Carpal Tunnel Syndrome: Surgery or Physical Therapy?

Carpal Tunnel Syndrome (CTS) is the most common entrapment neuropathy in the US, with a prevalence of 6-12% in the general population, and accounts for nearly 50% of all work-related injuries in America.^1,2  CTS is caused by compression of the median nerve as it passes through the wrist and is characterized by symptoms of pain, loss of strength, and tingling sensations in the affected hand.³  Early diagnosis and treatment are critical to achieving positive outcomes as sustained impingement of the median nerve has been demonstrated to lead to permanent nerve and muscle damage.⁴   

Management of CTS can be achieved through either surgery or through more conservative interventions such as corticosteroid injections, splinting, and manual therapy.⁵  Classically, if CTS symptoms are mild, conservative methods of management are generally attempted before resorting to surgical intervention.  However, in cases where symptoms are severe or persistent, carpal tunnel release surgery is often the favored treatment.⁶  Surgical intervention, however, does carry a greater risk of complications.⁷   

There continues to be much debate regarding the potential benefits and drawbacks of both surgical release and conservative treatments.  Consequently, several key studies and reviews have attempted to compare the efficacy of both methods, as well as prognostic factors that may influence their respective outcomes.  The most recent comprehensive review, analyzing surgical versus non-surgical treatments for CTS, conducted by the Journal of Orthopaedic Surgery, found that surgical release appeared to be only slightly superior to conservative methods in the improvement of pain and self-reported function at 6 and 12 months post-treatment.⁸  However, it has also been found that those who undergo surgery experience increased short-term disability and surveys have found that employed patients are unable to return to work for an average of 60 days after surgery.⁹ 

Some experts have also suggested that previous studies, such as those included in the previous review, fail to take into account recent evidence that suggests that CTS comprises a complex pain syndrome that may require comprehensive pain therapy in addition to localized treatments of the hand and wrist¹⁰.  To address this concern, a randomized clinical trial was conducted in 2015 to determine if the inclusion of multimodal manual therapies, such as desensitization maneuvers of the CNS, in addition to classical conservative methods of treatment, would result in different findings.  In the trial, conservative methods significantly outperformed surgical intervention, in terms of both pain and self-reported function, at 1 and 3 months after treatment.  The study found no significant difference between the two methods of treatment after 6 and 12 months¹¹. 

In 2017, a further clinical trial was devised to compare the effectiveness of surgical versus conservative treatments in improving objective measures of physical impairment in addition to the previously studied self-reported measures of functionality and pain.  These measures included pinch-grip strength and cervical range of motion.  The results of the trial indicated that at 1-month post-treatment, multimodal therapy significantly outperformed surgical intervention in terms of both objective measures and self-reported symptom severity.  This result may be attributed to the significant recovery time associated with carpal tunnel release surgery.⁵  Further, the study corroborated the previous trial’s findings with regards to long-term symptom severity, in that it determined that both methods yielded nearly equivalent improvement, in each metric, after 6 and 12 months.⁵ 

In conclusion, while some past studies have favored surgical intervention over conservative treatments, there is increasing evidence demonstrating that multimodal conservative physical therapies may be equally effective to surgery in the management and treatment of CTS.^5,11  Further, surgery is associated with greater short-term disability and carries a greater risk of side effects and complications.  Therefore, while surgical intervention may still be necessary for the alleviation of persistent or severe cases of the condition, the current literature supports a preference for conservative therapies as a first line of defense in the management of CTS.⁵ 

References 

1. Thiese, M. S., Gerr, F., Hegmann, K. T., Harris-Adamson, C., Dale, A. M., Evanoff, B., … Rempel, D. (2014). Effects of Varying Case Definition on Carpal Tunnel Syndrome Prevalence Estimates in a Pooled Cohort. Archives of Physical Medicine and Rehabilitation, 95(12), 2320–2326. https://doi.org/10.1016/j.apmr.2014.08.004 

2. Szabo, R. M. (1998). Carpal Tunnel Syndrome as a Repetitive Motion Disorder. Clinical Orthopaedics and Related Research, 351, 78, 89. https://doi.org/10.1097/00003086-199806000-00011 

3. Padua, L., Coraci, D., Erra, C., Pazzaglia, C., Paolasso, I., Loreti, C., … Hobson-Webb, L. D. (2016). Carpal tunnel syndrome: clinical features, diagnosis, and management. The Lancet. Neurology, 15(12), 1273–1284. https://doi.org/10.1016/S1474-4422(16)30231-9 

4. Carpal tunnel syndrome – Symptoms and causes. (2017). Retrieved May 2, 2020, from Mayo Clinic website: https://www.mayoclinic.org/diseases-conditions/carpal-tunnel-syndrome/symptoms-causes/syc-20355603 

5. ‌Fernández-de-las-Peñas, C., Cleland, J., Palacios-Ceña, M., Fuensalida-Novo, S., Pareja, J. A., & Alonso-Blanco, C. (2017). The Effectiveness of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy, 47(3), 151–161. https://doi.org/10.2519/jospt.2017.7090 

6. ‌Burton, C. L., Chesterton, L. S., Chen, Y., & van der Windt, D. A. (2016). Clinical Course and Prognostic Factors in Conservatively Managed Carpal Tunnel Syndrome: A Systematic Review. Archives of Physical Medicine and Rehabilitation, 97(5), 836-852.e1. https://doi.org/10.1016/j.apmr.2015.09.013 

7. ‌Verdugo, R. J., Salinas, R. A., Castillo, J. L., & Cea, G. (2008). Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd001552.pub2 

8. Shi, Q., & MacDermid, J. C. (2011). Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? a systematic review. Journal of Orthopaedic Surgery and Research, 6(1), 17. https://doi.org/10.1186/1749-799x-6-17 

9. ‌Parot-Schinkel, E., Roquelaure, Y., Ha, C., Leclerc, A., Chastang, J.-F., Raimbeau, G., … Descatha, A. (2011). Factors Affecting Return to Work After Carpal Tunnel Syndrome Surgery in a Large French Cohort. Archives of Physical Medicine and Rehabilitation, 92(11), 1863–1869. https://doi.org/10.1016/j.apmr.2011.06.001 

10. ‌De-la-Llave-Rincon, A. I., Ortega-Santiago, R., Ambite-Quesada, S., Gil-Crujera, A., Puentedura, E. J., Valenza, M. C., & Fernández-de-las-Peñas, C. (2012). Response of Pain Intensity to Soft Tissue Mobilization and Neurodynamic Technique: A Series of 18 Patients With Chronic Carpal Tunnel Syndrome. Journal of Manipulative and Physiological Therapeutics, 35(6), 420–427. https://doi.org/10.1016/j.jmpt.2012.06.002 

11. ‌Fernández-de-las Peñas, C., Ortega-Santiago, R., de la Llave-Rincón, A. I., Martínez-Perez, A., Fahandezh-Saddi Díaz, H., Martínez-Martín, J., … Cuadrado-Pérez, M. L. (2015). Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The Journal of Pain, 16(11), 1087–1094. https://doi.org/10.1016/j.jpain.2015.07.012