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. 2023 Feb 21;37:81–85. doi: 10.1016/j.jor.2023.02.011

Injections for treatment of carpal tunnel syndrome: A narrative review of the literature

Emily S Cage 1, Julia J Beyer 1,∗, Nabil A Ebraheim 1
PMCID: PMC10039115  PMID: 36974095

Abstract

Background

Carpal tunnel syndrome is an extremely common condition in the general population. Nonoperative treatment is a mainstay of management prior to surgical carpal tunnel release. Injections are frequently used as treatment, especially corticosteroid injections, but there is little consensus in the literature regarding injection number, volume, corticosteroid dose, and technique.

Methods

A comprehensive literature search was performed of PubMed to identify papers relating to corticosteroid injections as well as other injections performed in patients with carpal tunnel syndrome.

Results

A total of 45 articles were selected for inclusion in this review. Corticosteroid injections for carpal tunnel syndrome are discussed in detail, including injection number, volume, and technique as well as corticosteroid dose. Alternative injections for management of carpal tunnel syndrome are also discussed.

Conclusions

Corticosteroid injections have been identified as a safe, effective short term management option for carpal tunnel syndrome. However, there is no standardized recommendation for specifics of their use in relation to corticosteroid dose, number of injections, injectate volume, and use of ultrasound guidance. Further research is required to better establish the optimal role for corticosteroid injections in the treatment of carpal tunnel syndrome. Platelet rich plasma, lidocaine, and hyaluronic acid, among others, are additional injections that warrant further exploration for use in management of carpal tunnel syndrome.

Keywords: Carpal tunnel syndrome, Corticosteroid injection, Injection, Conservative management

Highlights of the Paper

  • •

    CSIs are a safe, effective nonoperative treatment method for CTS in the short term.

  • •

    Alternative injections are emerging, which include PRP, hyaluronic acid, and local anesthetics.

  • •

    There exists much variability in the literature regarding the use of corticosteroid injections, including injection number, corticosteroid dose, injectate volume, and use of ultrasound guidance.

1. Introduction

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity,1,2 affecting 0.6–5.8% of the general population.3 CTS tends to be more prevalent in females and adults aged 40–60 years.4

Patients classically present with numbness, tingling, or nighttime pain in the palmar aspect of the thumb and radial digits. Symptoms are exacerbated by extended periods of wrist flexion, and these typically improve by shaking the affected hand.1 Physical examination may show reproduction of symptoms with the Tinel sign, Phalen sign, and direct compression of the median nerve.2 Late presentation of severe CTS may reveal weakness and atrophy of the thenar musculature. Although the diagnosis is often made clinically, electrodiagnostic testing can help confirm the diagnosis and exclude other pathology.1

CTS occurs due to compression of the median nerve within the carpal tunnel. Although the exact pathophysiology of CTS is not yet fully understood, the two primary hypotheses regarding pathogenesis involve inflammation of the nerve secondary to compression versus non-inflammatory fibrosis of the surrounding connective tissue.5 These factors, likely in combination, lead to increased pressure within the carpal tunnel and microvascular injury to the median nerve, resulting in increased cross-sectional area of the median nerve and limited motion within the carpal tunnel as seen on ultrasound examination.5,6

Current treatment recommendations for CTS include operative and non-operative options. Nighttime splinting is typically used as a first-line treatment modality for mild to moderate CTS, working to keep the wrist in a neutral position and avoid extreme flexion or extension, which can increase pressure within the carpal tunnel.7 Although slightly more invasive, corticosteroid injections (CSIs) are another common non-operative treatment option shown to improve symptoms and delay time to surgical release. Oral non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics have not demonstrated a clear benefit and are not currently recommended while moderate evidence has shown oral steroids to have some short-term benefit.8 Hand therapy, aiming at improving tendon gliding within the carpal tunnel, ultrasound therapy, laser therapy, and phonophoresis have all been suggested as adjunctive or alternative therapies, but there is currently limited evidence regarding the effectiveness of these modalities.1,7 In severe cases of CTS, or when conservative treatment has failed, surgical release of the transverse carpal ligament via an open or endoscopic approach can be performed.1,8

In this review, we will discuss current evidence and recommendations regarding CSIs as a treatment option for CTS, and we will compare these to newer injection options that are being investigated as alternative treatments.

2. Corticosteroid injections

2.1. Overview

CSIs are a commonly used nonoperative treatment for CTS. They are theorized to cause symptom relief through reduction of inflammation and edema of the nerve and tissue within the carpal tunnel, thus decreasing the pressure on the median nerve.6,7,9, 10, 11, 12, 13 When compared with other nonsurgical treatment methods such as night splinting, CSI has been found to provide superior relief of nocturnal paresthesia for up to six months.9 In terms of pain and function, as measured by the Boston Carpal Tunnel Questionnaire (BCTQ), carpal tunnel injection showed a more rapid initial effect as evidenced by significantly greater score improvement at six weeks. Night splinting scores improved by the six-month mark, with no significant difference when compared with CSI at that time.14 In comparison with oral corticosteroids, local CSI is significantly more effective and provides longer lasting relief for up to three months.9,15,16

It is well established that CSIs are effective in the short term, with multiple studies reporting significant symptom relief one month after injection.15,16 Reports of long-term relief are more variable, with success rates ranging from 0 to 63%.17 Kirby et al. reported that 80.3% of patients receiving carpal tunnel injection experienced continued relief at six months and Berger et al. reported that 33% of patients had an “excellent response” one year after CSI.9,11 Patients expected to benefit most from CSIs include those with milder symptoms, those having symptoms for less than one year, and those with less severe electrophysiologic findings.1 In addition to their use for symptom relief, CSIs may aid in diagnosis. Relief of symptoms after CSI supports the diagnosis of CTS in patients where the presentation is atypical. Symptom improvement with CSI also predicts success of surgical management of CTS.1,18,19

In terms of need for subsequent intervention, Evers et al. found that at one year follow up, 56% of patients initially receiving CSI had required further treatment. Thirty percent of those patients had received a second CSI, while 70% had undergone carpal tunnel release (CTR).20 While patients may eventually require surgical intervention to relieve their symptoms in the long term, CSI may delay the need for surgery.19 Findings from one study showed that patients receiving CSI underwent surgery an average of two months later than patients receiving placebo.21 A 10-year study reported by Bland et al. found just 16% of patients initially treated with CSI had undergone surgery for their CTS at final follow-up,22 although a study reported by Hameso et al. reported 41% of patients had undergone CTR within eight years of their first CSI.23 Surgical management is intended to provide more definitive symptom relief and results in superior neurophysiologic parameters, functional status, and symptom severity in the long term when compared with CSI.1,24,25

Very few complications have been reported as a result of CSIs for CTS. The most common side effects include injection site pain, facial flushing, skin depigmentation, localized subcutaneous fat atrophy, and possible transient rise in blood glucose in diabetic patients.1,7,12, 13, 14,17,26 Severe complications are rare. In a study examining 9515 CSIs for CTS, Kaile et al. reported only four: two cases of gangrene of the fingertip, one intraneural injection, and one tendon rupture that occurred in a patient who had undergone 10 injections.26 The incidence of damage to the median nerve in association with carpal tunnel injection has been reported as 0.1%12 and the incidence of cellulitis has been reported as 0.4%.24 Therefore, CSIs are a safe option for the treatment of CTS.

2.2. Number of injections

There is considerable variability in the number of carpal tunnel injections that provide benefit to patients. Some report that two injections do not lead to meaningful clinical improvement when compared with one,15,16 while others report patients receiving benefit from subsequent injections.11,23 Berger et al. found that one year after injection, a quarter of patients had attained a good outcome with one injection, 9% after two injections, and 4% after three injections. They also reported that positive clinical response to the first injection predicted success of further injections.11 Patients receiving up to 12 CSIs have been reported.23 However, the European HANDGUIDE Study established a clinical practice guideline suggesting that patients should be limited to three CSIs for CTS.27 Some have expressed concern for increased risk of adverse effects with multiple injections,13 but evidence has not shown a change in side effects to be associated with number of injections.26

2.3. Injection volume

Evers et al. reported on the effects of injectate volume on patient outcomes in CTS. In a retrospective review of 856 carpal tunnel injections, they found that the average volume of injection was 3.54 mL. They identified a significant association between increased injection volume and decreased rate of failure of treatment at one year after injection. They theorized that higher volume may mobilize the median nerve through hydrodissection and that it may lead to a greater distribution of the corticosteroid or increased contact with the median nerve.20

2.4. Corticosteroid dose

There are multiple reports that have found no relationship between steroid dose and clinical outcomes in patients receiving injection for CTS.13,15,16,19, 20, 21 However, a review of literature by Ostergaard et al. reported a decrease in surgical intervention one year after injection in patients receiving higher methylprednisolone dosage.7 A commonly reported dosage in the literature is 40 mg triamcinolone acetonide or equivalent corticosteroid dose.13 A five-year study conducted by Hofer et al. showed no significant difference in change in symptom severity score in patients receiving 80 mg vs 40 mg injection of methylprednisolone.21 Hsu et al. also found similar improvements in Visual Analog Scale (VAS), BCTQ, and nerve conduction studies 12 weeks after injection with 10 mg vs 40 mg injection of triamcinolone acetonide. Due to concern for dose-dependent side effects of corticosteroids, they postulate that 10 mg triamcinolone acetonide may be a preferable dose for CSI.13

2.5. Ultrasound-guided versus landmark-guided

Ultrasound-guided injection for CTS is thought to increase accuracy of injection into the carpal tunnel through identification of anatomy and anatomic variations, which can aid in avoiding injury to the median nerve and surrounding structures.17,28 Some studies have found a decreased incidence of intraneural injection, decreased pain, increased efficacy of injection,26 and superiority in terms of adverse events, electrodiagnostic parameters, and BCTQ scores with ultrasound-guided injection.28 Other studies report BCTQ scores to be superior for ultrasound-guided injection at four weeks, but similar scores to landmark-guided through the rest of the 24 week follow up period.17 Reported accuracy for landmark-based injection is reported between 75.7% and 100%28 and incidence of intraneural injection is roughly 1 in 10,00026 with better results found when experienced practitioners administer the injection.17 However, access to ultrasound for carpal tunnel injections in primary care settings may be limited.14

2.6. Corticosteroid injections and carpal tunnel release

There is concern regarding administration of CSIs prior to surgery due to the risk of postoperative infection. In shoulder arthroplasty, many surgeons wait 6–12 months after CSI prior to performing surgery due to the theoretical risk of reactivation of undissolved corticosteroid in the joint which may subsequently affect the immune response to infection.29 However, a study performed by Rashid et al. did not identify an association between CSI and postoperative infection after shoulder arthroplasty.29 In knee arthroplasty, postoperative joint infection has been associated with CSI within three months of surgery.30 In hand surgery, preoperative CSI has been studied in relation to thumb carpometacarpal arthritis and trigger finger release. For arthritis of the first carpometacarpal joint, it has been reported that the risk of postoperative complication was increased by 20% in patients receiving prior CSI.31 A study performed by Qin et al. found patients had a 2.2 times increased risk of infection and wound complications if they had a CSI in the three months preceding surgery when compared with those who had not been injected within six months before surgery.32 In patients undergoing trigger finger release, CSIs were found to be associated with an increased risk of infection postoperatively, although an association between the time from injection to surgery was not identified.33

CSI prior to CTR may also predispose patients to postoperative infection and wound complications. In a retrospective review of patients who underwent CTR, Kirby et al. found a significantly higher incidence of infection in patients receiving CSI prior to surgery in comparison with patients receiving no injection. They also found patients with postoperative infection had CSIs 55 days closer to their surgery date than those who did not develop infection.9 Fakunle et al. also reported an association between CSI and postoperative infection or wound complication, with increased rates in patients receiving injections within 30 days of surgery. They hypothesize that wound complications may be caused by corticosteroid-mediated suppression of growth factors needed for wound healing and suggest delaying surgical intervention for at least 30 days following CSI.34 The incidence of infection after CTR is estimated to be 0.36%,18 and affected patients typically respond to antibiotics.9 However, every effort should be made to maximize patient safety. In terms of symptom severity and functional status as measured by the BCTQ, no significant difference was found in postoperative scores between patients receiving CSI prior to surgery and patients with no prior CSI.22 Intraoperative CSI for CTS has not been shown to be effective, with no significant difference in BCTQ or electrodiagnostic parameters.10

3. Comparison to other injection types

While corticosteroid remains the standard injectate for CTS, several other options have been suggested that may provide longer-lasting relief and avoid potential adverse effects from corticosteroids.

Platelet-rich plasma (PRP) is derived from autologous fractionated blood with a high concentration of platelets and growth factors, including transforming growth factor-β, platelet-derived growth factor, and vascular endothelial growth factor. Animal studies have suggested that it promotes wound healing and nerve regeneration, and it has been proposed as a potential intervention for several musculoskeletal pathologies.35,36 Malahias et al. demonstrated that a single PRP injection in patients with mild to moderate CTS resulted in significantly improved symptoms and decreased median nerve cross-sectional area when compared to placebo.37 When compared to CSIs for CTS, PRP injection was superior in improving clinical symptoms as well as median nerve motor conduction velocity, sensory latency, and sensory conduction after three months.35 While these findings are promising, more research will be needed to further investigate PRP's viability as an alternative therapy to CSIs.

Although local anesthetics are commonly injected in conjunction with corticosteroids, lidocaine alone has also been used as a treatment for CTS. The study by Dernek et al. comparing lidocaine and betamethasone dipropionate found significant decreases in pain and symptom severity compared to baseline but no significant difference between the two treatment groups.12 Given these results, lidocaine may be a good alternative to CSIs for CTS.

Hyaluronic acid, a glycosaminoglycan found within the extracellular matrix, has shown potential for augmenting nerve repair and decreasing post-op adhesion formation in animal studies.38 When injected as a treatment for CTS, it only showed significant improvement in pain levels and the BCTQ at the two-week follow-up compared to placebo.39 Further studies would be needed to further investigate its efficacy, but these results suggest that hyaluronic acid is likely not beneficial in chronic neuropathies. On the other hand, hyaluronidase has also been suggested as an injectate due to its ability to facilitate adhesiolysis. In a study by Alsaeid comparing dexamethasone and hyaluronidase as adjuvants to bupivacaine injections in 40 patients with mild to moderate carpal tunnel syndrome, hydrodissection with hyaluronidase significantly improved BCTQ and electrophysiologic outcomes up to 6 months post-injection.40 Again, further research is needed to determine its efficacy and utility.

Perineural progesterone,41 ozone,42 5% dextrose,43 hyalase,44 and insulin45 injections have also been proposed as alternative treatments for CTS. Current evidence for these therapies remains limited, but future research may point towards one or more of these as effective alternatives to CSIs.

4. Conclusion

There is significant variation in the literature on CSIs for CTS regarding injection number, volume, and dosage, use of ultrasound guidance, and proximity to surgical intervention. However, CSIs are a safe, effective nonoperative treatment method for CTS in the short term. Alternative injections are emerging, which include PRP, hyaluronic acid, and local anesthetics. Further studies are needed to determine their efficacy in the treatment of CTS.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Informed consent

N/A.

Institutional ethical committee approval

N/A.

Author statement

Emily Cage: Investigation, Writing- Original Draft, Writing- Review and Editing. Julia Beyer: Investigation, Writing- Original Draft, Writing- Review and Editing. Nabil Ebraheim: Conceptualization, Writing- Review and Editing, Supervision.

Declaration of competing interest

None.

Acknowledgements

None.

Contributor Information

Emily S. Cage, Email: emily.cage@utoledo.edu.

Julia J. Beyer, Email: julia.beyer@rockets.utoledo.edu.

Nabil A. Ebraheim, Email: nabil.ebraheim@utoledo.edu.

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