What's the best treatment for carpal tunnel syndrome? Should I ice my wrist and hand? Use heat? Wear an ace wrap or a splint? I've gotten all kinds of suggestions from friends and family but nothing sounds quite right to me.

The American Academy of Orthopaedic Surgeons has published a Clinical Practice Guideline (CPG) for physicians to use when planning treatment for patients with diagnosed carpal tunnel syndrome. The guideline has nine specific recommendations covering nonsurgical and surgical treatment. Efforts were made to address various topics studied including timing of surgery (early vs. late) and the use of local steroid injections, splinting, or ultrasound treatment.

You'll notice the guidelines are for patients with diagnosed carpal tunnel syndrome. If you haven't had your symptoms formally diagnosed, that would be the first step to finding the ideal treatment for you. Sometimes the best treatment is based on the underlying cause of the problem. Since most of the suggestions you've received have come from non-medical sources, perhaps you haven't been tested specifically for carpal tunnel.

More specifically, the guidelines are for a specific subgroup of patients who have reversible carpal tunnel syndrome. Usually that means there is a mechanical cause of the nerve compression that can be changed. Patients with diabetes-induced CTS or other microscopic nerve damage from disease rather than compression need a different treatment approach.

Most of the time conservative (nonsurgical) care is recommended first for mechanically caused CTS. This can include local steroid injections, oral steroids, or physical therapy. The therapist may use ultrasound, splinting, nerve and tendon gliding exercises, and joint mobilization to help take pressure off the nerve.

If the selected treatment does not reduce or eliminate the symptoms after seven weeks, then another form of conservative (nonoperative) care should be tried. This could be any of the approaches already mentioned but not already tried. There is fair evidence that different patients benefit from a variety of nonsurgical approaches. It may be just a matter or trial and error to find the right mix for each patient.

Surgery may be done early when it looks like the nerve is already damaged. The goal is to prevent irreversible nerve damage. Otherwise, a three to six-month course of conservative (nonoperative) care is the usual standard before considering a more aggressive approach.