Pillar pain after carpal tunnel release: an evidence-based review of pathophysiology, diagnostic strategies, and a structured clinical decision-making framework.

Pillar pain is a frequent, yet often overlooked, complication after carpal tunnel release (CTR). Although usually self-limiting, it can persist and interfere with recovery, hand function, and patient satisfaction. The pain typically localizes to the thenar and hypothenar regions and arises from a combination of inflammatory, biomechanical, and neurogenic factors. Diagnostic imaging and electrodiagnostic studies (EDS) mainly serve to rule out other conditions rather than confirm pillar pain directly. Conservative management through rehabilitation and individualized physical therapy remains the first-line approach, focusing on restoring mobility, strength, and comfort. If symptoms persist beyond 6 months despite these measures, surgical or interventional treatments may be considered. Chronic pillar pain may also be influenced by psychological and central sensitization mechanisms, highlighting the need for a holistic evaluation. Emerging technologies, particularly artificial intelligence and machine learning, show promise in improving risk stratification, intraoperative nerve preservation, and the prediction of postoperative outcomes. This review proposes a structured, stepwise management algorithm, guiding clinicians from early conservative care to advanced interventions when necessary. Future research should aim to validate predictive models, clarify neurogenic mechanisms, and establish standardized, evidence-based rehabilitation protocols to enhance recovery and optimize outcomes for patients experiencing pillar pain after CTR.