Carpal Tunnel Syndrome

Carpal tunnel syndrome happens when one of the nerves to your hand gets squeezed at the wrist.

That nerve is the median nervemedian nerveOne of three main nerves in the arm. It supplies feeling to your thumb, index, middle and half of the ring finger, and powers a few of the muscles at the base of your thumb.. The carpal tunnelcarpal tunnelA narrow channel of bone and ligament at the front of your wrist. The median nerve and the tendons that bend your fingers all pass through it. is the narrow passageway at the front of your wrist that the nerve passes through. When pressure builds inside the tunnel, the nerve sends garbled signals. You feel tingling, burning, or numbness. Over time, weakness can follow.

CTS is the most common entrapment neuropathy in Australian adults. It’s particularly common in:

• Adults aged 40–60, especially women
• People with diabetes, thyroid disease, rheumatoid arthritis, or kidney disease
• Pregnancy (often resolves after birth, due to fluid retention)
• Occupations involving sustained or repetitive wrist movement — keyboard work, manual trades, hairdressing, music performance
• Following wrist fractures or sustained vibration exposure

Typical pattern

• Pins and needles or numbness in the thumb, index, middle and half of the ring finger
• Pain or burning in the wrist that may radiate up the forearm
• Worse at night and on waking — many patients wake repeatedly to “shake the hand back to life”
• Provoked by driving, holding a phone, reading a book, or any sustained wrist position
• Eventually, weakness or clumsiness — especially fine pinch (turning a key, doing up buttons)

Tingling and numbness in the hand isn’t always carpal tunnel. A neurologist’s job is to make sure we’re treating the right problem. Common look-alikes:

• A pinched nerve in your neck (cervical radiculopathycervical radiculopathyNerve irritation where it leaves your spinal cord in the neck. C6 and C7 are the levels that most often mimic carpal tunnel.) — usually at the C6 or C7 spinal level. Causes hand and forearm tingling, often with neck or shoulder pain.
• The same median nerve trapped higher up, in the forearm — pronator or anterior interosseous syndrome. Same nerve, different location.
• Nerve damage affecting both hands and feet at once (peripheral neuropathyperipheral neuropathyDiffuse nerve damage typically affecting the hands and feet symmetrically. Diabetes is the most common cause in Australia.) — most often seen with diabetes.
• A trapped nerve at the elbow (cubital tunnel syndrome) — affects your little and ring finger, not your thumb.
• A nerve injury near your collarbone — a brachial plexus problem. The brachial plexus is the bundle of nerves that leaves your spine and runs to your arm.

Treating “CTS” that’s actually cervical radiculopathy with a wrist splint won’t help — which is why a careful examination, sometimes alongside nerve conduction studies, matters.

1. We start by listening

We ask about the pattern, timing, and triggers of your symptoms, and review your medical conditions and medications. Where appropriate, we examine the hand — sensation, the bulk and strength of the thumb-base muscles, and bedside provocative tests (such as Tinel’s, Phalen’s or Durkan’s). The specific tests performed at any given visit are at the clinician’s discretion and depend on the presentation; not every test is elicited at every consultation.

2. The nerve test (NCS and EMG)

The nerve test is the most reliable way to confirm CTS (AANEM / AAN / AAPM&R Practice Parameter — Jablecki et al.). We do it on-site — no separate hospital trip. There are two parts:

• NCS (nerve conduction study). Small electrical pulses measure how fast and how strongly signals travel along the median nerve. We compare your symptomatic hand to typical values, and to your other hand.
• EMG (electromyography). A fine needle checks whether the muscles your median nerve controls are losing signal. If they are, the compression is more advanced.

The test does more than confirm CTS. It grades how compressed the nerve is. The grade decides the right treatment.

3. Ultrasound and MRI — not routine

We do not routinely order ultrasound or MRI for carpal tunnel syndrome. Imaging may be performed in unique circumstances — for example, suspicion of a ganglion cyst or mass, an atypical presentation, or symptoms that return after surgery. Sometimes imaging has already been organised by your GP before the referral. If we think imaging is needed, we’ll explain why.

4. Blood tests

We may check for things that make CTS worse — usually thyroid function, blood sugar (HbA1c), and inflammation markers. Treating the underlying cause can improve symptoms and reduce recurrence.

Your nerve test gives you a severity grade. We talk about your result in three plain-language groups:

• Mild — splinting and activity changes are usually enough.
• Moderate — splinting first; we may consider a steroid injection if it doesn’t help.
• Severe — straight to a surgeon. The nerve has been squeezed long enough to start losing function, so a splint trial isn’t the right next step.

For your GP and report: this three-way grouping is CURA’s reporting convention. Underneath it we use the six-grade Bland scaleBland scaleA six-grade neurophysiology severity scale for carpal tunnel syndrome — from 1 (very mild, sensory slowing only) to 6 (no recordable signal). Bland, Muscle & Nerve, 2000. — a standard neurophysiology tool (Muscle & Nerve, 2000). Grades 1–2 map to mild, 3–4 to moderate, 5–6 to severe. The Bland grade itself appears in your written report.

The right treatment depends on your nerve-test severity grade, how long you’ve had symptoms, and what’s driving them.

The exception: if the nerve test is severe, or there’s already muscle wasting at the base of the thumb, splinting won’t fix it. You go straight to a surgeon.

Conservative care — first line for mild and most moderate cases

• Night-time wrist splints in a neutral position — the simplest and best-evidenced first step. Pregnancy CTS usually responds well. A neutral-position night splint is inexpensive; the easiest way to find one is to search “CTS splint” on Amazon (or any similar retailer) — you don’t need anything specialised to start.
• Activity modification and ergonomics — neutral wrist posture at the keyboard, regular breaks, avoiding sustained gripping. (High-quality evidence specifically for ergonomic interventions is modest, but they remain a sensible adjunct.)
• Treating underlying conditions — diabetes, hypothyroidism, inflammatory arthritis.
• Hand therapy — tendon-gliding and nerve-gliding exercises, plus splint fitting.

A trial of night splinting (typically 4–6 weeks) is a reasonable first step in mild or moderate CTS. (This timeframe is practice convention rather than a fixed rule.) If symptoms aren’t improving — or if any red flag appears — we move on.

Steroid injection — selected moderate cases

A steroid injection into the carpal tunnel can give real short-term relief (Marshall Cochrane review; Atroshi 2013, JAMA). It can also delay or avoid surgery in selected patients.

It’s not a cure. Symptoms come back within a year for many people. It’s most useful when you want to defer surgery (for example, in late pregnancy), or when the CTS is moderate and looks more inflammatory than mechanical. CURA coordinates referral to a proceduralist for an ultrasound-guided injection where indicated.

Surgery — carpal tunnel release

Surgery is the right next step in three situations:

• The nerve test is severe-grade
• There’s muscle wasting at the base of your thumb, or fixed numbness
• Splinting hasn’t helped after a fair trial in mild or moderate CTS

This is supported by the AAOS Clinical Practice Guideline.

We don’t do the surgery ourselves. CURA is a neurology and nerve-testing practice. When surgery is indicated, we coordinate referral to an experienced hand surgeon and send your full nerve-test report.

There are two types of release surgery: open and endoscopic (keyhole). Both are widely done in Australia. Long-term results are similar. Endoscopic release usually means a faster early return to work. Your hand surgeon will discuss which approach suits you.

Pregnancy-related CTS is common — fluid retention raises pressure inside the carpal tunnel. The good news: most cases settle after birth.

• Night-time splinting is first-line and is safe in pregnancy.
• Steroid injection or surgery are usually deferrable until after birth.
• If symptoms are severe, we’ll discuss the safest plan with you and your obstetric team.

• Australian Hand Therapy Association — ahta.com.au (find an accredited hand therapist)
• Better Health Channel — Carpal tunnel syndrome (Victorian Government) — betterhealth.vic.gov.au
• HealthDirect Australia — Carpal tunnel syndrome — healthdirect.gov.au
• RACGP / AJGP — Carpal tunnel syndrome — racgp.org.au (peer-reviewed Australian primary-care reference)
• Versus Arthritis — Carpal tunnel syndrome — versusarthritis.org
• MBS Online — Services Australia — mbsonline.gov.au (current item descriptors and rebates)