Executive summary
- Classic CTS: intermittent numbness, tingling, burning, or pain in the thumb, index, middle, and radial half of ring finger, often worse at night.
- Mild-to-moderate CTS can often start with conservative management in primary care.
- Severe CTS needs earlier escalation because persistent sensory loss or thenar weakness/wasting implies more advanced median nerve compression.
Clinical assessment
- Typical clues: nocturnal paraesthesia, symptoms while driving/holding a phone, shaking the hand for relief, and reduced dexterity.
- Examination: look for sensory change in the median distribution, weakness of thumb abduction/opposition, and thenar wasting in severe cases.
- Think of alternatives if symptoms involve the little finger, the whole arm, neck pain, or more proximal neurological features.
Management and referral
- Conservative first step: offer a 6-week trial of conservative treatment for mild/moderate disease, typically a neutral-position wrist splint worn at night.
- Corticosteroid injection can be considered where available and appropriate, especially if symptoms are troublesome or splinting has not worked.
- Urgent or early referral is appropriate for constant numbness, neurological deficit, thenar wasting/weakness, diagnostic uncertainty, or failure of conservative treatment.
- Pregnancy-related CTS is common and often improves postpartum; splinting is usually a sensible first option.
Frequently asked questions
What counts as severe carpal tunnel syndrome?
Persistent symptoms with neurological deficit, particularly constant sensory loss or thenar weakness/wasting, suggest severe disease and justify earlier referral.
How long should I trial conservative treatment first?
NICE CKS recommends a 6-week trial for mild or moderate symptoms where conservative treatment is appropriate.
Is night splinting still worth trying?
Yes. A neutral wrist splint at night remains a sensible and NICE-supported first-line option for many mild-to-moderate cases.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.