Carpal Tunnel Syndrome: A 9-Step Guide to Physical Therapy

Do you have carpal tunnel syndrome and are seeking information on physical therapy treatment for this issue? If you’re a physical therapist looking to update your knowledge on carpal tunnel rehabilitation, whether post-surgery or not, this article is for you.

As a physical therapist with 11 years of experience, I address the most frequently asked questions from both internet users and my patients on carpal tunnel syndrome without surgery.

My goal is to provide you with the most reliable and accurate information on this conservative, non-surgical treatment. I draw on:

• My experience as a physical therapist.
• In-depth research in international medical literature. You will find all the references at the end of the article.

I hope to address your main concerns! Feel free to leave your questions in the comments, and I’ll respond as much as I can within the limitations of a simple comment.

Also, feel free to share your experience if you believe it can benefit other readers!

Quick reminders about carpal tunnel, its symptoms, and its causes

Carpal tunnel syndrome is a very common condition, affecting approximately 5% of the global population, especially those aged between 40 and 60. It falls under the broad category of musculoskeletal disorders (MSDs), which encompass issues related to muscles, tendons, and joints.

It’s a problem that we are quite familiar with, at least more so than many others. That’s already a good thing! 👍

Symptoms

The 3 main symptoms are:

1. Pain: Sometimes sudden and more intense during a “flare-up.”
2. Numbness, tingling, and pins and needles sensation:
3. Loss of strength: This can lead to muscle atrophy in the hand, resulting in a loss of muscle volume and flexibility.

These symptoms can manifest in the palm, hand, and arm, sometimes extending up to the shoulder. They may occur on one or both sides. Initially, the pain is often more pronounced at night and may cause disruptions in sleep.

See also: other causes of pain in index fingers.

Causes of carpal tunnel syndrome

Why do these symptoms appear? What’s the cause?

One of the nerves in the arm, the median nerve, is compressed or pinched at the wrist. Blood vessels can also be compressed, intensifying the symptoms.

This tends to happen more often in individuals who are:

• Pregnant or using oral contraceptives.
• Engaged in repetitive wrist activities for several hours a day (such as typing on a computer keyboard, scanning products, or participating in certain sports).
• Obese.
• Afflicted with inflammatory rheumatic disease, renal insufficiency, hypothyroidism, congestive heart failure, or diabetes.
• Genetically predisposed to develop this problem.
• Alcoholics.

Diagnosis of Carpal Tunnel Syndrome

As the symptoms and risk factors are well-known, the diagnosis is often made through an interview and a clinical examination (by observing you). There is not necessarily a need for additional tests such as X-rays, ultrasound, CT scans, or electromyography (EMG).

Because when these tests are done, they often don’t provide more insight into identifying the right treatment!

So, these imaging tests are only conducted if there are genuine doubts: is it really carpal tunnel syndrome or something else, such as thumb arthritis, cervical radiculopathy, De Quervain’s tenosynovitis, or peripheral neuropathy?

Otherwise, we rely on the interview and examination. And possibly small tests like Tinel’s sign, Phalen’s maneuver.

Carpal tunnel syndrome is sometimes classified into three severity categories based on the duration and type of symptoms:

• Mild (less than a year).
• Moderate.
• Severe.

Carpal tunnel syndrome is often diagnosed simply by asking you questions and examining you because its symptoms are quite specific.

How to Tell If Physical Therapy Can Heal or Alleviate Carpal Tunnel Syndrome?

There are roughly three main approaches for carpal tunnel syndrome:

1. Wait and see if things improve on their own (for example, after pregnancy), providing some recommendations to reduce potential activities causing pain.
2. Opt for conservative treatment: everything that is non-surgical. Physical therapy, braces, medications, etc.
3. Consider surgery.

Each approach has its advantages and disadvantages. Ideally, in my opinion, we should clearly present the various alternatives, their pros, and cons. This is what I attempt to do in this article. It’s up to the patients to decide since they are the primary stakeholders!

In this section, we will focus on a part of conservative treatment: physical therapy (also called physiotherapy in most countries).

How to Know If Physical Therapy Is Effective?

How do you know if physical therapy works? Here are at least three ways:

1. Ask your relatives if they had this problem, underwent physical therapy, and if things improved after therapy. The issue here is that we can’t be sure if it’s thanks to physical therapy: carpal tunnel syndrome can get better without necessarily undergoing therapy.
2. Rely on the experience of a physical therapist who has treated many people with this condition. This is slightly better because the therapist will have a larger sample. However, there are still issues: is the therapist biased in judgment? Moreover, they cannot compare improvements with people who haven’t undergone therapy because they don’t know them!
3. Rely on clinical studies that compare the progress of patients with and without physical therapy. Here again, biases may exist. However, out of these three options, it is the most reliable by elimination.

So, I will focus on this third option, relying on the results of clinical studies. And if necessary, or to complement, I will draw on my professional experience.

What Does Physical Therapy Rehabilitation for Non-Surgical Carpal Tunnel Involve?

A German research team had some fun listing all the techniques used by physical therapists (and evaluated in studies) to manage a person with non-surgical carpal tunnel.

List of Physical Therapy Treatments Used for Carpal Tunnel

Here is that list:

• Manual therapy
• Neuro-dynamic technique of median nerve neuromobilization (performed by physical therapists or techniques demonstrated by physical therapists to patients who then perform the technique themselves)
• Mobilizations of soft tissues (fascias) along the median nerve (shoulder, elbow, forearm, wrist, or finger)
• Mobilizations of carpal bones or mobilizations of associated anatomical areas, massages
• Kinesiotaping
• Therapeutic ultrasound
• Shockwaves Therapy
• Laser
• Yoga

The effectiveness of these techniques was compared to:

• Doing nothing specific / waiting list
• Sham therapy
• Wearing a splint
• Another form of manual therapy

Here’s what this research team concluded after examining the results of these different studies:

• Neurodynamic techniques led to positive and clinically significant changes in symptom relief, pain, hypoesthesia, paresthesia, and hand functionality as early as 2 weeks.
• Neurodynamic mobilization proved significantly superior to carpal bone mobilization in terms of speed of effectiveness but comparable to the speed of effectiveness of soft tissue mobilization.
• Physiotherapy (laser, ultrasound) reduced pain, but it took several weeks.

Source: Gräf 2022

Do these study synthesis results align with others published on the subject? You’ll find references to these other syntheses at the end of the article, but to answer this question quickly, we can say: yes.

However, these studies do not follow patients in the long term, only over a few weeks, at most a few months.

Here are the conclusions of one of the best syntheses I’ve read on the conservative treatment of carpal tunnel:

“In the best case, treatment is not only based on a plausible theory explaining how it exerts its effect but is also effective (it presents significant benefits for the patient) in the context of one or more large, rigorously controlled placebo trials. It also brings relevant benefits in a pragmatic clinical context with a diverse population and healthcare providers (efficacy), and finally, it is worth using (cost-effectiveness).

None of the treatment modalities examined in this synthesis meets all these criteria. While most treatments showed slight advantages in individual trials, overall results are often inconsistent from one study to another, and most studies have serious methodological flaws.

In some studies, potentially important clinical benefits were even observed, but never in several independent high-quality studies.“

Karlajanen 2022

I know this may not be what you want to read or hear, but I prefer to provide you with the most factual information possible…

This stance is confirmed by other study syntheses on physical therapy treatments, exercises, and rehabilitation for carpal tunnel. You’ll find them referenced at the end of the article, including the Cochrane Collaboration.

Most Likely Effective Physical Therapy Treatment

In my recommendations for care, I always prioritize physical therapy treatments that require the least reliance on equipment or a third person.

And, of course, I maximize treatments that are most likely to be effective with the least possible side effects.

With all these criteria, the top-choice physical therapy treatment in my opinion is:

1. Identifying your current specific discomforts with you.
2. Defining realistic and achievable goals considering these discomforts.
3. Identifying things you can implement to reach these goals. This often includes:
   • Reassuring you about your concerns.
   • Encouraging you to be more active daily.
   • Identifying situations that are likely to worsen your musculoskeletal disorders (like carpal tunnel) and considering alternatives.
   • Performing median nerve release movements (a technique called neurodynamic treatment of the median nerve, ULNT). There are variants to tension the radial or ulnar nerve. Therapists conduct an assessment during the first session to identify the most suitable approach for you.

Here’s a deliberately simple video that explains this technique of stretching the median nerve:

Physical therapy is not limited to having you perform movements or exercises, or mobilizing and massaging to relieve pain.

What does physical therapy rehabilitation for carpal tunnel look like after surgery?

Firstly, know that it’s quite rare to have physical therapy sessions after carpal tunnel surgery. Simply because it’s not automatically covered by health insurance in many countries.

Some studies have been conducted to determine if rehabilitation after carpal tunnel surgery provides additional benefits. It doesn’t seem to be the case (Peters 2016).

When physical therapy is still proposed, here are the main areas of care:

• Reassure you, answer your questions about the evolution, what you are allowed to do, what is better to avoid, when and how to resume various activities.
• Observe the range of motion of your various hand and wrist joints. Show you exercises tailored to your situation to maintain or recover this mobility. And if everything is fine, simply tell you that you don’t need to do anything specific (this happens very often!).
• Check the strength of your muscles and recommend small exercises if necessary (again, often not needed).
• Provide advice to alleviate any pain.

Physical therapy rehabilitation sessions after carpal tunnel surgery are not often prescribed and require a prior authorization request from social security. Often, a gradual return to daily life is sufficient for a good recovery from the operation.

Who can prescribe carpal tunnel physical therapy sessions?

In many countries, physical therapy sessions must be prescribed by a doctor to be reimbursed by health insurance and supplementary insurance.

No matter the doctor:

• Your general practitioner,
• A rheumatologist,
• A surgeon,
• A sports doctor… All doctors, regardless of their specialties, can prescribe rehabilitation sessions for a carpal tunnel problem.

When to opt for carpal tunnel surgery?

To answer this question about the effectiveness of carpal tunnel surgery, I rely on the work of the Cochrane Collaboration.

An international association that brings together several hundred research teams trying to create high-quality syntheses on the effectiveness of health care interventions.

Treatment	Outcome	Reference
Comparison of the effectiveness of different carpal tunnel decompression surgical interventions	No strong evidence supports the justification of replacing traditional open carpal tunnel release with alternative surgical interventions in the treatment of carpal tunnel syndrome. The decision to perform endoscopic carpal tunnel release instead of open release seems to depend on surgeon and patient preferences.	Scholten 2007
Effectiveness of surgery compared to non-surgical treatments	Surgical treatment of carpal tunnel syndrome relieves symptoms much better than wearing a splint. Further research is needed to determine if this conclusion applies to individuals with mild symptoms and if surgical treatment is more effective than corticosteroid injections.	Verdugo 2008
Comparison of endoscopic release vs. other surgical techniques	Both are equally effective in relieving symptoms and improving functional status. Although endoscopic release may be significantly more beneficial in terms of functional improvement in grip strength. It also appears to be associated with fewer minor complications, but no difference was found in rates of major complications. Return to work is faster after endoscopic release, averaging eight days. The conclusions of this review are limited by a high risk of bias, statistical imprecision, and inconsistency in included studies.	Vasiliadis 2014

Conclusion: Surgery is more effective than wearing a splint for providing lasting relief from carpal tunnel pain.

What other treatments for carpal tunnel syndrome are available?

I rely once again on the research conducted by the Cochrane Collaboration to identify conservative treatments other than physical therapy aimed at relieving pain and other symptoms related to carpal tunnel syndrome.

Here are these conservative treatments, other than physical therapy, evaluated by Cochrane, along with their conclusions.

Treatment	Outcome	Reference
Local corticosteroid injection	Local corticosteroid injection is effective for mild to moderate carpal tunnel syndrome, with benefits lasting up to six months and a reduced need for surgery for up to 12 months. Serious adverse events were rare when reported.	Ashworth 2023
Laser therapy	There is insufficient evidence to support that laser therapy is better or worse than any other type of non-surgical treatment in managing carpal tunnel syndrome.	Rankin 2017
Therapeutic ultrasound	Only poor-quality data from very limited studies suggest that therapeutic ultrasound might be more effective than a placebo for improving symptoms in the short or long term in people with carpal tunnel syndrome.	Page 2013
Improving posture, setup, ergonomics	There is not enough data from randomized controlled trials to determine whether positioning or ergonomic equipment is beneficial or harmful in the treatment of carpal tunnel syndrome.	O’Connor 2012
Splints, day or night orthoses	Limited evidence does not rule out small improvements in carpal tunnel symptoms and hand function, but they may not be clinically significant, and the clinical relevance of small differences with the splint is unclear. Low-certainty data suggest that people are more likely to achieve overall improvement with nighttime splints than with no treatment. As splinting is a relatively low-cost and plausibly harmless intervention in the long term, small effects could justify its use, especially when patients do not wish to undergo surgery or injections.	Karjalainen 2023

Splints can be purchased at pharmacies, medical equipment stores, sometimes at large retailers, or online.

Conclusion: Corticosteroid injections can alleviate pain, as can wearing a night splint (with less effect but also less risk).

Is there natural remedies for carpal tunnel syndrome?

In this article, I have already discussed many “natural” treatments, assuming “without medication” or “without surgery”:

• Physiotherapy management
• Wearing a night splint
• Carpal tunnel release exercises (stretching)

Some people wonder if:

• Essential oils,
• Homeopathy,
• Acupuncture,
• Or other similar “remedies” can be useful.

Here is my position on this.

Many other treatments mentioned here are theoretically more likely to be effective than the latter listed. However, we often struggle to gather evidence of significant effectiveness for these theoretically more effective treatments.

In this context, I find it more reasonable to think that these other natural treatments are probably not more effective beyond a placebo effect.

Here are the conclusions of a Cochrane review on the subject:

Acupuncture and laser acupuncture may have little or no short-term effect on carpal tunnel symptoms compared to placebo or sham acupuncture.

It is uncertain whether acupuncture and related interventions are more or less effective in relieving symptoms than corticosteroids for nerve blocks, oral corticosteroids, vitamin B12, ibuprofen, splints, or when combined with NSAIDs and vitamins, given that the certainty of the conclusions drawn from the evidence is low or very low, and most of the data come from short-term observations.

Choi 2018