Carpal Tunnel Syndrome - Referral Pathway for patients with

Publication: 14/08/2007  
Next review: 01/07/2026  
Referral Guideline/Pathway
ID: 1163 
Approved By:  
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This Referral Guideline/Pathway is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Referral Pathway for patients with Carpal Tunnel Syndrome

Assessment and Management in Primary Care

The management must be based on making a firm diagnosis of CTS. This primarily depends on taking a history as most patients do not have physical signs and provocative tests (Phalen's and Tinel's) are unreliable. Also, there is a high incidence of false negative nerve conduction studies, especially when the history is short (less than 6-12 months). False positives do occur as well. In the majority of cases, the diagnosis can be made from a clinical assessment alone and nerve conduction studies are not required. (see Appendix 1).

Once a firm diagnosis has been made, management depends on the severity of the symptoms and the presence of any underlying cause. Many patients with the milder forms will remit spontaneously, particularly those that occur during pregnancy. Those with the more severe forms will still benefit from conservative treatment while waiting for surgery.

It is proposed that patients be categorised into three types (mild, moderate and severe) based on the severity of their symptoms and that the treatment given then depends on the grade of severity.

The recommended treatment, based on the category, can be summarised as follows (and see Appendix 1 and Appendix 2).

Assessment and Management in Primary Care

1. Mild CTS

The sensory symptoms occur:

  • No more than once during the day
  • Once or twice a week during the night
  • Lasting for up to 10 minutes
  • Pain is not present


  • Explanation of condition
  • Lifestyle Advice
  • Consider steroid injection if symptoms do not improve within a few weeks

2. Moderate CTS

The sensory symptoms occur

  • Two or three times during the day 
  • Once most nights 
  • Last for more than 10 minutes
  • Pain may be present. 


  • Explanation of condition
  • Lifestyle Advice
  • Nocturnal wrist splints if waking at night is troublesome
  • Steroid injection
  • Consider early or immediate referral for surgery

3. Severe CTS

The sensory symptoms occur

  • Frequently each day and can last for more than an hour at a time
  • Can be continuous
  • Sleep is disturbed with more than two wakings every night
  • Pain can be prominent
  • Wasting and weakness of the thenar muscles may be present, together with sensory loss in the median supplied digits.


  • Explanation of condition
  • Lifestyle Advice
  • Nocturnal wrist splints if waking at night troublesome
  • Consider palliative steroid injection
  • Immediate referral for surgery


Symptomatically there are two additional presentations

a) Acute CTS - this is not common.
The sensory symptoms come on suddenly, typically on waking up the day after a period of excessive use of the hand. They can be severe for several days then slowly improve. Pain may be prominent.
The symptoms can be managed with rest and analgesics.
Urgent surgical referral may be necessary if the symptoms do not improve quickly

b) Persistent numbness in the median area of the hand, without pain or much tingling. This is usually seen in the elderly. Wasting and weakness of the thenar muscles is often present.
A surgical opinion should be sought.

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Record: 1163
Clinical condition:

Carpal Tunnel Syndrome

Target patient group: Patients with Carpal Tunnel Syndrome
Target professional group(s): Primary Care Doctors
Secondary Care Doctors
Adapted from:

Evidence base

Not supplied

Document history

LHP version 1.0

Related information

Appendix 1 - Outline of symptoms in CTS

In mild to moderate CTS, the symptoms are typically intermittent, last minutes at a time and occur between once a week and several times a day. During the day, they may be brought on by sustained gripping, such as using a phone or driving. They often occur when patients are sitting still and watching TV. They can wake the patient from sleep, when they are usually at their worst. They are relieved by shaking the hand.

The cardinal symptoms are numbness and/or tingling in the hand. If they do not have these symptoms then they do not have CTS. Many patients are referred for EMG because of hand or arm pain with no other symptoms. This is unnecessary. The symptoms classically affect the thumb, index and middle fingers but there are many variants. Thus, only one or two digits may be affected. 50% of patients have symptoms which affect the whole hand, including the ring and little fingers (Stevens JC et al. Symptoms of 100 patients with electromyographically verified CTS. Muscle Nerve 1999; 22:1448-1456). The symptoms during the day may be confined to the median territory but during the night affect the whole hand.

In the more severe forms of CTS, the numbness and tingling can last much longer than a few minutes. In the most severe type and also in the acute type, the symptoms are continuous but may vary in severity. In most patients the onset is usually insidious and the symptoms can get progressively worse or stabilise for long periods of months or years. Spontaneous remission is not uncommon. The patients may report transient exacerbation following a period of increased use of the hands or note improvement when on holiday.

More than half the patients have pain in the hand or arm, sometimes felt as high as the shoulder. These pains occur at the same time as the sensory symptoms in the hand. Persistent pain felt throughout the day, with only infrequent sensory symptoms in the hand, is unlikely to be due to CTS.

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Appendix 2 - Treatment - Lifestyle Advice

Simple advice on the cause of CTS and how to improve the symptoms should be given to all patients. When patients ask what the cause is, I say it is due to the way we are designed and give a brief description of the anatomy of the carpal tunnel. I stress that the damage is done when the hand is used for any heavy or prolonged task but the symptoms come on when they are at rest, either from sleep or when sitting still watching TV or holding something like a phone. As soon as they notice the symptoms they should move the hand or put the phone down. I suggest avoiding heavy jobs if possible and trying to give their hands a rest. If sleep is disturbed I explain that wearing a wrist splint at night can help but do not recommend wearing it during the day.

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