Understanding Wrist Pain: Causes and Conditions

Prevalence of wrist pain

Wrist pain is a highly prevalent symptom that is particularly noted in people who partake in physically demanding or repetitive activities involving the upper limb or hand (Ferguson, et al., 2019). It can also occur with a range of conditions including, hyper-mobility, auto-immune issues or arthritis. According to Chen et al (2022), wrist pain is the fourth most common pain site after the shoulders, hands and elbows. Walker-Bone et al (2004) suggest non-specific hand and wrist pain take up 10% of the population. There is an array of evidence now which suggests that modifiable risk factors such as occupation and the demands of the job, as well as leisure pursuits such as sports are all associated with wrist pain (Ferguson, et al., 2019).

The wrist is a complex part of our anatomy, and it can be difficult to sometimes work out the cause of wrist pain. Clinical assessment by an experienced examiner such as a hand therapist or hand surgeon will typically lead to a diagnosis. Sometimes, further assessment is necessary through radiography which may include an X-ray or ultrasound in the first instance. For more complicated wrist issues an MRI, CT scan or bone scan could be ordered (Shehab and Mirabelli, 2013).

The wrist is a complex structure, compiled of:

• Bones: The wrist consists of 8 carpal bones, which form 2 rows. These bones articulate with the radius and ulna of the forearm and the metacarpal bones of the hand.

• Ligaments: Ligaments connect the carpal bones to each other and to the bones of the forearm. They provide stability to the wrist joint.
• Tendons: Tendons are fibrous tissues that connect muscles to bones. In the wrist, tendons from the forearm muscles pass through the wrist to control movement of the hand and fingers. We have 9 tendons that pass through the carpal tunnel and 11 tendons that pass on the back side (dorsum of the wrist)
• Nerves: Several nerves pass through or near the wrist, including the median nerve, ulnar nerve and radial nerve. These nerves provide sensory (ability to feel) and motor (ability to move) functions to the hand and fingers.
• Blood vessels: Arteries and veins pass through the wrist to supply blood to the hand and fingers.
• Synovium and synovial fluid: The soft tissue lining and fluid that helps to keep our joints lubricated and line our tendons for enabling movement and nourishment.

Every wrist condition affects one or multiple of these structures, therefore the puzzle begins with you and the assessor to explore your subjective experience (what you report) with objective tests (tests performed by examiner / assessor) to determine what is happening in the wrist.

To add to this puzzle, many symptoms are often similar. Many people will experience:

• Pain, stiffness, weakness in the wrist
• Difficulty gripping or grasping objects
• Painful sensations during daily activities

Pain could be sharp or dull. It may come on suddenly or slowly. It could only occur during sleeping or during a specific activity. These are all very helpful clues to discuss with your health professional (Porretto-Loehrke and Schuh (2016).

Importance of understanding the cause and seeking professional help

It is important not to push through pain. Pain is our bodies personal alarm system signalling that something is wrong. Therefore, it is highly encouraged that early diagnosis and treatment is sought so that recovery can be efficient, successful and complications are prevented (Glasgow, Cox, Laracy, Green , & Ross, 2020).

. . . So, what are some possible common causes of wrist pain?

RSI: Repetitive strain Injuries

RSI a very generalised term often used to describe a range of painful conditions all of which are caused by repetitive motions, overuse, or awkward positions that strain the muscles, tendons, nerves, or other soft tissues of the body.

Experiences can be pain and weakness which commonly impacts the thumb or thumb movement.

A hand therapist can review the extent of the strain and prescribe custom splinting options and work through ergonomic modifications with you. There are often tasks that aggravate symptoms, some of which can be the route of the problem. Altering posture or using adaptive equipment can ease the load on the wrist allowing you to maintain participation in activities that you enjoy and need to do (Horowitz, et al., 2022).

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome (CTS) is a condition that can cause wrist pain but also numbness and tingling in the thumb, index, middle, and half of the ring finger. It occurs when the median nerve, which runs from the neck to the forearm into the palm of the hand, becomes compressed or swollen at the wrist. This can happen due to swelling or irritation of the tendons in the wrist, leading to increased pressure on the median nerve (Muller, et al., 2004).

Splints during sleep are often helpful for a period of 8-10 weeks to prevent the wrist from flexing or extending into positions that compromise the nerve (which we often do during sleep). Nighttime splinting is the ideal time to rest the nerve and allow recovery. Exercises usually referred to tendon gliding or nerve gliding that improve blood flow and mobility of the median nerve are helpful (Muller, et al., 2004). In some cases, further intervention may be required if the nerve compression is moderate to severe. Extent of t his can be tested using a nerve conduction study. This may then necessitate onward referral to a hand and upper limb surgeon to consider corticosteroid injection or surgery.

Tendonitis

Tendonitis is a condition characterised by inflammation or irritation of a tendon. Tendons are strong, fibrous tissues that connect muscles to bones, and they play a crucial role in facilitating movement.

When we overuse or repeat a movement, we can strain the tendon beyond its capacity to recover. It is common for a tendonitis to occur in sports, manual labour, or even household domestic tasks.

Sometimes we can be prone to tendonitis with comorbid factors such as age, menopause, arthritis, or diabetes (Schiottz-Christensen, et al., 1999).

Tendonitis can feel like pain, tenderness and swelling on the tendon particularly when associated with movement. It can also be accompanied with stiffness and aching sensations. Ultrasound scan is usually sufficient to confirm the extent of tendon damage however a more comprehensive scan such as MRI is occasionally required.  

Stretches and exercises to assist with pain management and rehabilitation often help. Tendinopathy or tendinosis are other terms that are commonly used and generally describe a tendon problem than is chronic in nature rather than acute. The term “…itis” implies inflammation. Tendinosis implies a tendon that has damage to the collagen fibres and may be weak or have tiny micro-tearing (McAuliffe, 2010).

Ganglion cysts

A Ganglion cyst is a non-cancerous lump or mass that can form along the tendons or joints of the wrists and hands. It appears as a round or oval shaped lump just beneath the skin, often on the back of the wrist but can occur anywhere.

Sometimes they feel firm or spongy to touch and can cause pain or discomfort particularly with movement. They are filled with a jelly-like fluid and can vary in size. People whom have very lax or loose joints tend to be more prone to developing ganglions. They can often disappear as quickly as they developed (Zoller, Benner, & Iannuzzi, 2023).  

Occasionally we prescribe custom splints that immobilise the affected area to relieve pressure and promote healing / rest of the wrist. We may fabricate custom compression wraps which often provide relief of symptoms. Manual therapy and exercises can also assist with restoring normal movement patterns and enhancing tissue flexibility and strength around the ganglion cyst.

Triangular Fibrocartilage Complex (TFCC) tears

A TFCC tear is an injury to the ligaments particularly the triangular fibrocartilage disc. This ligament complex provides stability to the wrist joint and helps distribute forces during gripping and rotation movements. The TFCC sits on the little finger side of the wrist between the ulna bone of the forearm and the carpal bones. Tears can occur with trauma, degeneration or repetitive stress. It is often painful to weight-bear or push-down through the palm such as pushing off a chair.

Diagnosis can be completed through a thorough assessment or MRI imaging. Acute injuries benefit from reducing forearm rotation and weight bearing as much as possible. A custom strap or a TFCC stabilisation splint is often prescribed and worn for a period of time during activity. More significant tears that lead to instability or looseness in the wrist may be appropriate for a period of full rest in a long forearm brace that may or may not include the elbow. If the ligament has completely torn, then surgery may need to be considered (Sachar, 2012).

Piso-triquetral pain

The pisiform is a very small pea-shaped bone that articulates in the wrist with the triquetrum bone on the ulnar side (little finger side) of your wrist. It is slightly closer to your fingers than the TFCC. The surrounding structures such as the flexor carpi ulnaris tendon, piso-hamate ligament or ulnar nerve can all acquire irritation or inflammation when overused (Shehab & Mirabelli, 2013). This problem is reasonably common with osteoarthritis but is routinely missed or over-looked during physical examinations.

It may be more common in people that lean on the outside of their wrists such as during typing or riding a bicycle. Activity modification changes are necessary to reduce symptoms including use of soft pads and gloves with padding on the little finger side of the hand. Keyboard users may benefit from a foam or gel wrist rest or vertical mouse.

DeQuervein’s Tenosynovitis

DeQuervein’s tenosynovitis is a more common condition which affects the wrist at the thumb side. It is a often seen with new parents due to the action of breast feeding and handling a newborn. The abductor pollicis longus and extensor pollicis brevis muscles assist to move the thumb. The tendons that attach to those two muscles travel through a narrow tunnel called the ‘first dorsal compartment’. When these become inflamed from overuse or trauma it can cause pain and swelling making it difficult to use the thumb in gripping or twisting activities. Sharp pain is usually experienced.

Overtime, the swelling and inflammation can cause difficulty with thumb and wrist movement. The thumb can become weak during pinching tasks, or the tendon can catch / click in the compartment in extreme cases.

Custom splinting or a brace to reduce strain and immobilise the thumb and wrist is often effective when worn for a period of 4-6 weeks. Sometimes this needs to be combined with corticosteroid injection. Modalities such as ice, heat or therapeutic ultrasound can be helpful along with use of kinesiology tape application and massage (Ferrara, et al., 2020). A customised strengthening program and modification to activity are keyways to reduce symptoms.

Schapho-lunate ligament injury

The scaphoid and lunate are two of the eight bones that make up the wrist.  There is a ligament that connects the scaphoid and lunate that has 3 components; one on the dorsal or top surface, one on the volar or palm surface and a central portion. When injured it can result in injury to all or some of those portions and fibres (Wolff & Wolfe, 2016).

The scapho-lunate ligament can be mildly sprained, partially torn or have a complete tear. Pain is predominately on the back of the wrist and noticeable tenderness and swelling can be observed. There can be difficulties with strength, weight-bearing and rotating the wrist.  Occasionally a clicking or grinding sensation can be felt during movement.

These injuries in the acute phase tend to do well from use of a wrist splint for 6 weeks. They also will respond to a strengthening program. If the tendon is completely torn, it is sometimes recommended to have surgery (Wolff & Wolfe, 2016).

Taking charge of your wrist health:

Hopefully we have summarised some the key wrist conditions and their causes. It can be overwhelming having a wrist injury which causes pain and limits activities. The quickest path to recovery requires an accurate diagnosis in the first instance and then a detailed plan of treatment interventions.

If you are experiencing pain, weakness or stiffness in the hand or wrist, or you believe you might have one of the above conditions, an assessment is a wise idea. An experienced health professional whom specialises in hand and wrist assessment will help make that process more efficient and cost effective in the long run.

The wrist is a complex structure that works hard to assist us in our everyday activities. Let’s look after it!