General Guideline Principles for Carpal Tunnel Syndrome (CTS)
for workers compensation patients
The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Carpal Tunnel Syndrome (CTS).
These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.
The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.
Carpal Tunnel Syndrome (CTS) of Hand, Wrist and Forearm Injuries
The most prevalent and well-known entrapment neuropathies, in which the peripheral nerves of the body are squeezed or injured, is CTS. When symptoms develop that can be linked to aberrant median nerve compression within the carpal tunnel, CTS arises.
The thumb, index, middle, and radial halves of the ring finger, as well as the dorsal segment of each of those four fingers, get sensations from the median nerve, which extends from the DIP distally.
Numbness and tingling are necessary symptoms. Although it is not a necessary symptom and may be a sign of other illnesses, pain can also radiate close to the area in which it is present. The condition frequently appears out of nowhere.
The most prevalent and well-known entrapment neuropathies, in which the peripheral nerves of the body are squeezed or injured, is CTS. When symptoms develop that can be linked to aberrant median nerve compression within the carpal tunnel, CTS arises.
The thumb, index, middle, and radial halves of the ring finger, as well as the dorsal segment of each of those four fingers, get sensations from the median nerve, which extends from the DIP distally.
Numbness and tingling are necessary symptoms. Although it is not a necessary symptom and may be a sign of other illnesses, pain can also radiate close to the area in which it is present. The condition frequently appears out of nowhere.
Medical History of Carpal Tunnel Syndrome (CTS)
A physical examination and symptoms pointing to median nerve entrapment at the wrist are required for a diagnosis of CTS. It is necessary to confirm the diagnosis with electrodiagnostic testing (EDX) before surgery. typical indications ofCTS may cause tingling, numbness, or discomfort in one or both of the volar parts of the body. especially noticeable hands after work or at night.
Nighttime symptoms predominate in most of the patients.To alleviate these symptoms, patients regularly awaken at night or in the early morning and shake their hands.
These symptoms may be confined to the palmar surfaces of the thumb and the first two or three fingers, or they may be reported to affect the entire hand. Using a hand pain diagram, CTS sensory complaints can be localised.
More concerning symptoms that may indicate muscular damage include trembling in the hands or dropping objects. In the clinical setting of a potential CTS diagnosis, the presence of such symptoms necessitates immediate evaluation of EDX and surgical therapy.
These are some examples of medical illnesses that have frequently been linked to CTS conditions and are associated with CTS:
These need to be treated and could hinder the recovery from the workplace accident.
- Connective tissue disorders, rheumatoid arthritis, systemic lupus erythematosus, gout, osteoarthritis, and spondyloarthopathy are among the arthropathies;
- Diabetes mellitus, including gestational diabetes or familial history;
- Especially in elderly ladies, hypothyroidism
- Obesity
- Pregnancy
Physical Exam of Carpal Tunnel Syndrome (CTS)
There is no one physical finding that can diagnose CTS. Final diagnosis depends on a correlation between symptoms, physical exam results, and, if necessary, EDX testing, as any one of these factors by itself may result in a false positive or false negative.
Any patient with suspected CTS should have their neck and upper back thoroughly examined before moving on to the fingers and the opposite side. A description of any dystrophic alterations, variations in skin colour, or turgor should be included, as well as an assessment of the patient’s vascular and neurologic condition.
Depending on past medical history, a physical exam may need to include additional components.
A neurological examination normally involves bilateral evaluations of reflexes, motor strength, and touch, pinprick, and two-point sensation if appropriate.
Similar evaluations of the upper extremities are possible, including a vascular evaluation. It is advised to take extra precautions when evaluating for polyneuropathic conditions like diabetic neuropathy.
Every time a patient has: 1) a history of paresthesia in the thumb, index, or middle finger; and 2) at least one of the physical examination symptoms detailed below.
Provocative testing must reproduce symptoms in the distribution of the median nerve.
- The reverse and Phalen’s sign.
- The carpal tunnel symbol, Tinel.
- Test for compression.
- Pollicis brevis, the abductor’s weak point (see discussion EDX studies).
- There may be thenar atrophy, typically at the end of the therapy (see discussion of EDX studies).
- Sensory loss in a median nerve distribution to pinprick, mild touch, two-point discrimination, or Semmes Weinstein monofilament test.
The following may be included in clinical exam testing for CTS performance.
- Monofilament test –a test that uses nylon monofilaments that break when pushed perpendicularly up against the palm or fingers with a certain level of force. When a filament larger than usual is needed for the patient to perceive its application, the test is considered successful.
- Vibration Testing –Reduced capacity to detect vibrations using a typical vibrating tuning fork and comparing the index finger’s distal interphalangeal joint to the ipsilateral fifth finger
- Weak thumb abduction strength –Weakness of resisted abduction (patient resists examiner pulling thumb toward index finger while holding palm horizontal and thumb raised as vertically as possible)
- Hoffmann– Tinel’s (or “Tinel’s”) Sign – A reflex hammer or the tip of the examiner’s finger may be tapped up to six times on the soft tissue around the carpal tunnel. When the taps result in paresthesias or shooting pain in the distribution of the median nerve, the test is affirmative.
- Phalen Sign –According to the original explanation, bending of the wrist by having the patient’s wrists are passively flexed by the examiner for up to 60 seconds.
- More frequently, this is accomplished by having the patient press the dorsal aspect of both hands together for 60 seconds at a flexion of about 90 degrees.
- It is unknown whether these two methods for executing this sign produce different sensitivity and particulars.
- The distribution of the body experiences paresthesias after a positive test.
- Compromised median nerve.
- Carpal Compression Test –The examiner places direct, even pressure with both thumbs for up to 30 seconds over the transverse carpal ligament while holding the supinated wrist in both hands, flexing the wrist 45 degrees. Tingling or paresthesia in the thumb, index finger, middle finger, and lateral part of the ring finger within 30 seconds indicates a positive test.
Diagnostic Studies of Carpal Tunnel Syndrome (CTS)
Electrodiagnostic Studies
When EDX studies are required, they should be carried out in compliance with the American Association of Neuromuscular and Electrodiagnostic Medicine’s CTS practise guidelines (AANEM)
Physicians board-certified in neurology or physical medicine and rehabilitation are encouraged to perform and interpret EDX in the out-patient situation.
The median motor and median sensory nerve conduction velocity results from the EDX research will be included (NCV). If something is off, it should be compared to the ipsalateral ulnar motor/sensory and the contralateral median motor/sensory.
It is necessary to perform needle electromyography (EMG) on a sample of the paraspinal muscles, a thenar muscle innervated by the median nerve of the affected limb, and other muscles innervated by the C5 to T1 spinal roots.
Due to demyelination or axonopathy, EDX findings in CTS show a slowing of the median motor distal latency and sensory conduction (velocity) over the carpal tunnel region (axonal loss). When axonal loss is present, thenar muscles supplied by the median nerve exhibit aberrant EMG.
With some mild forms of CTS, NCS and EMG may be normal. Tests may be redone later on in the course of treatment if EDS are negative and symptoms continue. It’s also critical to understand that a significant fraction of people with no symptoms and, therefore, no CTS have abnormal electrodiagnostic testing.
EDS testing may therefore lead to an incorrect diagnosis of CTS in a patient with a low pre-test probability of the condition. EDS has not been effective in identifying CTS instances with no doubt.
NCV/EMG – The indications for frequency and maximum number of studies are listed below:
Indications for initial testing:
- Those with clinically severe CTS who do not experience symptomatic or functional improvement after taking conservative measures for CTS over a period of 3 to 4 weeks.
- Patients whose diagnoses are in doubt and who have had symptoms for at least three weeks.
- To rule out alternate radiculopathy or other nerve entrapments.
- Patients for whom surgery is being considered according to Section.
A second study could be conducted:
When the initial investigations were normal at 3 months or more and CTS is still suspected
The following EDS studies are advised for CTS patients in cases where electrodiagnostic confirmation would change treatment plans:
- If the hands are below 30 C, warm them up before testing to ensure accuracy. Keep the temperature above 32°C when measuring at the hand or fingers, if at all possible.
- Perform a 13–14 cm conduction distance median sensory NCS across the wrist. If the outcome is abnormal, contrast the median sensory NCS result with the sensory NCS result of one other nearby sensory neuron in the affected limb.
- One of the following additional studies is advised if the initial median sensory NCS across the wrist has a conduction distance higher than 8 cm and the outcome is normal:
- Comparison of ulnar sensory nerve conduction across the wrist over a similar 7 to 8 cm conduction distance to median sensory nerve conduction or mixed nerve Conduction across the wrist, or
- Comparison of ipsilateral radial or ulnar sensory conduction across the wrist with median sensory across the wrist, or
- Comparison of the proximal or distal segments of the ipsilateral median nerve’s sensory or mixed NCS to median sensory or mixed nerve conduction through the carpal tunnel.
- The thenar muscle and another ipsilateral nerve with distal latency were used in a motor conduction study of the median nerve.
- Ipsilateral median-ulnar motor nerve distal latencies and median-ulnar motor conduction variations are possible comparisons.
- Measuring the contralateral limb is useful for comparison and for the diagnosis of systemic diseases if the index limb is aberrant.
Electrodiagnostic Studies of Carpal Tunnel Syndrome (CTS)
- Electrodiagnostic Studies of Carpal Tunnel Syndrome (CTS) is not recommended for the initial evaluation of the majority of patients with a confirmed history of CTS and corresponding clinical symptoms because it won’t change the treatment strategy.
- Electrodiagnostic Studies of Carpal Tunnel Syndrome (CTS) is recommended to help those patients who have not yet received a definitive diagnosis of CTS to do so, as well as to determine whether axonopathies are present or not.
- Electrodiagnostic Studies of Carpal Tunnel Syndrome (CTS) is recommended prior to surgical release, to conclusively assess and get an objective diagnosis of CTS.
Rationale –to support the identification, management, and prognosis of CTS
Frequency –If the initial study was not diagnostic and CTS is still suspected, a second examination at three months may be advised.
EDS is also recommended 8 to 12 weeks after surgery in situations where the outcomes are insufficient or the symptoms have returned.
- Electrodiagnostic Studies of Carpal Tunnel Syndrome (CTS) is recommended Before administering glucocorticoids, a thorough medical history and clinical suspicion are seen to be sufficient justifications for the administration, which EDS is unlikely to change.
- Electrodiagnostic Studies of Carpal Tunnel Syndrome (CTS) is not recommended. It is neither advised nor acceptable to confirm a clinical diagnosis of CTS using handheld or portable automated technology.
- Electrodiagnostic Studies of Carpal Tunnel Syndrome (CTS) is not recommended Surface EMG is not advised for use in the diagnosis of CTS.
- Ultrasound (Diagnostic)
Ultrasound (Diagnostic) is not recommended for diagnosing CTS.
Ultrasound (Diagnostic) are recommended in a few situations where a space-occupying lesion is suspected and an MRI is are not recommended.
- Magnetic Resonance Imaging
Magnetic Resonance Imaging is not recommended in order to assess and identify CTS
Magnetic Resonance Imaging is recommended when there is a strong suspicion that a lesion is occupying space.
Initial Treatment of Carpal Tunnel Syndrome (CTS)
Conservative measures, such as: should be used as the first line of treatment for CTS.
- Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) sold over-the-counter or other analgesics for symptomatic alleviation
- Wrist splint at night.
- Limitations on behaviours including firmly grasping, uncomfortable wrist position, and constant wrist motion.
Wrist Splinting
Splinting is typically more successful than cautious waiting alone in treating milder forms of CTS and can improve symptoms and hand function. Depending on the type of job being done, splints may be worn throughout the day or while sleeping.
Splints should be comfortable and loose enough to support the wrist in a fairly neutral position.A flexible or rigid splint with a metal or plastic support can be used to achieve this.
The majority of the time, off-the-shelf splints are adequate, however for some people, custom thermoplastic splints may fit better. Providers should advise patients to refrain from excessive use because they are aware that it is ineffective.
- Wrist Splinting
Wrist Splinting are recommended wrist bracing at night to treat acute, subacute, or chronic CTS
Wrist Splinting is recommended depending on employment activity, some patients may need intermittent daytime splinting.
Indications – Carpal tunnel syndrome-related symptoms
Frequency/Dose – For 4 to 6 weeks, wrist splints are advised to be worn at night. Intermittent daytime splinting may be beneficial depending on employment duties. It takes one to four weeks for an impact to appear.
Discontinuation – Splints should be reevaluated and re-adjusted as necessary if there is no improvement after two weeks of treatment, especially to ensure that the patient is wearing them correctly and to evaluate fit.
Splints should be stopped and glucocorticosteroid injection and/or electrodiagnostic testing may be considered if symptoms don’t go away or don’t get any better.
- Patient Education
Training in self-management methods, such as ergonomics, a home rehabilitation programme, and sleeping positions that prevent excessive wrist flexion.
- Continuation of Activities
An acknowledged and well-established initial recommendation for CTS with or without neurologic symptoms is to carry on with everyday activities as usual. Avoiding a complete work stoppage should be a priority.
- Work Activities
The earliest feasible return to work should be encouraged for all patients. Modified duty may be the most effective way to speed up this process, especially when the patient’s occupational injury makes it so that the demands of the job are beyond what they can handle.
It is advised that only those jobs be performed at work that do not need using high acceleration vibrating hand-held tools or high force paired with repetitive hand gripping or pinching.
Recommendations For therapy and potential future intervention or prevention, ergonomic assessments that measure exposure and/or try to limit it may be useful.
Diagnosis of Carpal Tunnel Syndrome (CTS)
All of the following are necessary for a diagnosis of carpal tunnel syndrome linked to the workplace:
Activities at work that cause or contribute to CTS constitute exposure.
Result: CTS that satisfies the diagnostic CTS criteria listed in this recommendation
Relation to work: This involves an assessment of the likelihood that the ailment or injury is related to the job. The potential of a specific instance being work-related is not necessarily eliminated by the existence of a concomitant sickness.
Work-related Activities requiring substantial, forceful, repeated, or prolonged use of the hands and wrists are most frequently linked to CTS, especially when these potential risk factors are present together (for example, force and repetition or force and posture).
The following job circumstances are typically present on a regular basis to foster work-relatedness:
Use under duress, especially if it is repeated.
Using your hands repeatedly while exerting any sort of force, especially for long periods of time.
Constant, firm object gripping
Using one’s hand or wrist forcefully or against resistance
Medications of Carpal Tunnel Syndrome (CTS)
Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients.
For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even if the majority of research indicates it is just marginally less effective than NSAIDs. There is proof that NSAIDs are less dangerous and just as effective in treating pain as opioids, such as tramadol.
- Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic CTS
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic CTS are recommended to treat acute, subacute, or persistent CTS
Indications – NSAIDs are advised as a treatment for acute, subacute, or chronic CTS. First, try over-the-counter (OTC) medications to see whether they work.
Frequency/Duration: For many patients, use as necessary may be acceptable.
Indications for Discontinuation:the disappearance of symptoms, the ineffectiveness of the treatment, or the emergence of side effects that need stopping.
- NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is recommended for people at high risk of gastrointestinal bleeding to take misoprostol, sucralfate, histamine Type 2 receptor antagonists, and proton pump inhibitors together.
Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a prolonged course of treatment is planned. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.
Frequency/Dose/Duration: H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.
Indications for Discontinuation: Intolerance, the emergence of negative effects, or the stopping of NSAIDs.
- NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
The advantages and disadvantages of NSAID therapy for pain should be explored with patients who have a history of cardiovascular disease or who have several cardiovascular risk factors.
- NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended As far as harmful cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options.
- NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended As first-line treatments, acetaminophen or aspirin seem to be the least dangerous in terms of negative cardiovascular effects.
- NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended If necessary, non-selective NSAIDs are recommended to COX-2-specific medications. To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in individuals receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.
- NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
- Acetaminophen for Treatment of CTS Pain
Acetaminophen for Treatment of CTS Pain is recommended for the management of CTS discomfort, especially in individuals who have NSAID contraindications
Indications: Acute, subacute, chronic, and post-operative CTS discomfort in all individuals.
Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of liver toxicity.
Indications for Discontinuation: pain, side effects, or intolerance are gone.
- Systemic Glucocorticosteroids
Systemic Glucocorticosteroids is recommended among individuals who decline carpal tunnel injection in selected patients for the treatment of Acute, Subacute, or Chronic CTS Indication – CTS unresponsive to splinting.
Oral steroids should not be administered to the majority of patients. Oral glucocorticoids, however, may be necessary for patients who refuse injection.
Frequency/Dose. It is advised that a single course of oral glucocorticoids (10–14 days) rather than multiple regimens be provided.
To reduce the possibility of side effects, low dose prescriptions are advised rather than high dose prescriptions.
- Diuretics
Diuretics is not recommended if fluid retention conditions are not present, for the treatment of acute, subacute, or chronic CTS.
- Opioids
Opioids is not recommended for chronic, subacute, or acute CTS
Opioids is recommended for specific use (not more than seven days) for the management of postoperative pain in conjunction with more potent therapies
Indications: A brief prescription of opioids as an adjuvant to more effective medications (particularly NSAIDs, acetaminophen) is frequently needed for post-operative pain control, especially at night.
Frequency/Duration: Prescribed as needed throughout the day, later solely at night, and finally completely discontinued.
Rationale for Recommendation: When NSAIDs are ineffective in relieving a patient’s pain, opioids should be used sparingly, especially at night. Opioids are advised for brief, selective usage in postoperative patients, with nighttime use being the main recommendation for achieving postoperative sleep.
- Vitamins (including pyridoxine)
Vitamins (including pyridoxine) are not recommended for the regular management of acute, subacute, or chronic CTS in healthy people.
- Lidocaine Patches
Lidocaine Patches is recommended when other curable causes of the pain have been ruled out and more effective therapeutic methods, such as splinting and glucocorticosteroid injection(s), have been tried and failed in a small number of patients for the treatment of acute, subacute, or chronic CTS with pain.
Indications for Discontinuation – Resolution, intolerance, negative effects, a lack of benefits, or a failure to advance during a trial that lasts at least two weeks.
- Gabapentin
Gabapentin is not recommended to treat carpal tunnel syndrome.
Rehabilitation of Carpal Tunnel Syndrome (CTS)
If rehabilitation (supervised formal therapy) is necessary as a result of a work-related injury, it should be concentrated on restoring the functional ability needed for the patient to engage in daily activities and return to work; insofar as possible, the goal should be to return the injured worker to their pre-injury status.
Active therapy calls for the patient to put in an internal effort to finish a particular activity or assignment. The procedures known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their side.
Passive therapies are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Interventions that are active should be prioritised over those that are passive.
To sustain improvement levels, the patient should be advised to continue both active and passive therapies at home as an extension of the therapeutic process.
As a supplement, assistive technology may be introduced into the
rehabilitation strategy to promote functional improvements.
Therapeutic Exercise of Carpal Tunnel Syndrome (CTS)
- Therapeutic Exercise
- Therapeutic Exercise is recommended for the treatment of persistent CTS when functional impairments are present
Therapeutic Exercise is recommended for post-operative CTS therapy in individuals with stiffness and severe impairments
Frequency/Dose/Duration – For individuals with minor functional deficits, the total number of visits could be as low as two to three, whereas it could be as high as 12 to 15 for those with more severe deficits with continued objective functional improvement.
For individuals with minor functional deficits, the total number of visits could be as low as two to three, whereas it could be as high as 12 to 15 for those with more severe deficits with continued objective functional improvement.
- Yoga
Yoga is not recommended for the treatment of either chronic or subacute CTS.
- Biofeedback
Biofeedback is not recommended for the treatment of either chronic or acute CTS.
- Therapeutic Exercise is recommended for the treatment of persistent CTS when functional impairments are present
- Therapy – Passive
- Therapy – Passive Cryotherapy / Heat Ice / Self-Applied Ice
Therapy – Passive Cryotherapy / Heat Ice / Self-Applied Ice are recommended for the treatment of either chronic or subacute CTS.
- Heat / Self-Applied Heat
Heat / Self-Applied Heat is recommended to treat acute, subacute, or persistent CTS
- Diathermy
Diathermy are not recommended for the treatment of CTS that is acute, subacute, or chronic
- Therapy – Passive Cryotherapy / Heat Ice / Self-Applied Ice
Manipulation and Mobilization of Carpal Tunnel Syndrome (CTS)
- Manipulation and Mobilization
Manipulation and Mobilization are not recommended for the treatment of CTS that is acute, subacute, or chronic
- Manipulation of the Spine for Acute, Subacute, or Chronic CTS
Manipulation of the Spine for Acute, Subacute, or Chronic CTS are not recommended for the treatment of either chronic or subacute CTS.
- Devices
- Magnets
Magnets is not recommended for controlling pain brought on by short-term, long-term, or chronic CTS
- Pulsed Magnetic Field Therapy
Pulsed Magnetic Field Therapy is not recommended for the treatment of acute, subacute, or long-term CTS pain.
- Magnets
- Low Level Laser therapy (LLLT)
Low Level Laser therapy (LLLT) are not recommended to treat acute, subacute, or persistent CTS
- Massage and Soft Tissue Massage
Massage and Soft Tissue Massage are not recommended treatment of acute, subacute, or chronic CTS for the majority of individuals
Massage and Soft Tissue Massage are recommended for the treatment of a subset of individuals with severe myofascial pain and acute, subacute, or chronic CTS.
Indications – Carpal tunnel syndrome symptoms and forearm myofascial pain severe enough to warrant medical attention. The patient should, in general, have failed alternative therapies including splints and glucocorticosteroid injections.
Frequency/Dose –four to three visits. The documentation of improvement should include objective proof. Additional three or four treatments should be chosen based on a gradual improvement in the metrics that matter.
Discontinuation: Resolution, intolerance, or a failure to genuinely improve.
- Therapeutic Touch
Therapeutic Touch is not recommended to treat acute, subacute, or persistent CTS
- Ultrasound
Ultrasound is not recommended for the treatment of either chronic or subacute CTS.
There is Support for Using Ultrasound for CTS
- Phonophoresis
Phonophoresis is recommended to treat acute, subacute, or persistent CTS
Indications – CTS that is symptomatic enough to require medical attention.
Prior to attempting phonophoresis, patients should typically first receive splints and/or glucocorticosteroid injections as these treatments are thought to be more successful.
Frequency – 4 to 8 weeks, 5 to 15 sessions per week.
Discontinuation – Resolution, a lack of measurable improvement, or intolerance.
- Iontophoresis
Iontophoresis is not recommended for use in the management of CTS that is acute, subacute, or chronic.
Injection Therapy of Carpal Tunnel Syndrome (CTS)
- Injection Therapy of Carpal Tunnel Steroid Injections
Injection Therapy of Carpal Tunnel Steroid Injections is recommended to treat chronic or subacute CTS with modest EMG findings
Injection Therapy of Carpal Tunnel Steroid Injections is recommended providing short-term relief while awaiting surgery in a restricted group of individuals with moderate to severe EMG results.
Indications – CTS is typically characterised by symptoms lasting at least three weeks and is insensitive to nightly wrist bracing.
Frequency/Duration – Initial injections that show improvement, even in the short term, are thought to have significant prognostic value. Suppose the first steroid.
A second injection may be necessary if symptoms return after three to four weeks of partial or total symptom improvement following first injection. Surgical release may be necessary if the second injection results in three to four weeks of full or partial relief.
Failure to respond should prompt a critical reevaluation of the correctness of the diagnosis of CTS, especially if the median nerve was successfully anaesthetized by the injection.
Those patients are seen to be candidates for surgical release if they respond to carpal tunnel injections and experience repeated discomfort.
The choice to administer a second injection must be considered against alternative therapies such surgery if, after the first injection, symptomatic improvement is followed by recurrent symptoms.
- Carpal Tunnel Steroid Injections for Treatment of Acute, Traumatic CTS without Fracture
Carpal Tunnel Steroid Injections for Treatment of Acute, Traumatic CTS without
Fracture is Recommended for the treatment of acute CTS (without fractures) symptoms that have lasted at least three weeks and are resistant to conservative care.
The possibility of an urgent surgical release should be considered for acute CTS with fractures.
- Carpal Tunnel Steroid Injections for Treatment of Non Traumatic CTS Due to Acute, Repetitive Overload Injury
Carpal Tunnel Steroid Injections for Treatment of Non Traumatic CTS Due to Acute, Repetitive Overload Injury is recommended for the treatment of acute, repetitive overload injuries resulting in non-traumatic CTS. Oral steroids may be an alternative for people who decline injections (see
- Intramuscular Injections
Intramuscular Injections are not recommended for the treatment of either chronic or subacute CTS.
Indications for Intramuscular Injections in CTS
- Insulin
Insulin are not recommended to treat acute, subacute, or persistent CTS
- Botulinum Injections
Botulinum Injections are not recommended for the treatment of either chronic or acute CTS.
Surgery of Carpal Tunnel Syndrome (CTS)
The following CTS patients may benefit from surgical consultation:
Display major red flags;
- failing to react to non-surgical management, such as workplace changes; or
- possess convincing clinical and specialised evidence of a lesion that has been proved to benefit from surgical intervention both in the short and long terms.
- The established diagnosis of the presenting hand or wrist ailment will determine the surgical considerations.
Counselling regarding potential outcomes, risks, advantages, and especially expectations is crucial if surgery is being considered. The degree of preoperative neuropathy is the single most crucial factor in predicting symptomatic improvement after carpal tunnel release.
The patient should be referred for conservative therapy if there are no obvious indications for surgery.
In the presence of, surgery should be thought of as initial therapy
- Patients with open wounds, unstable fractures, or wrist fractures that cause acute CTS must be referred right once to a surgeon because treatment options other than surgery are limited.
- Due to compression of the median nerve, or when there is moderate to severe compressive neuropathy of the median nerve as detected by electrodiagnostic testing. Acute or chronic motor denervation is indicated by EMG results, which raises the likelihood of irreparable injury.
- Non-surgical treatment may be helpful in certain situations for cases with positive EDX findings and a motor latency less than 5.0 ms; as a result, conservative care, including job modifications, should be tried over a period of four to six weeks before surgery is considered.
- failing to react to non-surgical management, such as workplace changes; or
Surgical releases
- Surgical releases
Surgical releases are recommended for patients who have moderate to severe EMG findings and subacute or persistent CTS.
Surgical releases are recommended for patients with mild EMG findings and subacute or chronic CTS who experience recurring symptoms (3–4 weeks) after receiving partial or full symptom relief after glucocorticosteroid injections.
Rationale/Indications – Failure of two glucocorticosteroid injections as part of non-operative treatment. A second injection might be necessary if the first steroid injection only offers 3 to 4 weeks of full or partial symptom alleviation but results in symptom return.
Surgical release may be necessary if the second injection results in relief that lasts for 3 to 4 weeks, either completely or partially.
Indicated: It is thought that patients who initially respond well to corticosteroid injections but then experience repeated problems are candidates for surgical release.
If the initial injection results in symptomatic relief and then repeated symptoms, the choice to administer a second injection must be considered against other options, such as surgery.
Surgical Release are recommended Patients with urgent or emergent indications (such as compartment syndrome with persistent symptoms of nerve damage, acute compression owing to a fracture, arthritis, or other conditions)
Rationale/Indications – Patients should undergo an EDS that is consistent with CTS (see Electrodiagnostic Studies). A clinical impression of moderate or severe CTS with normal EDS is extremely rare and typically denotes a misdiagnosis. However, mild CTS with normal EDS does exist.
It is important to carefully choose patients for EDS and accurately interpret the results because positive EDS in asymptomatic people is fairly common and is not CTS.
Re-operation may be necessary in the event that I symptoms return after surgical release, (ii) electrodiagnostic findings are positive 8–12 weeks after surgical release, (iii) re-exposure to work-related factors is not remediable, and (iv) electrodiagnostic findings are supportive.
Patients who do not improve following initial surgery should have a thorough diagnostic workup.
- Open or Endoscopic Release
Open or Endoscopic Release is recommended for the management of chronic or subacute CTS. The procedure chosen is based on the surgeon’s assessment and judgement.
- Antibiotics for Patients Undergoing Carpal Tunnel Release
Antibiotics for Patients Undergoing Carpal Tunnel Release is not recommended for routine use.
- Antibiotics For Postoperative Infection
Antibiotics For Postoperative Infection is recommended as clinically indicated.
Other Supplementary Techniques or Procedures for Acute or Chronic CTS
Epineurotomy
Epineurotomy is not recommended
Internal Neurolysis
Internal Neurolysis is not recommended
Flexor retinacular lengthening
Flexor retinacular lengthening is not recommended
Ulnar Bursal Preservation
Ulnar Bursal Preservation is not recommended
Altering the Location of the Incision to “Superficial Nerve-Sparing Incision
Altering the Location of the Incision to “Superficial Nerve-Sparing Incision” is not recommended
Ulnar Incisional Approach
Ulnar Incisional Approach is not recommended
Flexor Tenosynovectomy
Flexor Tenosynovectomy is not recommended
Biopsy of Abnormal Tenosynovium
Biopsy of Abnormal Tenosynovium is not recommended for the treatment of chronic or subacute CTS
What our office can do if you have workers compensation Carpal Tunnel Syndrome (CTS)
We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.
We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.
We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.
I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.
You can see my full CV at my profile page.
