What is the prognosis of persistent wrist pain that started with pushups and is now a generalized ache, present for 5 weeks?

Prognosis of Exercise-Induced Wrist Pain Persisting 5 Weeks

The prognosis for wrist pain that began with pushups and has persisted for 5 weeks as a generalized ache is generally favorable with appropriate evaluation and management, though the transition from acute injury to chronic pain at this timeframe warrants systematic diagnostic workup to identify the underlying cause and prevent long-term complications.

Understanding the Clinical Timeline

Your presentation represents a critical transition point in wrist pain management:

• Pain persisting beyond 4-6 weeks crosses into the "chronic wrist pain" category, which requires a more systematic diagnostic approach than acute injuries 1.
• The mechanism (pushup-related loading) suggests possible occult fracture, ligamentous injury, or tendinopathy that may not have been initially apparent 2.
• The evolution from activity-specific pain to constant generalized aching indicates either ongoing structural damage or failed healing, which changes the diagnostic and prognostic considerations 3.

Immediate Diagnostic Approach

You need plain radiographs immediately as the first-line imaging study, including standard posteroanterior and lateral views to evaluate bony architecture, joint alignment, and soft tissue 1. This is critical because:

• Approximately 70% of wrist pain diagnoses can be determined from history alone, but imaging is essential to rule out structural pathology 2.
• Occult fractures (particularly scaphoid) can be missed on initial presentation and may only become apparent weeks later 4.
• Radiographs establish baseline bony architecture before considering advanced imaging 1.

If Radiographs Are Normal or Equivocal

MRI without IV contrast is the preferred next study when radiographs don't reveal the diagnosis and symptoms persist 1. This is particularly important in your case because:

• MRI accurately depicts bones, ligaments, triangular fibrocartilage complex (TFCC), and soft tissues that could be injured during pushup loading 5.
• Occult stress fractures, bone bruises, and early avascular necrosis are highly sensitive to MRI detection 1.
• Tendinopathy and ligamentous injuries that cause chronic pain are best visualized with MRI 1.

Specific Conditions to Consider Based on Your Mechanism

Occult Fracture or Stress Fracture

• Repetitive loading during pushups can cause stress fractures that aren't initially visible on radiographs 1.
• Scaphoid fractures are particularly concerning as they can lead to nonunion and avascular necrosis if missed 1, 4.
• MRI or CT without contrast are both appropriate for detecting occult fractures, though MRI has greater sensitivity for bone bruises 1.

Tendinopathy

• Overuse of forearm and wrist muscles during pushups commonly leads to tendinopathy 4.
• If pain localizes to the radial side, consider de Quervain tenosynovitis, which can be evaluated with ultrasound 5.
• Extensor tendon compartment inflammation typically improves with rest and activity modification 4.

Ligamentous Injury

• TFCC tears and intercarpal ligament injuries can present as chronic generalized wrist pain 1.
• These injuries may require MRI or MR arthrography for definitive diagnosis if clinical suspicion is high 1.

Prognostic Factors

Favorable Prognostic Indicators

• If imaging reveals tendinopathy or soft tissue inflammation without structural damage, prognosis is excellent with conservative management 3.
• Most overuse injuries respond to activity modification, immobilization, and gradual return to loading 4.

Concerning Prognostic Indicators

• Persistent pain at 5 weeks despite rest suggests possible structural pathology requiring intervention 2.
• Occult fractures, particularly scaphoid nonunion, can lead to chronic pain and arthritis if not properly treated 1.
• Avascular necrosis (Kienböck's disease) has variable prognosis depending on stage at diagnosis 1.

Clinical Algorithm Moving Forward

1. Obtain plain radiographs immediately (PA, lateral, and dedicated scaphoid views if radial-sided pain) 1, 5.

2. If radiographs are diagnostic, treat the identified condition appropriately 1.

3. If radiographs are normal/equivocal and pain persists, proceed to MRI without IV contrast 1.

4. If all imaging is negative but clinically significant pain continues, referral to a hand specialist for possible arthroscopy or advanced diagnostic procedures may be necessary 2.

Common Pitfalls to Avoid

• Don't assume "just a sprain" at 5 weeks—this duration warrants structural evaluation 3.
• Don't delay imaging in chronic wrist pain; early diagnosis of fractures prevents complications 1, 4.
• Don't order MRI before plain radiographs—this violates the established diagnostic algorithm 1.
• Don't continue loading activities (like pushups) until diagnosis is established, as this risks converting a treatable injury into chronic pathology 2.

Expected Outcomes

With appropriate diagnostic workup and treatment, most causes of chronic wrist pain have good to excellent outcomes 3. However:

• The 5-week timeframe means you're at risk for chronic pain if the underlying cause isn't identified and treated 2.
• A definite diagnosis can be established in approximately 70% of chronic wrist pain cases using systematic evaluation 3.
• Conservative management succeeds in most cases once the diagnosis is clear, though some conditions require surgical intervention 6.