Wrist Pain

Wrist pain frequently results from sudden injuries like sprains and fractures, but can also be caused by chronic conditions such as stress, arthritis, and carpal tunnel syndrome.

Diagnosing the exact origin of wrist pain can be challenging due to the multiple possible factors involved. However, obtaining an accurate diagnosis is crucial for appropriate treatment and recovery.

Introduction

A person may experience wrist pain due to various factors like a strain, carpal tunnel syndrome, or arthritis. Depending on the specific cause, wrist pain can manifest as a dull ache, sharp pain, or other sensations like numbness.

The wrist is not simply one joint; it consists of several small joints where the hand and forearm bones meet. Pain can arise from various sources, ranging from general fatigue to underlying problems. Common causes of wrist pain include crash injuries, muscle strains, and compression of the nerves passing through the wrist.

Anatomy of the Wrist Joint

The wrist joint consists of the following articulating surfaces:

• the articular disk and the inferior end of the radius.
• The upper row of carpal bones, excluding the pisiform bone.
• The carpal bones collectively form a rounded surface that fits into the concave shape of the radius and articular disk.

A fibrocartilaginous ligament, known as the articular disk, prevents the ulna from connecting with the carpal bones. Instead, the ulna articulates with the radius just above the wrist, at the distal radioulnar joint.

Joint Structure

The joint capsule of the wrist joint attaches to the radius, ulna, and the upper row of carpal bones. Internally, it is lined with a synovial membrane that secretes synovial fluid to reduce friction between the articulating structures.

Ligaments

Four primary ligaments are present at the wrist joint:

• Palmar radiocarpal ligament: Situated on the front side of the joint, it extends from the radius to both rows of carpal bones, enhancing stability and ensuring alignment of the hand with the forearm during supination.
• Dorsal radiocarpal ligament: Positioned on the back side of the joint, it runs from the radius to both carpal bone rows, contributing to wrist stability and alignment of the hand with the forearm during pronation.
• Ulnar collateral ligament: Connects the ulnar styloid process to the triquetrum and pisiform, preventing excessive lateral deviation of the hand.
• Radial collateral ligament: Extends from the radial styloid process to the scaphoid and trapezium, preventing excessive medial deviation of the hand.

Muscles:

The muscles responsible for wrist and hand movements originate in the forearm and connect to the bones via tendons. Some of the major muscles involved include the:

• Flexor muscles (e.g. flexor digitorum profundus, superficialis)
• Extensor muscles (e.g., extensor digitorum, extensor indices)
• Thenar and hypothenar muscles (responsible for thumb and little finger movements)

Nerve Supply:

The wrist joint and the surrounding structures are supplied by several nerves, including the median, ulnar, and radial nerves. These nerves provide sensation and control muscle movement in the hand.

Causes of Wrist Pain

Carpal Tunnel Syndrome

Carpal tunnel syndrome occurs when the median nerve, one of the forearm’s important nerves, becomes compressed or pinched. This condition affects the palm side of the hand, providing sensation to the thumb, index finger, middle finger, and part of the ring finger. Additionally, the median nerve supplies the necessary stimulation to the muscle responsible for thumb movement. One or both hands may be affected with carpal tunnel syndrome.

In addition to causing wrist pain, this syndrome may result in numbness, weakness, and tingling sensations near the thumb. Risk factors for carpal tunnel syndrome include engaging in repetitive tasks like typing, drawing, or sewing, pregnancy, certain medical conditions such as diabetes, and arthritis, and a family history of carpal tunnel due to possible anatomical differences that can be hereditary.

Gout

Gout is a form of inflammatory arthritis triggered primarily by excessive uric acid. Uric acid forms when the body breaks down purine-containing foods. While most uric acid is eliminated through urine, overproduction or inadequate excretion can accumulate in joints, causing pain and swelling, commonly in knees, ankles, wrists, and feet.

The risk factors for gout include excessive alcohol consumption, high intake of fructose-rich foods and beverages, a diet high in purine-rich foods like red meat and certain seafood, obesity, specific medications like diuretics, and other conditions such as hypertension, diabetes, and kidney disease.

Arthritis

Arthritis refers to the inflammation of joints, leading to swelling and stiffness in the affected area. Various factors can contribute to arthritis, including regular wear and tear, aging, and excessive use of the hands.

There are numerous types of arthritis, with the most common ones affecting the wrist being:

• Rheumatoid Arthritis (RA): This autoimmune disease can impact both wrists by causing the immune system to attack joint linings, resulting in painful swelling and potentially bone erosion over time.
• Osteoarthritis (OA): Common among older adults, OA is a degenerative joint disease caused by the deterioration of joint cartilage. The breakdown of this protective tissue due to aging or repetitive movements increases friction between bones, leading to swelling and discomfort.

While arthritis can develop at any age, certain risk factors can elevate the likelihood of its occurrence. These factors noted by the Centers for Disease Control and Prevention include:

• Obesity
• Untreated infections
• Smoking
• Untreated joint injuries from overuse

Ganglion Cysts

Ganglion cysts are benign, noncancerous lumps that typically occur in the hand, commonly found on the back of the wrist.

The cause of ganglion cysts remains uncertain; however, the American Academy of Orthopaedic Surgeons notes that they are most prevalent in individuals aged 15 to 40 years, gymnasts due to the repetitive stress on their wrists, and individuals who are assigned female at birth. Although ganglion cysts are often painless, they can become painful if they exert pressure on a joint or nerve in the wrist area. Treatment approaches vary from observation to wearing a splint to draining the cyst, depending on the situation.

Wrist Tendencies

The human wrist contains numerous tendons that work together to facilitate movement of the wrist, hand, and fingers. Wrist tendonitis occurs when a tendon in the wrist becomes inflamed, leading to pain, swelling, and a potential decrease in wrist mobility.

Several factors can contribute to the development of wrist tendonitis, including age, poor wrist posture, misaligned joints, acute injuries from falls or impacts, and conditions like diabetes. Thankfully, individuals can relieve tendonitis symptoms by stretching, using splints, applying ice, and taking over-the-counter medications to manage pain and reduce swelling.

To prevent wrist tendonitis, it is advisable to exercise the wrists regularly and take breaks during repetitive activities that strain them. These aggressive steps can help maintain wrist health and reduce the risk of developing tendonitis in the future.

Kienbock’s Disease

Kienbock’s disease is a rare condition that leads to the gradual decline of the lunate bone in the wrist due to insufficient blood supply. This disease may result in wrist pain, swelling, and a decrease in grip strength. The cause of Kienbock’s disease remains unknown, and the severity of symptoms can vary from mild to severe. Treatment options include medications, splinting of the affected area, and surgical procedures aimed at improving blood circulation in the affected area.

de Quervain’s condition

de Quervain’s condition, also known as Deervain’s tenosynov or tendinosis, is characterized by inflammation of the tendons and tendon sheaths near the base of the thumb, resulting in pain in the hand, wrist, and thumb.

The cause of de Quervain’s disease is not definitively known, but it is often linked to injury or repetitive strain. Symptoms may include a grinding sensation in the wrist, swelling, and weakness in the thumb, forearm, and wrist.

Triangular Fibrocartilage Complex

A triangular fibrocartilage complex injury involves damage to the structure of the wrist that supports the small bones and acts as a cushion. This damage can occur gradually over time or suddenly due to a traumatic impact.

When the triangular fibrocartilage complex is affected, an individual typically experiences pain along the side of the wrist near the small finger.

Symptoms of Wrist Pain

The underlying cause of wrist pain can affect the symptoms. Individuals may experience dullness or pain, while others might feel sharp pain. Additionally, the pain’s location may vary.

Apart from pain, additional symptoms may manifest, especially in the case of an injury like a wrist sprain, where swelling can occur. Carpal tunnel syndrome-related pain may result in numbness, tingling sensations, and hand weakness.

Some individuals may notice the following symptoms:

• Stiffness, which may be felt in the wrist and possibly extend to the fingers.
• Difficulty gripping objects due to wrist pain, making it challenging to hold onto or grasp items.
• A clicking sound when moving the wrist, particularly pronounced after periods of inactivity.

Symptoms may initially be mild but can increase over time. Pain might arise only during certain activities initially but may progress to being constant, even at rest. Numbness can worsen to the point of affecting the person’s ability to sense temperature changes and causing them to drop objects.

Risk factors

Wrist pain can affect individuals of all activity levels, whether they are highly inactive, very active, or fall somewhere in between. However, the risk of experiencing wrist pain may be increased by:

• Participation in sports: Wrist injuries are prevalent in various sports, including those involving impact and repetitive strain on the wrist. Football, bowling, golf, gymnastics, skiing, and tennis are some of these sports.
• Repetitive tasks: Almost any manual activity that engages the hands and wrists, such as knitting or hairstyling, if performed vigorously and frequently, can result in debilitating wrist pain.
• Certain medical conditions: Gout, rheumatoid arthritis, obesity, diabetes, and pregnancy may increase the risk of carpal tunnel syndrome.

Diagnosis

During the examination, your healthcare provider may perform the following tasks:

• Evaluate your wrist pain, swelling, or any abnormalities
• Request you to move your wrist to assess any limitations in movement
• Test your grip and forearm strength

Imagine Test

Various imaging examinations may be conducted, such as:

• X-ray: commonly used to identify bone fractures or signs of osteoarthritis with a low level of radiation
• CT scan: offers detailed views of wrist bones to detect fractures not visible on X-rays
• MRI: utilizes radio waves and a magnetic field to produce detailed images of bones and soft tissues
• Ultrasound: noninvasive method to examine tendons, ligaments, and cysts

Arthroscopy

In cases where imaging tests are inconclusive, an arthroscopy may be necessary. This procedure involves inserting a small arthroscope into the wrist through a minor incision. The arthroscope, equipped with a light and camera, displays images on a monitor and is considered the standard for evaluating chronic wrist pain. Repair of wrist issues can also be performed through arthroscopy.

Nerve Tests

Nerve tests, like an electromyogram, may be ordered if carpal tunnel syndrome is suspected. This test measures muscular electrical activity through a thin electrode inserted into the muscle, both at rest and during contraction. Nerve conduction studies are also conducted to evaluate the speed of electrical impulses in the carpal tunnel area.

Special Test for Wrist Pain

Physical therapists often use special tests and maneuvers to help diagnose specific conditions causing wrist pain. Here are some common physical therapy tests used for diagnosing wrist pain:

1. Phalen’s Test (for Carpal Tunnel Syndrome):

• The patient holds their forearms vertically and allows the wrists to fall into full flexion, with the backs of the hands pressed together.
• If this position reproduces or aggravates numbness, tingling, or pain in the median nerve distribution (thumb, index, and middle fingers), it may indicate carpal tunnel syndrome.

2. Tinel’s Sign (for Carpal Tunnel Syndrome):

• The therapist taps gently over the median nerve as it passes through the carpal tunnel at the wrist.
• A tingling sensation or electric shock-like feeling in the thumb, index, and middle fingers may indicate median nerve irritation or compression.

3. Finkelstein’s Test (for de Quervain’s Tenosynovitis):

• The patient makes a fist with the thumb put inside and the wrist is actively ulnar deviated (bent towards the little finger).
• If this maneuver reproduces pain along the thumb side of the wrist, it may indicate de Quervain’s tenosynovitis, which is an inflammation of the tendons in that area.

4. Grind Test (for Triangular Fibrocartilage Complex (TFCC) Injury):

• The therapist stabilizes the forearm and applies axial compression while moving the wrist through various ranges of motion.
• Pain or a grinding sensation may indicate a tear or injury to the TFCC, a cartilage structure in the wrist joint.

5. Resisted Wrist Extension Test (for Extensor Tendon Injury):

• The patient is asked to extend their wrist against resistance provided by the therapist.
• Increased pain or weakness during this maneuver may indicate an injury or inflammation of the extensor tendons on the back of the wrist.

6. Allen’s Test (for Vascular Insufficiency):

• The therapist compresses the radial and ulnar arteries at the wrist while the patient makes a tight fist.
• When the hand is opened, the color should return to the palm and fingers within 5-10 seconds if there is adequate blood flow.
• Delayed color return may indicate vascular insufficiency or occlusion.

Treatment of Wrist Pain

Specific treatments tailored to address specific causes of wrist pain

Carpal tunnel syndrome treatment options might involve:

• Using a wrist brace or splint to reduce swelling and alleviate wrist pain
• Applying hot or cold packs for 15 to 20 minutes at intervals
• Taking anti-inflammatory or pain-relieving medications like ibuprofen or naproxen
• Receiving steroid injections
• Engaging in physical therapy
• Consideration of surgical intervention to repair the median nerve in severe instances

To manage gout, one could:

• Utilize an anti-inflammatory medication such as ibuprofen or naproxen
• Ensure adequate hydration to lower uric acid levels
• Limit consumption of high-fat foods and alcohol
• Adhere to prescribed medication to decrease uric acid in the body

For ganglion cysts, treatment may involve:

• Using a splint to stabilize the wrist
• Draining the cyst through aspiration
• Surgical excision of the cyst

Kienbock’s disease is commonly addressed by:

• Immobilizing the wrist
• Taking pain relief medication
• Undergoing wrist surgery to improve blood circulation
• Requiring surgery to correct arm bone length discrepancies

In the case of a wrist injury, promoting healing may entail:

• Wearing a wrist splint
• Resting and elevating the injured wrist
• Using mild pain relief like ibuprofen or acetaminophen
• Applying ice packs intermittently to reduce swelling and pain

Individuals with arthritis might benefit from consulting a physical therapist who can demonstrate strengthening and stretching exercises to benefit the wrist.

Surgical Management

In certain situations, surgery can be required. For example, consider:

• Bone fractures. Surgery could be necessary in certain situations to stabilize bone fractures and allow for healing. It could be necessary for a surgeon to use metal hardware to join the pieces of bone together.
• Carpal tunnel syndrome. To release pressure on the nerve if your symptoms are severe, you might need to have the ligament that makes up the tunnel’s ceiling ripped apart.
• Ligament or tendon repair. Ruptured tendons or ligaments may require surgery to be repaired.

Physical Therapy for Wrist Pain

Stretching Exercises

Wrist Flexor Stretch

• Adopt an upright posture, whether standing or seated, with the affected arm extended forward at shoulder level, palm facing downwards. Utilize your opposite hand to grasp the fingers of the affected hand gently. Maintaining a straight elbow, gradually bend your wrist downwards by pulling your fingers towards you until you experience a stretching sensation in the forearm and wrist flexor muscles.
• Sustain this stretching position while breathing naturally for 30 seconds. Ensure that the stretching sensation is localized along the top of your forearm, and not radiating into your shoulder or upper arm region. Repeat this process 2-3 times, progressively increasing the intensity of the stretch with each repetition, provided it remains within a comfortable range.
• Through this controlled and deliberate movement, you can effectively target and alleviate the tension accumulated in the affected area, potentially alleviating pain and promoting increased mobility and flexibility in the wrist and forearm regions.

Wrist Extensor Stretch

• Stand or sit upright with your affected arm extended in front of you at shoulder height, palm facing down.
• Use your opposite hand to gently grasp the back of your affected hand.
• Keeping your elbow straight, slowly bend your wrist upwards by pulling the back of your hand towards you until you feel a stretch in the forearm and wrist extensor muscles.
• Maintain the stretch while breathing normally for 30 seconds.
• Ensure that you are feeling the stretch along the underside of your forearm and not in your shoulder or upper arm.
• Repeat 2-3 times, stretching a little further each time if comfortable.

ROM Exercises

Wrist Flexion/Extension

• Sit or stand with your affected arm rested on a table, forearm supported and wrist extended over the edge.
• Slowly bend your wrist upwards towards the ceiling as far as comfortable – this is wrist extension.
• Hold for 2 seconds.
• Slowly lower your wrist back down, bending it towards the floor as far as you can – this is wrist flexion.
• Hold for 2 seconds.
• Repeat 10-15 times, moving smoothly between extension and flexion.

Wrist Radial/Ulnar Deviation 

• Position yourself comfortably in a seated or standing posture, allowing your affected forearm to rest upon a table surface with the wrist extended over the edge and the thumb pointing upwards. Initiate a slow and controlled motion, moving your wrist laterally from side to side, guiding your hand downwards towards the little finger side – a movement known as ulnar deviation.
• Maintain this deviated position for a brief duration of 2 seconds, allowing the muscles to experience a gentle stretch. Then, return your wrist to the center position and proceed to move it in the opposite direction, guiding your hand downwards towards the thumb side – a movement referred to as radial deviation.
• Once again, hold this deviated position for 2 seconds, consciously engaging the associated muscles. Repeat this sequence of motions 10 to 15 times in each direction, ensuring a smooth and controlled execution throughout the process.
• This exercise targets the intricate musculature of the wrist, promoting increased flexibility, range of motion, and overall joint health. Incorporate this routine into your daily regimen to alleviate pain and enhance functional mobility in the affected area.

Forearm Pronation/Supination

• With the injured elbow tucked into your side and bent 90 degrees, sit or stand. Your forearm and the ground should be parallel.
• Supination is the movement of slowly rotating your forearm such that your palm faces upward toward the sky.
• For two seconds, hold.
• Next, carefully rotate your forearm downward so that your palm is facing the floor; this is known as pronation.
• For two seconds, hold.
• Repeat ten to fifteen times, effortlessly alternating between supination and pronation.

Strengthening Exercises

Wrist Isometrics

Flexion:

• Sit with your forearm resting on a table, wrist extended over the edge
• Push the back of your hand down onto the table as if trying to bend your wrist up
• Hold the isometric contraction for 5-10 seconds
• Relax and repeat 10 times

Extension:

• With a forearm on the table, the posture remains the same.
• Try lifting your hand off the table this time by using your wrist extensors to contract.
• Ten to fifteen seconds of holding
• Ten times over, repeat

Radial/Ulnar Deviation:

• Your forearm should rest on the table when you make a fist.
• Press your fist toward the thumb side as though attempting to bend your wrist in that direction to compensate for radial deviation.
• Hold for five to ten seconds, after letting go.
• Press against the side of your little finger for ulnar deviation.
• Do ten repetitions of each deviation.

Grip Strengthening

• Use a soft squeeze ball or therapy
• Squeeze it as hard as possible
• Hold for 2-3 seconds
• Relax and repeat for 10-15 reps
• Can also pick up and squeeze therapy putty between your fingers

Wrist Curls

Flexion Curls:

• Sit holding a weight (1-3 lbs) in your hand with your palm facing down
• Bend your wrist up as far as you can by curling the weight up towards the ceiling
• Use your other hand to gently assist and control the motion
• Carefully descend back down and perform 10–15 repetitions.

Extension Curls:

• Start with your forearm resting on a table and weight in hand
• Bend your wrist up so your hand clears the table
• Slowly lower down by contracting the extensors until your hand touches the table
• Repeat for 10-15 reps

Pronation/Supination with Resistance Band

• Secure one end of a resistance band by forming a loop, and carefully guide your affected hand through this loop, allowing it to rest comfortably around your wrist. Grasp the other end of the band with your non-affected hand.
• Assume the starting position by pronating your affected forearm, with the palm facing downwards, and tucking the elbow close to your side.
• Initiate a slow and controlled rotational motion, gradually supinating your forearm, and guiding the palm to face upwards. Maintain a stationary position for the elbow throughout this movement.
• Reverse the motion, returning to the pronated position, while simultaneously providing resistance against the band’s tension.
• Execute this sequence in a controlled and deliberate manner, aiming for two to three sets of ten to fifteen repetitions each.
• This exercise targets the intricate musculature of the forearm, promoting increased flexibility, range of motion, and overall joint health. Incorporate this routine into your regimen to alleviate pain and enhance functional mobility in the affected area.

When to seek medical attention

It’s crucial to contact a physician if:

• Your wrist pain is impacting your daily activities.
• Numbness or tingling sensations are worsening, resulting in reduced sensation in your fingers or hand.
• Simple hand movements become impossible.
• Weakness hinders your ability to hold objects.
  Complications of wrist pain can lead to weakness and a diminished capacity to perform tasks such as gripping objects or typing on a keyboard.

Prevention Tips for Wrist Injuries

It is not always possible to predict and prevent unexpected incidents leading to wrist injuries; however, following these fundamental suggestions can potentially offer some protection:

• Enhance bone strength by ensuring an adequate intake of calcium. Most adults should aim for a daily consumption of 1,000 to 1,200 milligrams.
• Reduce the risk of falls, as falling forward onto an outstretched hand is a common cause of wrist injuries. To minimize the chances of falling, sensible footwear, eliminate potential hazards in your home environment, ensure proper lighting, and, where needed, install grab bars in bathrooms and handrails on stairways.
• For activities with a high risk of wrist injuries, such as football, snowboarding, and rollerblading, utilize protective gear like wrist guards.
• Maintain good ergonomics especially if you spend extended periods at a computer keyboard. Take regular breaks, keep your wrists in a relaxed, neutral position while typing, and consider using an ergonomic keyboard or foam/gel wrist support for added comfort and support.

Summary

The wrist region, a complex structural composition, is susceptible to a range of discomforts arising from various causative factors, including overexertion, traumatic incidents, arthritic conditions, and other underlying medical circumstances. Understanding the complex anatomy of the wrist joint, surrounding bones, ligaments, tendons, muscles, and nerves, is primary in identifying and addressing wrist-related problems. Manifestations of wrist pain can present in multiple forms, such as persistent or acute pain sensations, swelling, stiffness, numbness, tingling, weakness, and visible deformities.

Diagnosing the root cause of wrist pain requires a comprehensive medical evaluation, inclose a thorough examination of the patient’s medical history, a physical assessment, and, if considered necessary, diagnostic imaging modalities like X-rays, MRI, or CT scans, as well as additional tests like nerve conduction studies or joint aspiration.

Non-surgical treatment modalities for wrist pain may include rest and immobilization, cold and heat therapy, medication (anti-inflammatory drugs, corticosteroid injections), physical therapy exercises, splinting or bracing, and occupational therapy. In severe or persistent cases, surgical interventions may be recommended, such as carpal tunnel release, tendon repair or reconstruction, wrist arthroscopy, wrist fusion or joint replacement, fracture repair, or ganglion cyst removal.

FAQs

References

• Wrist pain – Diagnosis and treatment – Mayo Clinic. (2022, October 28). https://www.mayoclinic.org/diseases-conditions/wrist-pain/diagnosis-treatment/drc-20366215
• Professional, C. C. M. (n.d.). Anatomy of the Hand and Wrist. Cleveland Clinic. https://my.clevelandclinic.org/health/body/25060-anatomy-of-the-hand-and-wrist
• Nadler, L. (2018, March 27). Severe Wrist Pain Symptoms, Causes & Common Questions | Buoy. https://www.buoyhealth.com/learn/severe-wrist-pain
• Prajapati, N. (2022, April 21). Exercises for wrist pain: Mobilization, Stretching – Strengthening Exercise. Samarpan Physiotherapy Clinic. https://samarpanphysioclinic.com/exercises-for-wrist-pain/
• D. (2022, June 10). Exercise for wrist Pain Health Benefits, How to do? | Mobile Physio. Mobile Physiotherapy Clinic. https://mobilephysiotherapyclinic.in/exercise-for-wrist-pain/#Symptoms_of_Wrist_Pain
• Phillips, N. (2023, February 1). Possible Causes of Wrist Pain and Treatment Tips. Healthline. https://www.healthline.com/health/wrist-pain#what-to-look-for

Author: Akshit Virani