What are the recommended management options for wrist tendinosis?

Wrist Tendinosis Management

Begin with relative rest and eccentric strengthening exercises as the foundation of treatment, reserving corticosteroid injections for acute pain relief and surgery only for patients who fail 3-6 months of conservative therapy. 1, 2

Initial Conservative Management (First-Line Treatment)

Activity Modification and Pain Control

• Implement relative rest by reducing activities that cause repetitive loading of the affected tendon, but avoid complete immobilization which leads to muscle atrophy and deconditioning. 1, 2
• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief. 3, 2
• For some patients, local heat application (paraffin wax or hot packs) before exercise may be beneficial, particularly for extensor tendinitis. 2

Pharmacologic Pain Management

• Prescribe NSAIDs for short-term pain relief, recognizing they provide symptomatic relief but do not alter long-term outcomes or affect the degenerative process. 1, 2
• Consider topical NSAIDs as a preferred alternative when treating localized wrist tendinosis, as they provide similar pain relief with fewer systemic side effects. 1, 2
• Paracetamol up to 4g/day can be used as an oral analgesic first choice due to its favorable safety profile. 2

Orthotic Support

• Consider wrist bracing or orthotics to unload and protect the tendon during activity, though evidence for definitive effectiveness is limited. 1

Rehabilitation Protocol (Essential Component)

Exercise Therapy

• Initiate eccentric strengthening exercises as they have proven beneficial in reversing degenerative changes, reducing symptoms, and increasing strength in tendinosis. 3, 1, 2
• Implement deep transverse friction massage to reduce pain. 3, 1, 2
• For athletes and manual laborers, modify technique to minimize repetitive stresses on tendons. 2

The American Academy of Family Physicians emphasizes that eccentric exercises are particularly important because most wrist tendinopathies are degenerative (tendinosis) rather than inflammatory in nature by the time patients present. 4, 2

Advanced Interventions (Second-Line Options)

Corticosteroid Injections

• Consider corticosteroid injections for better acute pain relief compared to oral NSAIDs, but use with caution as they do not alter long-term outcomes and may inhibit healing and reduce tensile strength. 1, 2
• Corticosteroid iontophoresis can be effective for pain and functional improvement in wrist extensor tendinitis. 2

Physical Modalities

• Extracorporeal shock wave therapy (ESWT) is a safe, noninvasive option for chronic tendinopathies, though it is expensive. 4, 3, 1, 2
• Therapeutic ultrasonography may be considered, though evidence for consistent benefit is limited and uncertain. 4, 3, 1
• Low-level laser therapy has shown effectiveness particularly for De Quervain tenosynovitis and may be a promising option. 5

Surgical Management (Last Resort)

• Surgery is indicated only for carefully selected patients who have failed 3-6 months of appropriate conservative management. 4, 1, 2
• Surgical techniques typically involve excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 2

Clinical Pearls and Pitfalls

Diagnostic Considerations

• Expect well-localized tenderness on palpation that reproduces the patient's activity-related pain. 4
• The presence of joint effusions is uncommon with tendinopathy and should raise suspicion for intra-articular pathology requiring different management. 4, 3
• Muscle atrophy on examination indicates chronicity and suggests the condition has been present longer than the patient may report. 4

Treatment Pitfalls to Avoid

• Never completely immobilize the wrist as this accelerates muscular atrophy and deconditioning. 3, 1, 2
• Recognize that most wrist tendinopathies are degenerative (tendinosis) with collagen disorientation rather than inflammatory (tendinitis), so anti-inflammatory treatments address symptoms but not the underlying pathology. 4, 2
• Multiple symptomatic tendons should prompt evaluation for rheumatic disease or rheumatologic referral. 4

Monitoring and Prognosis

• Monitor pain levels and functional improvement throughout conservative treatment. 3, 1
• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate outpatient treatment. 1
• If symptoms persist beyond 6 months despite well-managed conservative therapy, surgical consultation is warranted. 3, 2