From the Guidelines
The best management plan for this 49-year-old male with persistent right wrist pain would involve a comprehensive approach, prioritizing non-pharmacological and pharmacological treatments individualized to the patient's requirements, as recommended by the 2019 EULAR guidelines 1.
Key Recommendations
- Education and training in ergonomic principles, pacing of activity, and use of assistive devices should be offered to every patient 1.
- Exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient 1.
- Orthoses, such as wrist bracing, should be considered for symptom relief 1.
- Topical treatments, such as topical NSAIDs, are preferred over systemic treatments due to safety reasons 1.
- Oral analgesics, particularly NSAIDs, should be considered for a limited duration for relief of symptoms 1.
Treatment Approach
While continuing ibuprofen for temporary relief, the patient should consider switching to a different NSAID, such as naproxen (500 mg twice daily) or meloxicam (15 mg once daily), if ibuprofen isn't providing adequate relief, as suggested by the American College of Rheumatology 2012 recommendations 1.
- Acetaminophen (up to 4 g/day) is the oral analgesic of first choice and, if successful, is the preferred long-term oral analgesic 1.
- Intra-articular injections of glucocorticoids should not generally be used in patients with hand OA, but may be considered in patients with painful interphalangeal joints 1.
Follow-up and Further Evaluation
If conservative measures fail after 3 months, advanced imaging, such as MRI, should be obtained to evaluate for structural abnormalities that might require surgical intervention.
- Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain 1.
From the Research
Management Plan for Wrist Pain
The patient's history of steroid injection in the right wrist and current use of ibuprofen for wrist pain suggests a need for a comprehensive management plan.
- The plan includes prescribing a wrist brace, acetaminophen, and diclofenac for the patient, as well as scheduling a follow-up appointment in three months to assess the need for a steroid intraarticular injection 2, 3.
- The use of diclofenac gel has been studied in the treatment of wrist extensor tenosynovitis, with mixed results 3.
- Corticosteroid injections have been shown to be effective in reducing wrist pain in patients with distal radius fractures, but the effect may not be persistent 4.
- A review of corticosteroid and other injections in the management of tendinopathies found that corticosteroid injections can be beneficial in the short term, but may be worse than other treatments in the intermediate and long terms 5.
- Techniques and procedures for injections, such as ultrasound-guided injections, can vary and may offer significant improvement in certain conditions, such as carpal tunnel syndrome 6.
Treatment Options
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and rest are often initial treatments for wrist pain, but injections may be considered if these treatments fail 6.
- Corticosteroid injections can offer pain relief, but possible risks, such as infection and cartilage damage, should be discussed with the patient 6.
- Other treatment options, such as immobilization, kinesio taping, relative rest, and analgesics, may be considered for specific conditions, such as triangular fibrocartilage complex injury 6.
- Conservative treatment, including palpation- or ultrasound-guided corticosteroid injection, splinting, occupational therapy, and activity modification, may be effective for de Quervain tenosynovitis 6.