A 35-year-old right-handed construction worker presents with complaints of nocturnal numbness and pain involving the right hand. Symptoms wake him and are then relieved by shaking his hand. There is some atrophy of the thenar eminence. Tinel sign is positive. What is the best advice for this patient?

Carpal tunnel syndrome results from median nerve entrapment and is frequently associated with excessive use of the wrist. The process can be associated with thickening of connective tissue, as in acromegaly, or with deposition of amyloid. It also occurs in hypothyroidism, RA, and diabetes mellitus. As in this patient, numbness is frequently worse at night and is relieved by shaking the hand. Atrophy of the abductor pollicis brevis as evidenced by thenar wasting is a sign of advanced disease and an indication for surgery. Tinel sign (paresthesia induced in the median nerve distribution by tapping on the volar aspect of the wrist) is characteristic but not specific. A reasonable first approach is to recommend a wrist splint at night or throughout 24 hours as initial therapy. If symptoms persist or worsen, it is typical to obtain nerve conduction velocity/EMG testing followed by carpal tunnel release surgery. The other options listed have not been proven to be effective in the condition.