Objective: To analyze the clinical efficacy of ultrasound-guided acupotomy and injection therapy in the treatment of adult carpal tunnel syndrome (CTS). Methods: 210 patients with CTS were divided into T1 group (short-axis out-of-plane guidance group), T2 group (long-axis in-plane guidance group) and D group (injection therapy group) according to different treatment regimens, with 70 cases in each group. T1 group was treated with short-axis ultrasound-guided out-of-plane guided acupotomy, and T2 group was given long-axis ultrasound-guided in-plane guided acupotomy, and D group received ultrasound-guided injection therapy. The VAS score of finger movement before treatment, immediately after treatment and at 1 week, 1 month and 3 months after treatment, wrist function [Boston Carpal Tunnel Questionnaire Symptom Severity Scale (BCTQ-SSS), Boston Carpal Tunnel Questionnaire Functional Status Scale (BCTQ-FSS)] before treatment and at 1 week, 1 month and 3 months after treatment and median nerve sensory conduction parameters were recorded in the three groups. The clinical efficacy was compared among the three groups of CTS patients. Results: The VAS score in the three groups of CTS patients immediately after treatment and at 1 week, 1 month and 3 months after treatment was lower than that before treatment (P<0.05), and the score in T2 group was lower than that in T1 group and D group (P<0.05), and was lower in T1 group than that in D group (P<0.05). The BCTQ-SSS score and BCTQ-FSS score in the three groups of CTS patients were lower at 1 week, 1 month and 3 months after treatment than those before treatment (P<0.05), and the scores in T2 group were lower than those in T1 group and D group (P<0.05), and the scores in T1 group were lower than those in D group (P<0.05). The cross-sectional areas of the median nerve at both the outlet and entrance of the carpal tunnel, as well as the thickness of the transverse carpal ligament at these respective locations, along with the flat rate of the hamate bone hook plane in all three groups were observed to be lower at 3 months post-treatment compared to their measurements prior to treatment (P<0.05), and the above indicators in T2 group were lower than those in T1 group and D group (P<0.05), and were lower in T1 group than those in D group (P<0.05). Compared to D group, both T1 and T2 groups showed a significantly greater percentage of excellent and good results (P<0.05). Nevertheless, the difference between T1 group and T2 group revealed no statistical significance (P>0.05). Conclusion: Compared with ultrasound-guided injection therapy, ultrasound-guided acupotomy for adult CTS can more effectively alleviate the pain, improve the wrist function, and relieve the median nerve compression. The effect of long-axis ultrasound-guided in-plane guided acupotomy therapy is better than that of short-axis ultrasound-guided out-of-plane guided acupotomy therapy.