Updated guidance on carpal tunnel syndrome: What the 2026 clinical practice guidelines mean for your practice

The first major update to the APTA Orthopedics clinical practice guidelines for carpal tunnel syndrome (CTS) in 7 years has just been published in JOSPT, bringing a range of revised and new recommendations that are worth working through if CTS is a regular feature of your caseload.

Carpal tunnel syndrome (CTS) affects around 14% of the global population and remains one of the most common presentations in musculoskeletal physiotherapy practice. The 2026 revision of these guidelines, developed by APTA Orthopedics and the APTA Hand and Upper Extremity Academy adds recommendations on several interventions that were not covered in previous guidelines from 2019, including extracorporeal shockwave therapy, dry needling and kinesiology taping.

For assessment, the guidelines now recommend the CTS-6 as the preferred test battery for diagnosis. This tool combines subjective symptom questions with findings from the Phalen test, Tinel sign, 2-point discrimination and assessment for thenar atrophy, and has a stronger evidence base than the Wainner criteria recommended in the previous version. The Katz and Stirrat hand symptom diagram remains recommended, and the Kamath and Stothard questionnaire is now included as an option for screening work-related presentations.

On outcome measures, the guidelines consolidate support for the Boston Carpal Tunnel Questionnaire Symptom Severity Scale as the primary tool for tracking change over time, used alongside either the DASH or QuickDASH for functional assessment. For patients who have had carpal tunnel release surgery, the PROMIS Pain Interference and Upper Extremity subscales are now recommended as additional options, supported by new responsiveness data not available at the time of the previous guideline. Grip and lateral pinch strength are again not recommended as outcome measures for short-term change.

For intervention, the core recommendation remains unchanged: a forearm-based wrist immobilisation orthosis holding the wrist near neutral, worn at night, is the first-line treatment for mild to moderate CTS. The guidelines confirm that extending wear time to daytime use and adjusting joint position are reasonable options when night-only use is insufficient. Beyond the orthosis, several adjuncts carry a “may use” recommendation for short-term benefit, including laser therapy (both low-level and high-intensity), kinesiology taping for mild CTS, interferential current, superficial heat, and diathermy. Extracorporeal shockwave therapy now receives a formal recommendation for short- and mid-term improvement in mild to moderate CTS, with radial ESWT preferred over focused. Iontophoresis and phonophoresis with corticosteroids and magnet therapy continue to receive a “should not use” recommendation. Dry needling did not receive a recommendation due to insufficient evidence.

One area the guidelines address more thoroughly than previously is the role of psychosocial factors and central pain mechanisms. Approximately 30% of people with CTS have co-existing anxiety or depression, and extramedian spread of symptoms, often interpreted as a sign of central sensitisation, is common. The guidelines do not yet offer clinical tools to screen for central sensitivity in CTS specifically, but highlight this as an important area for clinicians to be aware of when patients present atypically or report disproportionate pain.

The Physiopedia page on Carpal Tunnel Syndrome will be updated to reflect these revised recommendations. If you spot evidence or guidance across any condition area that you think should be reflected in a Physiopedia page, we always welcome suggestions from the community, keeping content current is a shared endeavour.

Read the full open-access guidelines to support your work if CTS features regularly in your practice.