What is the initial management for bursitis or tendonitis of the wrist?

Initial Management of Wrist Bursitis and Tendonitis

For wrist tendonitis or bursitis, begin with conservative management including relative rest (avoiding activities that worsen pain while maintaining mobility), ice application for 10 minutes through a wet towel, and NSAIDs such as naproxen 500 mg twice daily, with escalation to corticosteroid injection only for refractory cases. 1

First-Line Conservative Approach

Activity Modification and Rest

• Continue activities that do not worsen pain while avoiding complete immobilization to prevent muscular atrophy and deconditioning 1
• Tensile loading of the tendon through controlled movement stimulates collagen production and guides normal alignment of newly formed collagen fibers 1
• Eccentric exercise has proven beneficial in tendinopathies and should be incorporated once acute inflammation subsides 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods for short-term pain relief and reduction of swelling 1
• Ice reduces tissue metabolism and blunts the inflammatory response in acute inflammatory tendinopathies 1

Pharmacological Management

NSAIDs as First-Line

• NSAIDs effectively relieve tendinopathy pain and offer additional benefit in acute inflammatory conditions 1
• For acute tendonitis and bursitis, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours with initial total daily dose not exceeding 1250 mg 2
• Topical NSAIDs reduce tendon pain and eliminate the increased risk of gastrointestinal hemorrhage associated with systemic NSAIDs 1

Stepped Care for Patients with Cardiovascular Risk

• Start with acetaminophen or aspirin at the lowest efficacious dose for patients with known cardiovascular disease or risk factors 1
• Progress to non-COX-2 selective NSAIDs only if acetaminophen is ineffective 1
• Consider adding aspirin 81 mg and proton pump inhibitor for patients at increased thrombotic risk, though this may not provide sufficient protection 1

Second-Line: Corticosteroid Injection

Indications and Cautions

• Local corticosteroid injections may be more effective than oral NSAIDs for acute phase pain relief but do not alter long-term outcomes 1
• Use corticosteroid injections with caution as there may be deleterious effects when injected into the tendon substance 1
• The optimal drugs, dosages, techniques, intervals, and post-injection care remain unknown and require further research 1
• Peritendinous injections should be used cautiously due to unknown effects 1

Diagnostic Imaging When Indicated

Initial Imaging

• Plain radiographs are usually appropriate as the initial imaging study for chronic wrist pain to exclude bony pathology 1

Advanced Imaging for Persistent Symptoms

• Ultrasound or MRI without IV contrast is usually appropriate when there is concern for tendon injury, tenosynovitis, or tendon pathology after normal or nonspecific radiographs 1
• Ultrasound can demonstrate tendon thickening, heterogeneous echogenicity, and tenosynovitis with high accuracy 1
• MRI provides superior soft tissue contrast resolution and can diagnose tendinopathy, tendon tears, and tenosynovitis 1

Common Pitfalls to Avoid

• Avoid complete immobilization as it leads to muscular atrophy and deconditioning 1
• Do not inject corticosteroids directly into tendon substance due to potential deleterious effects 1
• In patients with cardiovascular disease, avoid starting with COX-2 selective NSAIDs without first trying acetaminophen or aspirin 1
• Do not combine NSAIDs with aspirin routinely as aspirin increases the rate of naproxen excretion without demonstrated additional benefit 2

Surgical Consideration

• Reserve surgical intervention for recalcitrant bursitis that fails conservative management 3