Is a patient's persisting wrist pain after performing pushups likely a ligament injury?

Wrist Pain After Pushups: Ligament Injury Assessment

Persistent wrist pain after performing pushups is highly likely to be a ligament injury, particularly affecting the scapholunate ligament or other dorsal wrist structures. MRI evaluation is recommended as the next diagnostic step after normal radiographs to confirm this diagnosis 1.

Mechanism and Common Ligament Injuries

• Pushups place significant stress on the wrist in extension, creating compression injuries dorsally that commonly affect ligamentous structures 2
• Weight-bearing exercises in extended wrist positions (like pushups, planks, yoga poses) frequently cause dorsal wrist pathology, with MRI studies showing identifiable dorsal abnormalities in 84% of patients with this presentation 1
• The dorsiflexion mechanism during pushups creates tension injuries on the palmar aspect of the wrist, potentially disrupting supporting ligaments or interosseous membranes 2
• Common ligamentous injuries include:
  • Scapholunate ligament tears or degeneration 1
  • Lunotriquetral ligament tears 3
  • Triangular fibrocartilage complex (TFCC) tears 3

Diagnostic Approach

Initial Assessment

• Standard radiographs should be performed first, including posterior-anterior and lateral views in neutral position, often supplemented by oblique views 3
• Stress positions and maneuvers may be needed to elicit dynamic instability not visible on standard radiographs 3

Advanced Imaging

• MRI is the recommended next study when radiographs are normal or nonspecific in patients with dorsal wrist pain 4
• MRI accurately depicts abnormalities of bones, bone marrow, articular cartilage, intrinsic and extrinsic ligaments, TFCC, synovium, tendons, and neurovascular structures 4
• For persistent pain despite conservative management, consider MR arthrography or CT arthrography 4

MRI Findings

• Occult dorsal ganglion cysts are the most common pathology (76% of cases) in patients with dorsal wrist pain during extended loading positions 1
• Partial scapholunate tears are the second most common finding 1
• MRI has moderate sensitivity for scapholunate ligament tears and lower sensitivity for lunotriquetral ligament tears 3

Treatment Considerations

• Conservative management can provide significant clinical improvement for patients with dorsal central wrist pain associated with acute peri-scapholunate ligament injury 5
• A structured rehabilitation program including immobilization, scapholunate-stabilizing muscle strengthening, and proprioception training has shown promising results 5
• For gymnasts and individuals who regularly perform weight-bearing exercises on their wrists, treatment may need to be modified based on training and competition demands 6

Pitfalls and Caveats

• MRI may overestimate the severity of ligament injuries, with specificity rates reported as low as 64-77% for soft-tissue injuries 3
• Standard MRI may miss partial ligament tears; MR arthrography has higher sensitivity for complete and incomplete scapholunate and lunotriquetral ligament tears 3
• CT arthrography may be more sensitive than conventional MRI for tears of the biomechanically important dorsal ligament fibers 3
• Dynamic instability may be missed on standard MRI unless sequences are performed in specific positions 3

In conclusion, the clinical presentation of wrist pain after pushups strongly suggests a ligament injury. MRI is the recommended diagnostic tool after normal radiographs, with special consideration for MR arthrography if standard MRI is inconclusive 4, 1.