Hand Clin 18 (2002) 279–289
Nonoperative carpal tunnel syndrome treatment
A. Lee Osterman, MDa,b, Marc Whitman, PTc,1,
Linda Della Porta, OTR, CHTc,2,*
Philadelphia Hand Center, 834 Chestnut street, Philadelphia, PA, USA
Department of Orthopedic and Hand Surgery, Thomas Jeﬀerson University Hospital, USA
Recipient of the Evelyn J Mackin Hand Therapy Fellowship, 834 Chestnut Street, Philadelphia, PA, USA
Carpal tunnel syndrome (CTS) has been cited As CTS continues to manifest itself as a signiﬁ-
as the most common of the upper extremity com- cant economic and debilitating entity, it will be
pression neuropathies [1–3]. A recent study exam- more important to research and develop treatment
ined the prevalence osf CTS in a Swedish general approaches. We believe that nonoperative treat-
population. The authors found, in a population ment is a viable option for the management of
of 170,000, self-reported sensory changes and/or CTS. The following discussion will explore the
pain in the median nerve (MN) distribution in various treatment options presented in the litera-
14.4%, clinical and electrophysiologically con- ture and the rationale behind their use.
ﬁrmed CTS in 2.7% . Among workers, the inci- Why choose nonsurgical treatments? There are
dence of CTS, based on claim data, was reported several reasons:
as 24.5 per 10,000 full-time employees in Washing-
1. Conservative management can cost less than
ton State . In addition, the Bureau of Labor
surgical management. In California (1993),
Statistics (BLS) reported 1,702,500 work-related
the average cost of surgical intervention was
injuries involving time away from work, and of
$20,925, as compared with $5,246 for nonop-
those 27,900 cases or 1.6% were CTS .
erative intervention .
In terms of cost and time away from work, CTS
2. Various nonsurgical treatments for CTS have
has resulted in lost revenue for the employer and
been shown to ameliorate symptoms in 13–
employee. The BLS considers median days away
92% of patients [3,9–16]. These studies docu-
from work a key indicator as to the severity of
ment that conservative management is
occupational injury. In 1999, CTS required the
highest time away at 27 days, followed by fracture
3. There is a population of CTS patients that is
(20 days) and amputations (18 days) . In Wash-
appropriate for conservative treatment
ington State, there were 27,148 claims ﬁled for
[17,18]. Patients with carpal tunnel symptoms
CTS at an average cost of $12,627 per claim
can generally be categorized based on chron-
between 1992 and 1998 . This resulted in more
icity and severity of signs and symptoms.
than $300,000,000 for the management of CTS
[1,19,20]. Those patients with underlying sys-
and may not include other costs such as litigation,
temic disease or severe changes indicative of
lost productivity, lost wages, or retraining.
MN compromise need surgical decompres-
sion or further medical management [18,21].
But as recommended by several authors
* Corresponding author.
[10,11,13,14,22], conservative treatment is
E-mail address: email@example.com (L. Della
indicated for mild to moderate symptoms
Present address: P.O. Box 112192, Anchorage, AK with early intervention generally more predic-
99511-2192 tive of satisfactory outcomes.
Present address: 56 Parkton Road #1, Jamaica 4. It has been speculated  that many patients
Plain, MA 02130 with the signs and symptoms of CTS are now
0749-0712/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 2 3 - 9
280 A.L. Osterman et al / Hand Clin 18 (2002) 279–289
seeking treatment earlier caused by the tunnel of the wrist. Currently, there is a debate
improved access to information by various regarding whether ischemia or mechanical forces
media sources. If this is the case, then nonsur- exerts the greatest impact on changes to the MN
gical intervention will continue to be instru- [17,19,22–26]. Controversy also exists about the
mental in treatment of this condition. role of inﬂammation. Although tissue studies do
5. Finally, as with any surgery, there are risks not support inﬂammation as a precursor to CTS
associated with the procedure to release the [27,28], strategies to ‘‘reduce inﬂammation’’ have
carpal tunnel. These include infection, stiff- been used with some success [29,30]. CTS is
ness, reﬂex sympathetic dystrophy, and nerve regarded as a multifaceted syndrome, and causal-
or tendon injury , which makes nonoper- ity is largely unknown. It has been associated,
ative management a more appealing ﬁrst line however, with various conditions that can pre-
of treatment. dispose individuals to its development. These
conditions are as follows: 1) acute trauma,
We are not advocating that surgical interven-
2) endocrine disorders, 3) inﬂammatory arthritis,
tion for CTS is unncessary or warranted, but,
4) chronic renal failure, 5) pregnancy, 6) mass
potentially, surgery may be avoided and overall
lesions within the carpal canal, 7) occupational/
cost and time away from work may be reduced
recreational factors, 8) lifestyle, 9) traction injury,
through the use of nonoperative treatment strat-
and 10) double crush [1,31–33]. The development
egies if applied consistently and early in the course
of this neuropathy can also occur for seemingly
of treatment (see Box 1).
no reason at all and is thus labeled ‘‘idiopathic
carpal tunnel syndrome.’’
CTS generally is considered a compressive neu- Treatment
ropathy of the MN as it courses through the carpal
The ﬁrst course of treatment for CTS generally
consists of prescribed medication consisting of
nonsteroidal anti-inﬂammatory drugs (NSAIDs)
Box 1 Current nonoperative and/or steroids that can be delivered orally or by
treatment injection. The action of these medications is to
inhibit the chemical mediators of inﬂammation in
Medicinal response to injury. By limiting the inﬂammatory
• NSAIDs response, they also suppress pain by desensitizing
• Steroids nociceptors to these same chemicals . The eﬀec-
Injectible tiveness of NSAIDs versus steroids for treatment
Oral of CTS was examined in a 1998 study. In a 4-week
trial evaluating eﬀect of medication as the sole
• Pyridoxine (B6)
treatment short-term, low-dose oral steroids were
Modalities more eﬀective than NSAIDs, diuretics, and pla-
• Ultrasound cebo . This was supported in another study,
• Iontophoresis which also found low-dose, short-term oral ste-
roids more eﬀective than placebo only. This trial
Splinting period was 8 weeks, however, and demonstrated
Activity modiﬁcation that the initial improvement provided by the ste-
• Ergonomic intervention roid was temporary with a return in symptoms
• Avocational assessment . Oral steroids seem to show more promise in
the short-term management of CTS than NSAIDs
Exercise but are associated with negative side-eﬀects if used
• Tendon gliding for long periods.
• Nerve gliding Local steroid injection into the carpal canal is
• General conditioning an option to avoid the systemic actions of oral
Yoga steroids. The injectable steroid of choice is water-
Stretching soluble and can be combined with an anesthetic
to reduce injection discomfort. A study examining
A.L. Osterman et al / Hand Clin 18 (2002) 279–289 281
injections  found long-term relief of symptoms at 20–30° of extension (Fig. 1). Ideally, a thermo-
(‡1 year) in only 24% of subjects. An additional plastic splint should be custom-ﬁt to ensure that
27% responded initially but then had a reoccur- the wrist is at a neutral angle (Fig. 2). It has been
rence of symptoms within 1 year. Various other reported that individuals will experience a decrease
studies have reported success rates from 13% to in symptoms after wearing a splint for 2 weeks .
92% utilizing injections alone or combined with Optimal results with splints were obtained if
splinting [10,14,16]. Success rates were deﬁned as applied within the ﬁrst 3 months of onset .
lasting improvement in symptoms 11–18 months But a 2-week trial is worthwhile regardless of
in duration. Response to an injection can also cor- how long the individual has been experiencing
relate and predict the response to surgical release symptoms . The eﬀect of lumbrical incursion
. This is particularly true when there are con- with ﬁnger position has been studied. It was deter-
founding conditions, such as double crush syn- mined that increased ﬁnger ﬂexion increases carpal
drome , diabetes, and discrepancies on the canal pressures. Therefore, it was concluded that
cervical spine exam. Complications and risks asso- ﬁnger motion as well as wrist position plays a role
ciated with injection of the carpal canal include in carpal canal pressure . A study of cadaveric
tendon rupture, nerve injuries, pain, transient gly- dissections conﬁrmed that the lumbrical muscles
cemic elevation in diabetics, skin atrophy, and originate distal to the carpal canal with the ﬁngers
depigmentation. extended. With ﬁngers ﬂexed, lumbrical muscles
Controversy still exists regarding the role of were found within the carpal canal. It was sug-
pyridoxine (Vitamin B6) as a component in the gested that the lumbricals can contribute to com-
treatment of CTS [37–40]. The current literature pression within the carpal tunnel . Because
does not clearly support or detract from the use increased ﬁnger ﬂexion as well as wrist position
of vitamin B6. Therefore, if utilized, it should be play a role in carpal canal pressures, a metacarpal
in conjunction with other treatments (Box 1). block may be a consideration if symptoms do not
subside with a standard wrist splint.
Immobilization of the wrist through splinting is
a component of nonoperative treatment. Individu-
als are instructed to wear splints while sleeping
because that is when symptoms tend to be most
pronounced. In addition, it is more diﬃcult to
maintain the wrist in a neutral position at this
time. During wakening hours, individuals can be
instructed to monitor wrist position with activity
and to maintain the wrist in a neutral alignment,
avoiding ulnar deviation.
Carpal tunnel pressures have been studied with
ﬂexion and extension to determine the position of
the wrist that results in the lowest carpal canal
pressures. It was reported that 2þ/ÿ9° of exten-
sion and 2þ/ÿ6° of ulnar deviation is the position
with the lowest carpal canal pressure. Immobiliza-
tion of the wrist closest to neutral was recom-
mended . Symptom relief at neutral and at
20° of wrist extension have been compared.
Results indicated that symptom relief was found
to be greater at neutral than with 20 degrees of
wrist extension . With immobilization of the
wrist, the angle of the splint should be carefully
evaluated, as even small diﬀerences can aﬀect
carpal canal pressures and symptom relief. Fre-
quently, prefabricated splints position the wrist Fig. 1. Commercially available splint.
282 A.L. Osterman et al / Hand Clin 18 (2002) 279–289
other conservative measures. It would also be ben-
eﬁcial to study the eﬀects of fewer ultrasound
treatments as 20 treatments may be costly.
Iontophoresis is an electrical modality used
to deliver medication in an ion form with the
objective of delivering a higher local concentra-
tion, minimizing systemic concentration . In a
study by Banta, a standard treatment protocol was
utilized using wrist splinting, NSAIDs, and ionto-
phoresis with dexamethasone sodium phosphate
. The study revealed a success rate comparable
with splinting plus injection of dexamethasone
into the carpal tunnel space. It should be noted
that the study had several shortcomings: a small
sample size, lack of randomization and blinding,
and no use of a sham iontophoresis group. In those
individuals that are unable to tolerate steroid
injections into the carpal canal, however, the use
of iontophoresis may be an option.
Pressure over the carpal canal , wrist posi-
tioning [41–43], low temperatures , vibration
[51,52], and high force with high repetition 
have been cited as occupationally related risk fac-
Fig. 2. Custom-made splint by hand therapist.
tors in the development of CTS. Nonoccupational
risk factors such as diabetes, rheumatoid arthritis,
thyroid disease, and obesity have also been cited as
risks [50,53]. Weight and body mass have been cor-
Therapeutic ultrasound is a modality that pro- related with slowing of sensory conduction of the
duces acoustical high-frequency vibrations with median nerve . It was suggested that individual
both thermal and nonthermal eﬀects . It has characteristics, not job-related factors, were pri-
been observed, ‘‘The literature suggest[s] that low mary determinants of CTS. The development of
intensity pulsed ultrasound is the most appropriate carpal tunnel syndrome is multifactorial, therefore
to promote healing of open wounds, to resolve controversy remains regarding the primary inﬂu-
acute and subacute inﬂammation, and to enhance encing and etiologic factors .
repair in tendon, nerve and bone’’ . With CTS, Despite this controversy regarding primary
ﬂexor tendons may be inﬂamed. If ultrasound is inﬂuencing factors, it may be beneﬁcial to address
used, pulsed or nonthermal mode would be the individuals’ occupational and nonoccupational
most appropriate as continuous or thermal mode risk factors in order to maximize the eﬀectiveness
may irritate inﬂamed tendons. of conservative treatment. Though ergonomic
Recently, the eﬀects of ultrasound for the treat- measures have not been shown to inﬂuence the
ment of mild to moderate idiopathic CTS were development of CTS, they have been useful in
studied. Twenty treatments of pulsed ultrasound the conservative management of those patients
were applied to the area over the carpal tunnel. with established mild CTS.
Results suggested satisfying short- to medium- Mechanical stress or direct pressure over the
term eﬀects. Individuals receiving ultrasound carpal canal has been shown to increase carpal
treatments experienced reduced symptoms and canal pressures . Wrist positioning with tool
improved nerve conduction compared with results use can be modiﬁed when indicated. If a keyboard
in a placebo control group . This study utilized or tool is positioned incorrectly, direct pressure
ultrasound as the sole treatment. Our opinion, may be placed over the carpal canal, causing an
however, is that if ultrasound is used for carpal increase in carpal canal pressures. Rounding and
tunnel treatment, it should be in conjunction with padding edges of workstations can be helpful.
A.L. Osterman et al / Hand Clin 18 (2002) 279–289 283
Positioning the wrist closest to a neutral align- of exposure to environmental factors through
ment helps to achieve the lowest possible carpal job rotation or elimination of aggravating factor
canal pressure [41–43]; therefore, this neutral wrist may be necessary.
alignment should be maintained with work and
avocational activities. With the increasing use of
computers at home, it is insuﬃcient to consider Exercises
keyboard positioning for work needs only. Indi-
An evaluation of upper extremity musculature
viduals should be encouraged to apply ergonomic
and cervical screen should be completed prior to
principles with all other daily activities. Ulnar
prescribing exercises or stretches for CTS. A prox-
deviation in excess of 20° has been associated
imal weakness may be contributing to overuse
with increased carpal tunnel pressures . Ergo-
of distal musculature. An individual can also pre-
nomic tools that are designed with bent handles or
sent with muscle imbalances secondary to overuse
adaptations can decrease ulnar deviation. An
of ﬂexors. In cases where extensor weaknesses
ergonomic split keyboard maintains the wrist
is noted, stretches of ﬂexor musculature and
as straight, decreasing wrist deviation. But because
strengthening of extensors would be the most
an item is labeled ergonomic does not mean that
appropriate. Repetitive gripping exercises with
it is the most appropriate. Items should be care-
grip tools or balls can contribute to further inﬂam-
fully evaluated and basic principles applied. An
mation of ﬂexor musculature and therefore should
ergonomic keyboard will not be as eﬀective if it
be avoided. An assessment of daily activities or
is placed at a level where the individual is unable
components of work is helpful in determining the
to maintain the wrist in neutral alignment. In a
most appropriate stretches or exercises for an indi-
recent study, it was found that in many partici-
vidual. Stretch breaks from repetitive activities
pants, carpal tunnel pressures measured during
should be encouraged. In a recent study, signiﬁ-
mouse use were greater than pressures known to
cant decreases in carpal tunnel pressures were
alter nerve function and structure. Although not
noted following 1 minute of hand and wrist exer-
clinically demonstrated, authors’ recommenda-
cises. Brief intermittent wrist and hand exercises
tions include minimizing wrist extension, pro-
were recommended to reduce intratunnel pressure
longed mouse dragging, and performing other
. Based on these ﬁndings, speciﬁc exercises
tasks with the mousing hand .
were developed for CTS [29,57].
It was reported by Silverstein that high force
combined with high repetitiveness increases the
risk more than 5· that of either factor alone .
Tendon gliding exercises and median nerve
Strategies to decrease repetitiveness may include
alternating repetitive with nonrepetitive work
activity, stretch breaks, or job rotation. In order The eﬀectiveness of nerve and tendon gliding
to change force requirements, the tool itself may exercises for the conservative treatment of CTS
need to be changed. Whenever possible, educate has been studied (Fig. 3 and Fig. 4). The study indi-
the individual to avoid overuse of ﬂexors or cated that 43% of those who performed the exercises
exerting more muscle force than is required. Bio- did not undergo surgery, whereas 71.2% of those
feedback can be helpful in increasing an indivi- who did not perform the exercises underwent sur-
dual’s awareness of hand postures. In a study gery. The experimental and control groups both
comparing the eﬀects of biofeedback with CTS, received traditional conservative treatment with
individuals reported that this feedback was help- splinting, nonsteroidal anti-inﬂammatory medica-
ful in improving awareness. There was no direct tion, and steroid injections. The diﬀerence was that
objective evidence, however, that biofeedback the experimental group also performed tendon and
was helpful in reducing the symptoms of CTS nerve gliding exercises as developed by Totten and
. There is a correlation between carpal tunnel Hunter [15,58]. The authors of this study postulated
syndrome and prolonged exposure to environ- that guiding the wrist and ﬁngers through this pro-
mental conditions such as vibration [51,56] and/ gram of nerve and tendon gliding exercises would
or cold temperature exposure . Work gloves help to maximize MN excursion in the carpal tunnel
may be helpful but need to be carefully evaluated. and excursion of the ﬂexor tendons relative to one
An individual may grip more forcefully secondary another. They proposed that a ‘‘ milking’’ eﬀect
to a decrease in sensory feedback. When possible, would promote venous return and decrease the
modify the tool to dampen vibration. Reduction pressure inside the perineurium [15,58]. Further
284 A.L. Osterman et al / Hand Clin 18 (2002) 279–289
Fig. 3. (A–D) Tendon gliding exercises. (From Totten PA, Hunter JM. Therapeutic techniques to enhance nerve gliding
in the thoracic outlet and carpal tunnel syndrome. Hand Clin 1991;7(3):505)
A.L. Osterman et al / Hand Clin 18 (2002) 279–289 285
Fig. 4. (A–E) Wrist level median nerve gliding exercises. (From Totten PA, Hunter JM. Therapeutic techniques to
enhance nerve gliding in the thoracic outlet and carpal tunnel syndrome. Hand Clin 1991;7(3):505.)
286 A.L. Osterman et al / Hand Clin 18 (2002) 279–289
to avoid aggravating symptoms. As symptoms
decrease, the individual can progressively perform
the remaining movements of the sequence .
Double crush syndrome, originally described
by Upton and McComas , refers to the co-
existence of dual lesions along the course of a nerve.
They proposed that a more proximal lesion would
lessen the ability of the nerve to withstand a more
distal compressive force. The coexistence of CTS
with cervical radiculopathy has been reported in
the literature [32,64]. If the individual being
treated for CTS presents with a more proximal
lesion, performing wrist level median nerve gliding
exercises only may be insuﬃcient. Proximal
shoulder or cervical issues should be evaluated.
The eﬀects of performing brachial plexus nerve
glides have not been studied for the treatment of
CTS. Further research on proximal as well as dis-
tal stretches, nerve glides, or exercises would be
beneﬁcial to determine potential beneﬁt in the
treatment of CTS.
Recently, a preliminary study compared eﬀects
of a yoga-based regimen in the treatment of CTS
Fig. 4 (continued ) . Subjects assigned to the yoga group per-
formed 11 yoga postures along with relaxation
research is needed to evaluate the most eﬀective twice weekly for 1–1.5 hour sessions. Subjects in
exercises and nerve gliding techniques for CTS. the yoga groups demonstrated improvements in
grip strength, pain reduction, and improvements
with Phalen’s sign. Signiﬁcant diﬀerences were
Brachial plexus gliding program
not demonstrated with Tinel’s sign, sleep disturb-
The median nerve has been shown to move ance, or in motor and sensory conduction time.
within the carpal tunnel and the upper extremity This study demonstrated improvements with the
with various positions. McLellan and Swash dem- use of yoga postures; however, several limitations
onstrated movement of the MN longitudinally in exist. In addition to small sample size, medication
the upper extremity, depending on joint position use, and splint angle for controls were not
. They also demonstrated longitudinal move- recorded.
ment of the MN with proximal joint motion of It is important to realize that speciﬁc postures
the shoulder and elbow. It was theorized that this were utilized; therefore, it is diﬃcult to generalize
longitudinal sliding is necessary to minimize local that all of yoga may be eﬀective in improving car-
stretching and to prevent entrapment along the pal tunnel symptoms. There are many diﬀerent
course of the nerve as the limb moves. schools of yoga, and varieties of teaching. Each
In work by Butler, this longitudinal movement type of yoga emphasizes diﬀerent postures, relaxa-
of the peripheral nervous system is recognized. tion, and breathing techniques. Hatha yoga is the
Butler describes selective tensioning of the upper branch of yoga involved with movement. There
limb for treatment of neural entrapment. He has are forms of yoga that do not involve movement
elaborated on Elveys brachial plexus tension test, and emphasize relaxation or attainment of spiri-
with median ulnar and radial nerve bias [61,62]. tual goals. The yoga utilized in this study is based
A brachial plexus gliding program has also been on movement or hatha yoga along with relaxation
described to facilitate nerve gliding from proximal techniques. The exercises utilized emphasize upper
to distal. With this program, the individual extremity movements and stretches, both proximal
attempts to move to the point of tension, not pain, and distal. In our opinion, this study reinforces the
A.L. Osterman et al / Hand Clin 18 (2002) 279–289 287
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