Management of Carpal Tunnel Syndrome: Guidelines From the AAOS

Carpal tunnel syndrome (CTS) is caused by compression of the median nerve under the transverse carpal ligament of the wrist, and it affects up to 1 in 20 adults. The most common symptoms are sensory disturbances that disrupt sleep and can impair strength and dexterity. Some patients also experience pain in the wrist and fingers. The American Academy of Orthopaedic Surgeons (AAOS) has published guidelines on the management of CTS.

In the opinion of the guidelines working group, there is no association between high keyboard use and CTS. No high-quality studies address the effect of keyboard use on CTS, and only one low-quality study found an association.

For the diagnosis of CTS, the AAOS strongly recommends using the CTS-6 clinical prediction tool. Strong evidence supports the CTS-6 tool being as effective for diagnosis as ultrasonography, nerve conduction studies, and electromyography, with high correlations and positive predictive values using the other methodologies as reference standards. It is also less expensive and less painful than other testing options.

Ultrasonography, Nerve Conduction Studies, and Electromyography

Most patients with CTS will not need further study when diagnosed with the CTS-6 tool. Further evaluation with ultrasonography, nerve conduction studies, and electromyography should be considered when the CTS-6 result is negative but clinical suspicion is high.

Magnetic Resonance Imaging and Upper Limb Neurodynamic Testing

Magnetic resonance imaging and upper limb neurodynamic testing are not recommended to diagnose CTS because they are less accurate than the CTS-6 tool, ultrasonography, and nerve conduction studies and have higher cost.

Although corticosteroid injections are commonly used to treat CTS, the AAOS finds high-quality evidence that these injections do not provide long-term symptom improvement. Injections can reduce symptoms in the short term, but no improvement is seen in follow-up intervals of 6 months to 5 years compared with other conservative treatments such as night splinting. The most common risks are localized pain and swelling and a small possibility of nerve damage.

Platelet-rich plasma does not reliably improve symptoms or function in the short or long term. The most common risks are mild and related to venipuncture itself. Similarly, hyaluronic acid injections do not reliably improve short-term symptoms, and long-term studies are lacking.

The AAOS also finds no long-term benefit to hydrodissection, in which a solution is injected around the median nerve with ultrasound guidance to separate it from surrounding structures within the carpal tunnel. Most of the few existing studies combine hydrodissection with prolotherapy, which is the injection of an irritant to stimulate an inflammatory response and potentially increase healing. Although a short-term (3–6 months) benefit has been demonstrated, there are no studies evaluating long-term effects.