noticed for a year or less
- You don't have hand weakness
- Your pain is new and not severe
Are nonsurgical treatments worth trying before surgery?
Usually the answer is yes. Most people get short-term relief from a combination of nonsurgical treatments — for example, splints and corticosteroid injections. And if these treatments do help, it usually confirms that you have carpal tunnel syndrome, not a different condition with similar symptoms.
Trying nonsurgical treatments for a few months isn't likely to jeopardize the outcome of surgery, if you eventually do take that route. However, waiting several years before deciding on surgery may prolong your discomfort and make the operation less successful because your condition has worsened.
When is it time to consider surgery?
You may be a candidate for surgery if:
- Your symptoms have lasted one year or more and are either severe or worsening
- Underlying causes of your carpal tunnel syndrome have been ruled out, including arthritis, thyroid disease, diabetes and pregnancy
- Nerve conduction studies indicate moderate to severe median nerve compression
- You have hand weakness or the muscle at the base of your thumb has shrunk
- You've tried nonsurgical treatments and they don't provide adequate long-term relief
What kind of outcome can you expect from surgery?
Both types of surgery usually offer better symptom relief and hand-function improvement than does splinting or corticosteroid injections — short term and long term. Surgery promptly relieves pain in up to 90 percent of cases. Hand strength and sensation usually return more slowly. However, some degree of pain and hand weakness may persist. Recurrence of symptoms once they disappear is unusual, but does happen.
