What could cause sudden onset wrist pain in a 39-year-old female that worsens over time, especially with activities like lifting or turning her wrist?

Sudden-Onset Wrist Pain in a 39-Year-Old Female

The most likely cause is overuse tendinopathy (tendinosis), which typically presents with insidious onset of load-related pain that progressively worsens with continued activity—exactly matching this clinical presentation. 1

Most Probable Diagnosis: Tendinopathy

The clinical pattern described—sudden onset pain with lifting and wrist turning that progressively worsens over a week—is classic for tendinopathy, which affects women and men equally and is most common after age 40. 1

Key Clinical Features Supporting Tendinopathy:

• Load-related pain that worsens with specific activities (lifting, turning) 1
• Progressive worsening over days to weeks rather than immediate severe pain 1
• Pain described as "sharp" or "stabbing" during activity 1
• Most patients report new activity or increased intensity of current activity before symptom onset 1

Specific Wrist Tendinopathies to Consider:

• De Quervain tenosynovitis if pain is on the radial (thumb) side of the wrist 2
• Extensor or flexor tendon involvement depending on which movements reproduce pain 2

Other Important Differential Diagnoses

Ligamentous Injury (TFCC Tear):

• Triangular fibrocartilage complex (TFCC) lesions cause ulnar-sided wrist pain and can occur with twisting injuries 1
• Both traumatic and degenerative TFCC lesions produce chronic pain exacerbated by loading 1

Occult Fracture:

• Scaphoid fracture is the most commonly fractured carpal bone and can occur without definite trauma 3
• Conventional radiography misses up to 30% of scaphoid fractures initially 3
• Pain typically localizes to the anatomic snuffbox 3

Early Inflammatory Arthritis:

• Rheumatoid arthritis can present with wrist pain in this age group 1
• Look for morning stiffness, bilateral involvement, or multiple joint involvement 1

Nerve Entrapment:

• Carpal tunnel syndrome presents with wrist discomfort plus sensory symptoms in median nerve distribution 2
• Ulnar neuropathy causes wrist pain with sensory changes in 4th and 5th digits 3

Recommended Diagnostic Approach

Initial Evaluation:

• Plain radiographs are the most appropriate first imaging study (posteroanterior, lateral, and oblique views) 1, 2
• Radiographs can identify fractures, arthritis, bone tumors, and alignment abnormalities 2
• For suspected scaphoid fracture, obtain specialized views including posteroanterior in ulnar deviation 3

Physical Examination Findings to Assess:

• Localized tenderness on palpation that reproduces the activity-related pain supports tendinopathy 1
• Finkelstein test (positive in De Quervain tenosynovitis) 3
• Well-localized pain with loading maneuvers that simulate the problematic activity 1
• Swelling, erythema, or asymmetry commonly noted with pathologic tendons 1
• Muscle atrophy suggests chronicity if present 1

Advanced Imaging (If Radiographs Normal):

• MRI without contrast is usually appropriate next for suspected soft tissue pathology including tendon, ligament, or TFCC abnormalities 2
• Ultrasound is effective for examining tendons, tendon sheaths, and can guide therapeutic injections 2
• Repeat radiographs in 10-14 days if scaphoid fracture suspected but initial films negative 3

Initial Management for Presumed Tendinopathy

Conservative Treatment (First-Line):

• Relative rest and reduced activity to decrease repetitive loading of the damaged tendon 1
• Cryotherapy with melting ice water through wet towel for 10-minute periods provides acute pain relief 1
• NSAIDs for short-term pain relief (2-3 weeks maximum), though they don't alter long-term outcomes 1
• Topical NSAIDs are effective with fewer systemic side effects 1

Important Caveats:

• Pain at rest or night pain suggests more advanced tendinopathy or alternative diagnosis 1
• Multiple symptomatic tendons should prompt evaluation for rheumatic disease 1
• Joint effusion is uncommon with tendinopathy and suggests intra-articular pathology 1
• If conservative treatment fails after 3-6 months, surgical evaluation may be warranted 1

Red Flags Requiring Urgent Evaluation:

• Fever, erythema, or warmth suggesting infection—requires joint aspiration 1
• Severe trauma history with deformity suggesting fracture-dislocation 1
• Progressive neurologic symptoms suggesting nerve compression requiring urgent intervention 3