Carpal Tunnel Syndrome (CTS): Rehabilitation and Postoperative Management

Physiotherapy in non-operative management aims to alleviate symptoms, improve nerve gliding, reduce inflammation, and enhance functional outcomes. Common physiotherapeutic modalities include splinting, tendon and nerve gliding exercises, ultrasound therapy, low-level laser therapy, extracorporeal shockwave therapy (ESWT), magnet therapy, and acupuncture.

Splinting is the most widely used non-operative intervention. Wrist-neutral splints reduce pressure on the median nerve by maintaining the wrist in a neutral position, preventing extremes of flexion or extension known to increase carpal tunnel pressure. Nighttime splinting has moderate evidence supporting its effectiveness for symptom relief and functional improvement in the short term, but benefits tend to diminish long term. Full-time splinting lacks evidence for superiority over nighttime splinting.

Exercise therapy, particularly tendon and nerve gliding exercises, is prescribed to optimize nerve mobility and reduce adhesions within the carpal tunnel. These exercises involve specific finger and wrist movements designed to promote median nerve excursion and tendon glide. Evidence for their efficacy is limited yet promising, especially when combined with other treatments. Tendon and nerve gliding exercises have been shown to improve symptoms and functional status in patients awaiting surgery or with mild symptoms.

Physiotherapy modalities such as therapeutic ultrasound and low-level laser therapy have mixed and generally limited evidence. Some studies suggest ultrasound may improve symptoms and nerve conduction parameters in the short term, but results are inconsistent and more research is needed. Low-level laser therapy shows little or no significant benefit over placebo.

Extracorporeal shockwave therapy (ESWT) has moderate evidence for short- and long-term symptom relief in CTS, but its comparison to other treatments, like corticosteroid injections, is inconclusive.

Magnet therapy and acupuncture currently have insufficient or conflicting evidence to support their routine use in CTS.

Pharmacological approaches such as corticosteroid injections show strong evidence for short-term symptom relief and functional improvement, with effects diminishing over time. Oral steroids may provide short-term benefits but lack evidence for long-term efficacy. NSAIDs and gabapentin have limited or no demonstrated benefit.

Criteria for selecting non-operative management include mild to moderate symptom severity without significant motor weakness or thenar atrophy, symptom duration less than one year, and lack of electrodiagnostic findings indicating severe nerve damage.

Following surgical intervention, postoperative rehabilitation is crucial to optimize recovery, minimize complications such as pillar pain and scar adhesions, and restore function. However, the literature demonstrates a lack of consensus on the optimal rehabilitation protocol post-carpal tunnel release.

1. Hand Therapy Visit and Home Exercise Program
   • Patients typically have a single postoperative hand therapy visit around 10-14 days after surgery.
   • At this visit, patients receive education and instruction in a home exercise program that includes:
     • Active digital flexor tendon gliding
     • Wrist flexion and extension active range of motion (AROM)
     • Active thumb opposition
     • Active isolated flexor pollicis longus glide
     • Passive wrist extension stretch
     • Strengthening exercises for grip, tip pinch, lateral pinch, and rolling out across the palm with sponge ball or putty resistance start between 3 and 4 weeks postoperatively.
2. Tendon and Nerve Gliding Exercises
   • Tendon-gliding exercises include finger stretches, hook fist, full fist, table top, and straight fist.
   • Nerve gliding exercises involve a series of specific wrist, finger, thumb, elbow, forearm, and cervical spine positions held for 5 seconds and repeated multiple times per day.
   • These exercises help prevent adhesions and encourage nerve gliding to promote healing.
3. Scar Management
   • Instruction in scar mobilization massage
   • Use of scar pads worn at least 8 hours per day (typically overnight)
   • Compression sleeves to reduce edema and hold scar pads in place
4. Edema Control and Pain Management
   • Elevation, massage, whirlpool, hand fisting with overhead position
   • Use of tubular compression sleeves for edema
5. Gradual Return to Activities and Strengthening
   • Avoid heavy lifting, gripping, or grasping for the first 2 weeks
   • Gradual return to activities without pain starting around weeks 3-5
   • Grip strengthening exercises introduced around 5-6 weeks post-op, progressing as tolerated
   • Return to work typically after 8 weeks for sedentary jobs, 10-12 weeks for heavier jobs.

• Keep the postoperative dressing in place for 4-5 days, then remove and keep the incision clean and dry.
• Avoid submerging the incision until after suture removal.
• Elevate the hand to reduce edema.
• Avoid wrist flexion or extension beyond pain tolerance until 2 weeks post-op.
• Stop exercises immediately if pain occurs in the wound or palm during exercise.
• Avoid heavy lifting, gripping, and grasping for at least the first 2 weeks.
• Patients with prolonged paresthesia or hypersensitivity may require desensitization therapy using different textures, pulsed ultrasound, or topical ointments.
• Scar massage and use of silicone scar pads to prevent scar hypertrophy or sensitivity.

• Postoperative complications include pillar pain (localized tenderness near the transverse carpal ligament), palm pain (generalized ache), wound dehiscence, wound infection, persistent symptoms, nerve injuries, and surgical revisions.
• Incidence of pillar and palm pain combined is around 7%-13%.
• Infection rate is low (about 1%) without routine use of perioperative antibiotics.
• No nerve injuries or revision surgeries were reported in some large studies with standardized protocols.

1. Hirata, J., Suzuki, T., Yamamoto, T., Miyazaki, Y., Ogasahara, Y., Hashizume, H., & Inoue, K. (2016). Effects of tendon and nerve gliding exercises and instructions in activities of daily living following endoscopic carpal tunnel release. Asian Journal of Occupational Therapy, 11(35-41).
2. Huisstede, B. M., Randsdorp, M. S., Verhagen, A. P., Koes, B. W., & Hoogvliet, P. (2010). Carpal tunnel syndrome. Part II: Effectiveness of surgical treatments—a systematic review. Archives of Physical Medicine and Rehabilitation, 91(7), 1005-1024.
3. Mack, E. M., Callinan, N. J., Reams, M., Bohn, D. C., & Chmielewski, T. L. (2017). Patient-reported outcomes after open carpal tunnel release using a standard protocol with 1 hand therapy visit. Journal of Hand Therapy, 30(1), 58-64.
4. Nazarieh, M., Hakakzadeh, A., Ghannadi, S., Maleklou, F., Tavakol, Z., & Alizadeh, Z. (2020). Non-surgical management and post-surgical rehabilitation of carpal tunnel syndrome: An algorithmic approach and practical guideline. Asian Journal of Sports Medicine, 11(3), e102631.
5. Multanen, J., Uimonen, M. M., Repo, J. P., Häkkinen, A., & Ylinen, J. (2021). Use of conservative therapy before and after surgery for carpal tunnel syndrome. BMC Musculoskeletal Disorders, 22, 484.
6. Ostergaard, P. J., Meyer, M. A., & Earp, B. E. (2020). Non-operative treatment of carpal tunnel syndrome. Current Reviews in Musculoskeletal Medicine, 13(2), 141–147.
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8. Huisstede, B. M., Fridén, J., Coert, J. H., & Hoogvliet, P. (2014). European HANDGUIDE group. Carpal tunnel syndrome: hand surgeons, hand therapists, and physical medicine and rehabilitation physicians agree on a multidisciplinary treatment guideline—results from the European HANDGUIDE study. Archives of Physical Medicine and Rehabilitation, 95(12), 2253-2263.