Wrist Pain: Scary to Manage?

By Ian Gatt

Let’s be honest, unless you work regularly with wrists, it can be a rather scary joint to manage. So many hard and soft tissue structures! However, is it that different from other joints you manage on a regular basis? Then this poses the question of how you manage these other joints? So, let’s start from the beginning. I have been using and teaching the following equation for donkey’s years now:

Prognosis = Diagnosis + Function

So, what does this equation represent? It supports the notion that the role of a physiotherapist or any other allied professional is to ‘predict’ - rather than focus on diagnosis - what an individual can do in the short-to-long term future based on their current presentation. If you were working in sports it would be the prediction of when someone could return to their sport. Therefore, to support this prediction or prognosis, we need the best combined understanding of potential pathologies and functional abilities at the wrist. Let’s therefore consider these areas separately first. 

Diagnosis 

Is it a traumatic, sudden or overuse mechanism? Or is it insidious in nature? If we take sudden traumatic events then a fall onto an outstretched hand (FOOSH) - where the wrist is typically placed in extension - is a common mechanism. This can happen in sporting activities and leisure activities like snowboarding if, like me, you decided to hit the slopes over the winter. Luckily no injuries…albeit a few epic falls! Older people are also prone to falls in everyday life too. Various structures can get injured but definitely ones not to miss are scaphoid fractures and significant scapho-lunate ligament tears. If missed, complications can be quite impactful on function, potentially causing long-term problems...Ouch!

What about overuse? It’s useful to consider whether the symptoms are mild, moderate or severe. Then it depends on what structures we are considering. We should also take note of any associated factors/comorbidities, which can impact prognosis. Here we definitely need to think tendons (e.g. De Quervain’s) and/or nerves (e.g. Carpal Tunnel). Sometimes it is easy to think that because these problems have come on gradually, we don’t need to have any urgency. For mild and possibly moderate symptoms, this is likely the case. However, with severe symptoms we should consider any current gross impairments and whether there is anything which could become potentially permanent. 

What about insidious onset wrist pain? Here I’m differentiating from an overuse-induced mechanism and focusing rather on those pathologies which happen without a distinct mechanism. A common one is a dorsal wrist ganglion, which is typically benign and, for the majority, doesn't warrant further investigations. No - whacking a ganglion with a heavy book is properly not the best ‘therapeutic’ approach as there are other methods we should consider. Bottom line though, there is no immediate urgency…nice to know! 

Function

Various people will likely have a different definition of what function means. I like to think that function is the ability of an individual to interact, without unwarranted effort, within a familiar environment in order to perform tasks. Obviously there are various situations where you could struggle in an environment to perform tasks, but the difference here is the expectation to struggle (e.g. like in a gym if you are a novice or pushing yourself harder), as compared to having a limitation caused by some form of injury and/or pathology. I hear you saying, so all we need is to ask the person what their limitations are and through interventions we somehow get them there. In part, true. However, what we don’t know, as yet, is how much the functional ‘gap’ is and what exactly we need to focus on. That’s why at the wrist, and in great part for other anatomical areas, it is useful to use objective measures to ‘quantify’ what this gap is and better guide both the assessment and subsequent interventions. 

A simplistic but not reductionist place to start when considering objective measures is range of motion (ROM) and force (not strength…I’ll explain shortly). Many times these are the forgotten basics. At the wrist, do they have relative equal (within 10-15% of the unaffected side) ROM? If restrictions are in a diagonal pattern (extension and radial deviation or flexion and ulnar deviation), are you aware of the dart throwing motion occurring biomechanically at the wrist? If you don’t know, sorry for throwing in something like this, but you know what, it does matter for function and also can prove really useful not just for assessment but as an option for interventions. By the way, don’t forget rotation (i.e. pronation and supination), which although are predominately forearm actions, link closely to the wrist [Fig 1].  

Figure 1 - source from Gatt (2023).

The great thing is that ROM can be measured and even better, there are various apps available on your phone [Fig. 2], meaning there is no need for walking around with goniometers. Little secret…measuring with a phone app is ‘biomechanically’ more correct! 

Figure 2

Let’s now move onto force. Force refers to the actual physical exertion like pushing or pulling, while strength represents the capacity or ability to exert that force. So why all this chat about force? Because the nice thing is that force can be measured. A very simple and cheap method is using a Hand-Grip Dynamometer (HGD). Similar to measuring ROM, you want a relative equal difference (i.e. within 10-15%). If there is a difference, but pain is present, we should consider the chronology of the injury. If it’s an acute injury, the difference is likely due to pain (i.e. pain inhibition) rather than strength. So, this notion of telling people with an acute injury that they need to strengthen their wrist is absurd, obviously unless the trauma directly affects the muscles/tendon (i.e. tears) or if there was some pre-existing weakness. Prolonged periods of immobilisation and post-operative situations can also lead to potential muscle weakness. If it’s a chronic problem, yes maybe there is true weakness due to disuse/avoidance mechanisms, especially in the absence of pain on testing. When testing, it’s useful to consider this equation:

Force = Strength - Pain

The equation is a reminder that the more pain is present on performing a functional activity or test, the less likely it is that force will be produced, even if there is no strength deficit. Conversely in the absence of pain, force reduction would be linked to a strength deficit. The clinical utility of this approach enables practitioners to focus on strength gains, when a true deficit exists rather than the classic “you need to get stronger” being told to every individual walking through the door. It enables the practitioner to start considering not only the appropriate intervention, but in the case of a true identified weakness, the dosage best suited to improve the required muscle properties. 

So, someone presents to you with a complex wrist issue. Do you panic? No, you gather the available information for both diagnosis and function to enable the best possible prognosis at the time. A consideration for the equation ‘Prognosis = Diagnosis + Function’ is that even in the absence of a diagnosis, as long as there are no apparent red flags, we can still have a workable prognostic value if we focus more on gathering information on function. This approach enables the formulation of a plan which can improve motivation and adherence to strategies, even when there is uncertainty and likely frustration about the diagnosis.  

What is the best intervention for wrist pain?

Easy…whatever floats your boat, however aim to  target the identified gap. Remember though, the wrists really love loading. If you combine that with person self-efficacy, then I’d be considering rehab exercises as the first line of approach. I typically see more positive effects with this compared to lots of hands-on therapeutic approaches. Now, I’m not saying that adjuncts might not add value, however sometimes this approach is way overplayed. Less is definitely better when it comes to adjuncts, especially as it causes less discomfort for the individual combined with less cost for the individual. So really, it’s always worth thinking about the efficacy (i.e. impact versus cost) of any proposed strategy, in combination with an individual's context. 

Summary

Next time you see a wrist, hopefully you will be more comfortable and empowered to support the person in front of you. Wrist injuries are no more complex than those in other areas of the body. Indeed, it requires an overview of pathologies to ensure certain conditions are managed safely and in a timely way. It also requires a systematic approach towards identifying what the functional gap is, and in doing so, provide an intervention tailored for that gap!

References

Gatt, I. (2023), Effects of Bandaging Techniques and Shot Types on Wrist Motion in Boxing, Ph.D. thesis, Sheffield Hallam University