Is a steroid injection helpful for dorsal central wrist pain with a history of hypermobility?

Steroid Injection for Dorsal Central Wrist Pain with Hypermobility

Steroid injections are not recommended as first-line treatment for dorsal central wrist pain in patients with hypermobility, as they provide only short-term relief and may worsen outcomes in the long term. 1, 2

Understanding Dorsal Central Wrist Pain in Hypermobility

Dorsal central wrist pain in patients with hypermobility is often associated with peri-scapholunate ligament injury, which can lead to decreased functional performance. The combination of hypermobility and wrist pain suggests potential ligamentous instability that requires careful management.

Key Diagnostic Considerations:

• Physical examination should include specific wrist provocation tests 1
• MRI is the preferred imaging modality for evaluating dorsal central wrist pain when radiographs are normal or nonspecific 1
• MRI provides high accuracy for diagnosing scapholunate ligament tears and can detect both intra-articular and extra-articular abnormalities 1

Treatment Approach

First-Line Treatment:

• Structured rehabilitation program including immobilization with orthotic devices, scapholunate-stabilizing muscle strengthening, and proprioception training 3
• Recent evidence shows that a 16-week home-based rehabilitation program can significantly reduce pain and improve functional performance in patients with dorsal central wrist pain associated with peri-scapholunate ligament injury 3
• Rest and activity modification to avoid movements that worsen pain 1
• Ice therapy for 10-minute periods through a wet towel for short-term pain relief 1

Pharmacological Options:

• NSAIDs (oral or topical) for pain relief 1
• Acetaminophen may be considered for short-term pain management, though its effect size is small 1

Role of Steroid Injections:

While intra-articular glucocorticoid injections are conditionally recommended for hand osteoarthritis 1, their use in dorsal central wrist pain with hypermobility presents several concerns:

• Short-term benefits vs. long-term risks: Corticosteroid injections may provide short-term pain relief but can lead to worse outcomes in the intermediate and long term 2
• Potential complications: Steroid injections directly into tendon substance should be avoided due to risk of tendon rupture 1, 4
• Limited evidence: There is insufficient data to support the use of steroid injections specifically for dorsal central wrist pain in hypermobility 1
• Hypermobility concerns: In patients with hypermobility, injections may further compromise already lax ligamentous structures 3

Alternative Injection Options:

• Sodium hyaluronate injections have shown some benefit for lateral epicondylalgia in both short and long term, but evidence for wrist pain is limited 2
• Platelet-rich plasma injections remain investigational with mixed evidence 1

Follow-up and Progression

• If conservative management fails after 8-12 weeks, reassessment with advanced imaging may be warranted 1
• For persistent symptoms despite conservative management, referral to a hand specialist for consideration of surgical options may be appropriate 3

Pitfalls and Caveats

• Avoid direct injection into tendon substance as it may lead to tendon rupture 1, 4
• Hypermobility predisposes to recurrent ligamentous injury, making long-term stabilization strategies more important than temporary pain relief 3
• The presence of hypermobility should guide treatment toward stabilization rather than solely focusing on pain relief 3
• Multiple steroid injections should be avoided as they may contribute to further tissue weakening 1

In conclusion, a structured rehabilitation program focusing on stabilization and strengthening represents the most evidence-based approach for managing dorsal central wrist pain in patients with hypermobility, while steroid injections should be used cautiously, if at all, due to potential long-term negative effects.