Carpal tunnel syndrome (CTS): management and referral pathway
Patient presentation
Hand paraesthesia in median
nerve distribution - NOT as a
result of trauma
Does the patient have any of
the following?
1. Nocturnal paraesthesia
not easily relieved by
movement
2. Symptoms aggravated by
hand use
3. Spontaneous shaking of hand
for relief
4. Positive Tinels sign* or
Phalens test*
5. Abductor pollicis brevis
weakness*
Phalens test: Flex wrist
for 60 seconds. Note
occurrence of pain or
paraesthesia in median
nerve distribution.
Tinels sign: Tap initially
lightly, then firmly over
median nerve in palm and
the distal forearm. Positive
symptoms are distal
lancinating paraesthesia in
median nerve distribution.
Abductor pollicis brevis
weakness: Turn palm
to ceiling and thumb to
ceiling and test resisted
power.
Primary care Surgical care Treat conservatively as CTS:
Does the patient have Refer if symptoms persist or are Wrist splints at night (straight so wrist in neutral not dorsi-
any of the following? severe, especially if associated flexed), available from NMATS & OT via MSK referral centre
with altered sensation in the If symptoms brought on by work/hobbies, try conservative
1. Thenar muscle wasting
median nerve distribution or treatment for 12 weeks
2. APB weakness
with weakness/muscle wasting. If symptoms restricted to nocturnal paraesthesia, try
3. Loss of dexterity
conservative treatment for 12 weeks
Yes Include the following
Discuss shared decision making (SDM) options (e.g. Right
information:
Care) with patient
No Yes Conservative management Direct patient to Right Care SDM patient decision aid tool
tried (e.g. any relief through Corticosteroid injection in appropriate patients. If not
No Is splintage?) available in practice, refer to NMATS (specialist physio or
the patient Any history of neck problems sport exercise medicine consultant)
pregnant or No If patient is diabetic,
diabetic? pregnant, or has a thyroid Shared decision The Health Foundation
n
r i for
lick fo
ma io
Does the patient have disorder making information MAGIC brief decision aid
t
If symptoms are unilateral or
n
C
either of the following?
Yes bilateral
1. Symptoms (paraesthe- If patient has had nerve Look for other causes of symptoms
sia or numbness) that conduction study
are constant Hand symptoms due to cervical spine pathology should be
2. Symptoms present for excluded. The paraesthesia from cervical nerve root irritation
more than 6 months tends to be (but not absolute):
Yes 1. Associated with some neck pain and pain radiating down
from shoulder
Yes
No 2. Continuous rather than intermittent
3. Likely to be worse at night
Version 2.6 October 2014
4. Not well localised to the median nerve distribution
Treat conservatively as Intractable
To investigate possible medical causes, do full blood count
CTS symptoms?
(FBC), glucose, and thyroid function tests (TFTs)
Look for
other causes of symptoms No er
nal li
Useful
i Right Care SDM patient decision aid tool:
nk
Ext
information
s
sdm.rightcare.nhs.uk/pda/carpal-tunnel-
for patients syndrome
Look for other causes of If improvement: wean
symptoms off therapy and advise to
return if symptoms recur www.nhs.uk www.hse.gov.uk/msd/dse www.patient.co.uk
Document version information

Document title NNE CCG carpal tunnel syndrome: management and referral
pathway
Description Carpal tunnel syndrome: management and referral pathway
with NHS Shared Decision Making information and links to
external information for patients and GPs
Document version number Version 2.6
Revision date 15th October 2014
Approval date 15th October 2014
Approved by NNE CCG Joint Planned and Unplanned Care Group
Clinical lead (development) Dr James Hopkinson, GP, NNE CCG
Clinical input (development) Dr Paul Oliver, GP/Clinical Lead, NNE CCG
Dr David Hannah, GP, NNE CCG
Neil Marshall, Clinical Lead Physiotherapist, MSK Outpatients
and NMATS, Nottingham University Hospitals NHS Trust
CCG Administrative support Vickie Walker, Senior Service Improvement Manager, NNE CCG
Nick Lupton, Service Improvement Manager, NNE CCG
 Shared Decision Making

Deciding what to do about carpal tunnel syndrome

This short decision aid is to help you decide what to do about your carpal tunnel syndrome. You can use it on
your own, or with your doctor, to help you make a decision about what's right for you at this time.
There are five main options for treating carpal tunnel syndrome. The choices are:

Changing lifestyle and working habits to put less pressure on hands, and self-managing symptoms
Pain medications, for quick relief from pain
Physical management of symptoms, including hand exercises and wrist splints
Corticosteroid injections into the carpal tunnel, to reduce pain, swelling, and pressure
Surgery to reduce pressure on the carpal ligament nerve.

Page 1 of 7
 Shared Decision Making

What are my options?

Lifestyle Pain relief Physical Steroid Surgery

changes medication management injection

What is the People with carpal Pain medications Physical Having a steroid Surgery involves
treatment? tunnel syndrome are drug management injection (the full an operation on
can choose to treatments of carpal tunnel name of this type the wrist. The
self-manage their designed to reduce syndrome usually of medication is surgeon cuts free
condition. That pain. means hand corticosteroid) a band of tissue
just means they exercises or means having called the carpal
Some of these
find out about splinting. an injection into ligament from the
tablets can be
the condition the carpal tunnel. median nerve.
bought from a Hand exercises
themselves, and This is done by a The operation is
pharmacy without are exercises that
do things to try to doctor. usually done under
a prescription. involve stretching
improve it. local anaesthetic.
These include the fingers and Corticosteroids
This operation
People with carpal paracetamol, wrist into different are sometimes
can be done by
tunnel syndrome paracetamol positions to see if called steroids
either open or
can try making combined with low- this can release for short, but they
keyhole (also
changes to their strength codeine, the pressure on are not the same
called endoscopic)
workplace or their and some non- the nerve. Wrist as the anabolic
surgery.
daily lifestyle, steroidal anti- splints keep the steroids used by
activities, and inflammatory drugs hand and wrist some bodybuilders Surgery is usually
hobbies that may (NSAIDs) such straight and reduce and athletes. only recommended
help improve their as ibuprofen and the pressure on Corticosteroids for people who
symptoms. aspirin. Other drug the trapped nerve. are similar to the have severe
treatments need to natural chemicals symptoms and
be prescribed by a the body makes to have tried other
doctor. reduce swelling. treatments first.

Lifestyle Pain relief Physical Steroid Surgery

changes medication management injection

What is the We don't know We don't know Nerve and tendon A corticosteroid Six months after
effect on pain? whether lifestyle whether or not exercises may help injection into the surgery, most
changes can non-steroidal to reduce pain. We carpal tunnel can people say their
reduce pain. There anti-inflammatory don't know for sure make the hand, pain has improved.
has not been much drugs (NSAIDs) because there has arm, and wrist [7]
research in this or paracetamol not been much feel less painful
The two types of
area. help pain. There research into this. and swollen.[5]
surgery (open and
hasn't been much [3] People may feel an
We don't know for keyhole) seem
research.[2] improvement for
sure whether using Wearing a wrist to work as well
up to one month
specially designed splint at night can as each other in
after the injection.
keyboards or help to reduce treating the pain
[6]
equipment can pain. About 50 of carpal tunnel
reduce pain for in 100 people syndrome.[8]
people with carpal with carpal tunnel
tunnel syndrome. syndrome say
[1] their symptoms
are improved
three months after
starting using a
splint.[4]

Page 2 of 7
 Shared Decision Making

Lifestyle Pain relief Physical Steroid Surgery

changes medication management injection

What is the We don't know We don't know We don't know Corticosteroid Carpal tunnel
effect on whether lifestyle whether NSAIDs whether nerve and injections into surgery usually
movement? changes can improve hand and tendon exercises the carpal tunnel makes it easier to
improve how easily wrist movement improve how well can improve move the hand and
people can move in carpal tunnel people can move how well people wrist.[18][19][20]
their hands or syndrome. There their hands or can move their
Six months after
wrists. There has hasn't been much wrists.[13] hands and wrists.
surgery, about 56
not been much research.[10] People may feel
Wearing a wrist in 100 people say
research in this an improvement up
Someone with splint at night can they can move
area. to one month after
carpal tunnel help to improve their wrists better
the injection.[16]
We don't know for syndrome may find how well someone than before the
sure whether using it easier to move with carpal tunnel Someone with operation.[21]
special keyboards their hand and syndrome can carpal tunnel
Some people
or equipment can wrist if they wear move their hand or syndrome may
find that surgery
make it easier for a splint as well as wrist.[14] find it easier to
does not improve
people with carpal taking NSAIDs.[11] move their hand
People who have movement or
tunnel syndrome to After six weeks of and wrist if they
a corticosteroid strength.[22]
move their hands treatment, people wear a splint as
injection as well
or wrists. There with carpal tunnel well as having
as wearing a splint
has not been syndrome who a corticosteroid
find it easier to
enough research. take NSAIDs and injection.[17]
do things such
[9] wear a splint say
as write, button
they find it easier
clothes, grip a
to write and to pick
telephone receiver,
up small objects.
open jars, do
[12]
housework, carry
grocery bags, and
bathe themselves.
[15]

Page 3 of 7
 Shared Decision Making

Lifestyle Pain relief Physical Steroid Surgery

changes medication management injection

How much Some lifestyle Some pain relief People may need Corticosteroid Surgery for carpal
time is spent changes require medication can be to go to hospital injections are tunnel syndrome
in hospital daily commitment, bought over the to have a number usually given at is done in hospital.
or having or take some counter, without of physiotherapy a GP surgery or People should be
getting used to, a prescription. sessions. They at a special clinic. able to go home
treatment?
such as using A doctor may won't need to stay To begin with, the same day.
new equipment. also prescribe in hospital. doctors usually
People who have
A session with pain medication. recommend one
Wrist splints are surgery will need
an occupational People with carpal injection. They
usually available to wear a bandage
therapist at work tunnel syndrome may suggest
from larger for about two days
may be needed. might need to more injections if
pharmacies, or a after the operation.
take medicines necessary.[23]
GP may be able Their doctor may
regularly to
to recommend a recommend gentle
manage their pain.
suitable supplier. hand, wrist, and
The splint can be elbow exercises to
used for several prevent stiffness.
weeks or months,
It's possible that
depending on
surgery will not
how severe the
work and a second
symptoms are.
operation will be
needed.[24]

Lifestyle Pain relief Physical Steroid Surgery

changes medication management injection

How quickly We don't know If pain medications People who Corticosteroid About 80 in 100
does the how quickly help, they should find that nerve injections may start people who have
treatment lifestyle changes start working and tendon working one week surgery say their
work? or using special quickly, within exercises help after treatment.[28] symptoms have
equipment can minutes rather their symptoms People might feel improved three
improve the than hours. say that the an improvement months after the
symptoms. There improvement for up to one operation.[30]
has not been much happens within month after the
research.[25] three months.[26] injection.[29]
People who find
that wearing a
wrist splint at
night helps their
symptoms say they
start to notice an
improvement after
about four weeks.
[27]

Page 4 of 7
 Shared Decision Making

Lifestyle Pain relief Physical Steroid Surgery

changes medication management injection

How long do For people who People need to We don't know About 94 in 100 For people who
the effects of find that lifestyle keep taking pain how long the people say their benefit from
treatment last? changes or special medications for benefits of nerve symptoms improve surgery, the
equipment help, them to keep and tendon soon after a benefits last for at
we don't know how working. If pain exercises may corticosteroid least six months,
long the benefit medications stop last, as most of the injection. Two and can last a
will last. There helping, doctors research has only years after the lifetime.[36][37]
hasn't been much may advise people looked at the first injection this
About 75 in 100
research.[31] to stop taking three months after number is 60 in
people who have
them. treatment starts. 100.[35]
surgery say that
[32]
their symptoms
About 50 in 100 improve. After two
people say their years, the number
symptoms are is 69 in 100.[38]
better three
months after
starting using a
wrist splint.[33]
People may
continue to feel
better even after
they stop wearing
the splint, but we
don't know for
certain. There
hasn't been much
research.[34]

Page 5 of 7
 Shared Decision Making

Lifestyle Pain relief Physical Steroid Surgery

changes medication management injection

What side Making lifestyle NSAIDs can We don't know There is a Carpal tunnel
effects or changes, or using cause bleeding for sure whether chance that the surgery can cause
complications special keyboards in the stomach nerve and tendon nerve could be unwanted effects.
does the or equipment, are when taken over exercises can damaged when The most common
unlikely to have a long period of cause unwanted corticosteroids are are skin irritation,
treatment have?
any side effects or time. They can effects, because injected into the scarring, infection,
complications.[39] also damage the the research carpal tunnel. The and blood
kidneys. NSAIDs doesn't tell us. It's injection could also collecting under
may increase possible that some lead to an infection the skin at the
the chance of exercises could in the wrist.[42] site of the wound
heart attacks and make symptoms (haematoma).
strokes. NSAID worse.[40] [43] The scar from
tablets may not be surgery can be
Wearing a wrist
suitable for some irritated and painful
splint is generally
people with certain for two to three
safe. Some people
conditions, such as months after the
may experience
asthma, a peptic operation.
discomfort and
ulcer, or angina,
swelling of the It's possible that
or in people who
hands and wrist, surgery will not
have had a heart
difficulty falling work and a second
attack or stroke.
asleep when operation may be
Paracetamol is wearing a splint needed.[44]
unlikely to cause at night, or pins
side effects in and needles when
people who take taking it off in the
the correct dose. morning.[41]
Taking too much
can damage the
liver.

Page 6 of 7
 Shared Decision Making

What are the pros and cons of each option?

People with carpal tunnel syndrome have different experiences about the health problem and views on
treatment. Choosing the treatment option that is best for the patient means considering how the consequences
of each treatment option will affect their life.
Here are some questions people may want to consider about treatment for carpal tunnel syndrome:

Are they willing to wait and see what happens to their symptoms?
Do they want to be able to do more everyday things than they can manage at present?
Are they willing to spend time having treatment?
Are they willing to spend time recovering from treatment?
Are they willing to try a treatment that may take a long time to have an effect?

How do I get support to help me make a decision that is right for me?

Go to http://sdm.rightcare.nhs.uk/pda/carpal-tunnel-syndrome/ for more detailed information about

treatments for Carpal Tunnel Syndrome. People using this type of information say they understand the
health problem and treatment choices more clearly, and why one treatment is better for them than another.
They also say they can talk more confidently about their reasons for liking or not liking an option with health
professionals, friends and family.

References

References can be viewed online at http://sdm.rightcare.nhs.uk/pda/carpal-tunnel-syndrome/references/

Page 7 of 7
 Carpal Tunnel Syndrome
(Pressure on the median nerve in the wrist)
Management Options
Brief Decision Aid

There are five options for the management of carpal tunnel syndrome:
Watchful waiting seeing how things go with no active treatment.
Splinting wearing a splint on the wrist which reduces pressure on the nerve.
Physiotherapy can involve advice on position and working on soft tissues or the nerve.
Injection of steroid (cortisone) into the wrist to reduce inflammation around the nerve.
Surgery decompression of (taking the pressure off) the carpal tunnel. This is a hospital
operation under local anaesthetic (injection). In certain situations, such as rapidly worsening
symptoms, signs of muscle wasting/weakness or severe functional impairment, your doctor
is likely to recommend this option.

Benefits and risks of watchful waiting

Treatment Option Benefits Risks or Consequences
Watchful waiting About 35 in 100 people will find their About 70 in 100 people will still
- no active symptoms resolve within six months. This have symptoms after six
treatment is more likely if you are young (20-29yrs), months.
female or pregnant.
It is already having an impact on
No side-effects or hospital treatment. your life and well-being.

You can choose another option any time.

Benefits and risks of splinting

Treatment Option Benefits Risks or Consequences
Splinting Between 50 and 70 in 100 people will Between 30 and 50 in 100
This involves a have significantly improved symptoms at people will not notice much of a
splint that is six months. difference in their symptoms.
strapped to the
hand and wrist It is especially good for night-time It can be worn during the day
sometimes worn symptoms. though some people may find
just at night and this a nuisance or restricting.
sometimes during Some clinicians can issue these straight
the day as well. away. Sometimes you can only get the
splint from a Physiotherapy
Department or you might have
to buy the splint.

Benefits and risks of physiotherapy

Treatment Option Benefits Risks or Consequences
Physiotherapy May help if your symptoms tend to This may involve several
This can involve happen during certain activities and if you sessions with the
advice on position, are found to have nerve or muscle physiotherapist.
working on soft tightness on assessment by a
tissues or the physiotherapist. There is limited evidence in
nerve. formal trials of physiotherapy.
.
2

Benefits and risks of injection

Treatment Option Benefits Risks or Consequences
Injection About 70 in 100 people will About 30 in 100 people will not get
This involves find their symptoms settle improvement following an injection. Less
injecting a small within 1-2 weeks of the useful if symptoms are very severe, if you
dose of steroid injection. are diabetic, or if symptoms have been
(cortisone) into the present for more than a year.
wrist to reduce You may avoid surgery.
inflammation There is a very small risk of damage to the
around the nerve. The injection can be repeated median nerve this could happen once in
after an interval of a month or every 1000 injections.
two if necessary.
Over time, the symptoms recur in about 30-
Particularly useful if symptoms 50 in every 100 people after single
have occurred in pregnancy or injection.
if you have had
hypothyroidism (low thyroxine The injection is sometimes painful although
level). most people cope with it very well.

Benefits and risks of surgery

Treatment Option Benefits Risks or Consequences
Carpal tunnel 80 - 90 in every 100 10 20 in every 100 people are not satisfied
decompression people are satisfied with with the operation at one year post-op, with 8 in
This is an operation the operation at one year 100 feeling they are worse off at two years.
done in hospital post-op.
under local Heavy lifting is not advised for two weeks after
anaesthetic. Performed under local surgery. Heavy gripping/pinching is not advised
Can be done with anaesthetic so very little for up to six weeks.
an open cut risk of side effects.
(incision) or with There is a very small risk of injury to the nerve
use of an Very low recurrence rate. or surrounding structures.
endoscope
(keyhole surgery). You are left with a small scar (4-5cm) on the
inside of your wrist and there is a small chance
of this becoming sensitive, painful or thickened.

In making a decision you need to ask yourself What is important to me? This leaflet and your
health professional can tell you the evidence and give their suggestions but you need to make a
decision that is right for you. What are your preferences?
You might like to think about:
Is it possible for me, or am I prepared to wear a splint every night?
What do I think about having an injection?
Do I want relief now which might not last, or relief that is more gradual but might last
longer?
Is the problem bad enough that I would want to have an operation?

Brief Decision Aids are designed to help you answer three questions: Do I have options? What are the
benefits and risks of these options, (and how likely are they)? How can we make a decision together that
is right for me?

BDA Carpal Tunnel Syndrome V1.7 final pilot version 14.4.12 1st Authors Dr Tom Holland & Dr. Dave Tomson 2nd Author Dr Roland Pratt
And Darren Flynn Date written 13.4.12 planned revision date April 2013
Main sources and supplementary sources EMIS 2011 Reviewed: 20 May 2011 Doc ID: 4211 Version: 40