Published 10/1/2008

AAOS Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome

Summary of Recommendations
See the online version of the guidelines, available at
www.aaos.org/guidelines, for a complete description of how the quality of evidence is rated and the recommendations are graded.

Recommendation 1
A course of nonoperative treatment is an option in patients diagnosed with carpal tunnel syndrome (CTS). Early surgery is an option when there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment. (Grade C, Level V)

Recommendation 2
We suggest another nonoperative treatment or surgery when the current treatment fails to resolve the symptoms within 2 weeks to 7 weeks. (Grade B, Level I and II)

Recommendation 3
We do not have sufficient evidence to provide specific treatment recommendations for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace. (Inconclusive, No evidence found)

Recommendation 4a
Local steroid injection or splinting is suggested when treating patients with carpal tunnel syndrome, before considering surgery. (Grade B, Level I and II)

Recommendation 4b
Oral steroids or ultrasound are options when treating patients with carpal tunnel syndrome. (Grade C, Level II)

Recommendation 4c
We recommend carpal tunnel release as treatment for carpal tunnel syndrome. (Grade A, Level I)

Recommendation 4d
Heat therapy is not among the options that should be used to treat patients with carpal tunnel syndrome. (Grade C, Level II)

Recommendation 4e
The following treatments carry no recommendation for or against their use: activity modifications, acupuncture, cognitive behavioral therapy, cold laser, diuretics, exercise, electric stimulation, fitness, Graston instrument, iontophoresis, laser, stretching, massage therapy, magnet therapy, manipulation, medications (including anticonvulsants, antidepressants, and nonsteroidal anti-inflammatory drugs [NSAIDs]), nutritional supplements, phonophoresis, smoking cessation, systemic steroid injection, therapeutic touch, vitamin B6 (pyridoxine), weight reduction, yoga. (Inconclusive, Level II and V)

Recommendation 5
We recommend surgical treatment of carpal tunnel syndrome by complete division of the flexor retinaculum regardless of the specific surgical technique. (Grade A, Level I and II)

Recommendation 6
We suggest that surgeons do not routinely use the following procedures when performing carpal tunnel release: skin nerve preservation (Grade B, Level I); epineurotomy (Grade C, Level II)

The following procedures carry no recommendation for or against use: flexor retinaculum lengthening, internal neurolysis, tenosynovectomy, ulnar bursa preservation. (Inconclusive, Level II and V)

Recommendation 7
The physician has the option of prescribing preoperative antibiotics for carpal tunnel surgery. (Grade C, Level III)

Recommendation 8

  • We suggest that the wrist not be immobilized postoperatively after routine carpal tunnel surgery. (Grade B, Level II)
  • We make no recommendation for or against the use of postoperative rehabilitation. (Inconclusive, Level II)

Recommendation 9
We suggest physicians use one or more of the following instruments when assessing patients’ responses to CTS treatment for research:

  • Boston Carpal Tunnel Questionnaire (disease-specific)
  • DASH—Disabilities of the Arm, Shoulder, and Hand (region-specific; upper limb)
  • MHQ—Michigan Hand Outcomes Questionnaire (region-specific; hand/wrist)
  • Patient Evaluation Measure (region-specific; hand)
  • SF-12 or SF-36 Short Form Health Survey (generic; physical health component for global health impact) (Grade B, Level I, II, and III)