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J Am Acad Orthop Surg, Vol 17, No 6, June 2009, 397-405.
© 2009 the American Academy of Orthopaedic Surgeons
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Treatment of Carpal Tunnel Syndrome

Michael Warren Keith, MD, Victoria Masear, MD, Peter C. Amadio, MD, Michael Andary, MD, MS, Richard W. Barth, MD, Brent Graham, MD, Kevin Chung, MD, MS, Kent Maupin, MD, William C. Watters, III, MD, Robert H. Haralson, III, MD, MBA, Charles M. Turkelson, PhD, Janet L. Wies, MPH and Richard McGowan, MLS

This clinical practice guideline was approved by the American Academy of Orthopaedic Surgeons.

Dr. Keith is Professor, Orthopaedics and Biomedical Engineering, and Chief, Hand Surgery Service, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH. Dr. Masear is Orthopaedic Surgeon, Orthopaedic Specialists of Alabama, Birmingham, AL. Dr. Amadio is Orthopaedic Surgeon, Mayo Clinic, and Professor of Orthopedics, Mayo Clinic College of Medicine, Rochester, MN. Dr. Andary is Professor, Department of Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI. Dr. Barth is Chief, Section of Orthopaedic Surgery, and Chief, Section of Hand Surgery, Sibley Memorial Hospital, Washington, DC, and a member of the Board of Councilors, American Academy of Orthopaedic Surgeons, Rosemont, IL. Dr. Graham is Head, University Hand Program, and Assistant Professor, Department of Surgery, University of Toronto, Toronto, ON, Canada. Dr. Chung is Professor, Plastic Surgery, University of Michigan Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI. Dr. Maupin is Orthopaedic Surgeon, Michigan Hand Center, Grand Rapids, MI. Dr. Watters is Orthopaedic Surgeon, Bone and Joint Clinic of Houston, Houston, TX. Dr. Haralson is Executive Director of Medical Affairs, American Academy of Orthopaedic Surgeons. Dr. Turkelson is Director, Department of Research and Scientific Affairs, American Academy of Orthopaedic Surgeons. Ms. Wies is Manager, Clinical Practice Guidelines Unit, American Academy of Orthopaedic Surgeons. Mr. McGowan at the time this guideline was being developed was Medical Research Librarian, American Academy of Orthopaedic Surgeons.

Dr. Masear or a member of her immediate family serves as a board member, owner, officer, or committee member of the American Society for Surgery of the Hand and is affiliated with the publication The American Journal of Orthopedics. Dr. Amadio or a member of his immediate family serves as a board member, owner, officer, or committee member of the Orthopaedic Research Society, and Immanuel St. Joseph Hospital; is affiliated with the publication/publisher Journal of Orthopaedic Research and Saunders/Mosby-Elsevier; has received research or institutional support from the Musculoskeletal Transplant Foundation and the National Institutes of Health (NIAMS and NICHD); has stock or stock options held in Johnson & Johnson, Merck, and Procter & Gamble; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from the Journal of Bone and Joint Surgery American. Dr. Andary or a member of his immediate family is a member of a speakers’ bureau or has made paid presentations on behalf of Pfizer and Allergan. Dr. Barth or a member of his immediate family has stock or stock options held in Amgen, Merck, and Pfizer. Dr. Graham or a member of his immediate family is affiliated with the publications Journal of Bone and Joint Surgery American and Journal of Hand Surgery American. Dr. Chung or a member of his immediate family has received research or institutional support from Stryker. Dr. Watters or a member of his immediate family serves as a board member, owner, officer, or committee member of Bone and Joint Decade USA, North American Spine Society, Intrinsic Therapeutics, Work Loss Data Institute, and American Board of Spine Surgery; is affiliated with the publication The Spine Journal; serves as a paid consultant to or is an employee of Blackstone Medical, Medtronic Sofamor Danek, Stryker, Intrinsic Therapeutics, and McKessen Health Care Solutions; and has stock or stock options held in Intrinsic Therapeutics. Dr. Haralson or a member of his immediate family serves as a paid consultant or is an employee of Medtronic and Medtronic Sofamor Danek, and has stock or stock options held in Orthofix. Ms. Wies or a member of her immediate family has stock or stock options held in Shering Plough. None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Keith, Dr. Maupin, Dr. Turkelson, and Mr. McGowan.

In September 2008, the Board of Directors of the American Academy of Orthopaedic Surgeons approved a clinical practice guideline on the treatment of carpal tunnel syndrome. This guideline was subsequently endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. The guideline makes nine specific recommendations: A course of nonsurgical treatment is an option in patients diagnosed with carpal tunnel syndrome. Early surgery is an option with clinical evidence of median nerve denervation or when the patient so elects. Another nonsurgical treatment or surgery is suggested when the current treatment fails to resolve symptoms within 2 to 7 weeks. Sufficient evidence is not available to provide specific treatment recommendations for carpal tunnel syndrome associated with such conditions as diabetes mellitus and coexistent cervical radiculopathy. Local steroid injection or splinting is suggested before considering surgery. Oral steroids or ultrasound are options. Carpal tunnel release is recommended as treatment. Heat therapy is not among the options to be used. Surgical treatment of carpal tunnel syndrome by complete division of the flexor retinaculum is recommended. Routine use of skin nerve preservation and epineurotomy is not suggested when carpal tunnel release is performed. Prescribing preoperative antibiotics for carpal tunnel surgery is an option. It is suggested that the wrist not be immobilized postoperatively after routine carpal tunnel surgery. It is suggested that instruments such as the Boston Carpal Tunnel Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire be used to assess patient responses to carpal tunnel syndrome treatment for research.




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K. L. Weber
The AAOS Clinical Practice Guidelines
J. Am. Acad. Ortho. Surg., June 1, 2009; 17(6): 335 - 336.
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