CARPAL TUNNEL SYNDROME

If you wake in the night with a hand that feels dead, swollen or full of pins and needles, and you find yourself hanging it over the side of the bed or shaking it to bring it back to life, you are describing carpal tunnel syndrome almost exactly. That night-time pattern is the most reliable clue there is.

The carpal tunnel is a narrow passage on the palm side of your wrist. Its floor and walls are formed by the small carpal bones and its roof by a tough band of connective tissue. Nine tendons and one nerve pass through it. There is very little spare room, so anything that increases the pressure inside, whether swelling of the tendon sheaths, fluid retention or thickening of the tissue, compresses the median nerve. That nerve supplies sensation to the thumb, index finger, middle finger and half the ring finger, which is why symptoms follow that specific pattern and spare the little finger.

It is often assumed to be a typing injury. Heavy repetitive or forceful hand use certainly contributes, but the strongest risk factors are systemic. Pregnancy is a common trigger through fluid retention. Diabetes roughly doubles the risk, and an underactive thyroid, rheumatoid arthritis and a higher body weight all raise it. It is more common in women and becomes more likely after 50. Understanding which of these applies to you changes what treatment should target, and it is a large part of why two people with identical symptoms can need quite different plans.

Diagnosis is primarily clinical. A careful history and examination, including tests that briefly provoke the symptoms and an assessment of sensation and grip strength, identify most cases. Nerve conduction studies are useful when the picture is unclear, when symptoms could be coming from the neck or when surgery is being considered, because they grade how severely the nerve is affected. That grading matters: mild and moderate cases have a great deal to gain from conservative care, whereas severe compression with constant numbness or visible wasting of the muscle at the base of the thumb is a different situation and needs a surgical opinion.

The evidence for treating this without surgery is stronger than most people expect. A 2024 Cochrane review concluded that surgery probably does not produce a clinically important improvement in symptoms or hand function compared with splinting, and that the overall benefit of surgery remains unclear (Lusa et al., 2024). A 2025 network meta-analysis pooling 49 randomised trials and more than 3,300 patients ranked manual therapy the single most effective conservative treatment for pain in both the short and medium term (Chen et al., 2025).

Perhaps the most useful study for anyone weighing up their options followed 120 patients for four years after being randomly assigned to either manual therapy or surgery. At four years the two groups were equivalent on pain, function and symptom severity, and only 15% of those treated with manual therapy had gone on to have an operation (Fernández-de-las-Peñas et al., 2020). An earlier analysis of the same trial found manual therapy actually outperformed surgery in the first three months and cost less, with less time off work (Fernández-de-las-Peñas et al., 2015; 2019).

We always assess the neck and shoulder as well as the wrist. The nerves that supply your hand begin in the cervical spine and pass through the shoulder and forearm on the way down. Irritation at any point along that route can produce hand symptoms, and when a nerve is compressed in two places at once, a pattern known as double crush, treating only the wrist tends to disappoint. This is one of the more common reasons carpal tunnel treatment fails, and checking for it costs nothing.

Treatment combines mobilisation of the wrist and hand bones to improve the mechanics of the tunnel itself, nerve gliding exercises that restore the median nerve's ability to slide freely through it, soft tissue work to the forearm muscles and treatment of the neck and shoulder where they are contributing. We will usually recommend a neutral wrist splint for sleeping, which addresses the night-time compression directly, alongside practical changes to how you use your hands at work.