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Carpal Tunnel Syndrome

Symptoms and Signs

General advice
  • Tingling and numbness in lateral (radial) 3 1/2 digits- median nerve distribution (Thumb, index, middle, ½ ring)
  • May be associated with hand/ wrist/ forearm pain
  • More common in women
  • Dropping items/clumsiness/weakness of pinch grip. Difficulty with loose change/buttons
  • Aggravated by holding e.g. phone/newspaper or driving
  • +/- Weakness in abductor pollicis brevis, +/- Wasting in abductor pollicis brevis (may indicate axonal loss)
  • Wake up at night & relieved with movement for 15-20 minutes
  • Positive Tinel’s (produces symptoms)
  • Positive Phalen’s (produces symptoms)

Initial Management

  • Exclude cervical radiculopathy (Nerve root compression/cord compression)
  • May resolve or significantly improve in around 50% of cases with splints: 'Futuro' wrist splint should be worn overnight only for 6/52 (in a neutral position) to determine efficacy. Can be bought from any chemist or online. 
  • Activity modification may be beneficial in some cases - avoiding repetitive hand/wrist movements, arranging workplace assessment if appropriate. 
  • Medication: Mild diuretics may be of benefit in patients with oedema. NSAIDs may be of benefit if inflammation is present  
  • Refer to MSK physiotherapy for neural gliding exercises and/or corticosteroid injection if unable to administer in GP Practice. May give relief for patients with mild/moderate CTS (sensory and motor abnormalities but no axonal loss). Neurophysiology testing can be requested by MSK Physiotherapy service if necessary. Direct listing or onward referral to hand service can be organised by AHP colleagues without further need for GP intervention/referral. 

Additional Resources

Carpal Tunnel Syndrome Patient Leaflet (NHS Fife)
NICE CKS Carpal Tunnel Syndrome 

Who to Refer

Consider referral to secondary care if: 
  • Signs of severe median nerve compression e.g thumb (thenar) wasting or weakness
  • Rapid progression of symptoms
  • Diabetes mellitus
  • Previous Carpal tunnel decompression surgery with recurrence
  • Poor or no response to conservative treatment

Include the following information:
  • Conservative management tried (e.g. any relief through splintage?)
  • Any history of neck problems
  • If patient is diabetic, pregnant or has a thyroid disorder
  • If symptoms are unilateral or bilateral
  • If motor weakness is present
  • CTQS score if known

Who not to refer

  • Uncomplicated symptoms less than 3 months duration with no conservative treatment tried.
  • Pregnancy related or post-partum CTS can take up to 2 years to resolve. Please treat conservatively and refer only if symptoms are no better at all after one year. 

How to Refer

  • If being seen by MSK physiotherapy service, onward referral to hand service will be organised by Physiotherapist. 
  • SCI Gateway/Hand Surgery. Patients will be seen by Advanced Practice Physiotherapist initially.