What are the treatment and management options for wrist pain?

Treatment and Management of Wrist Pain

Initial Management Approach

For wrist pain, begin with topical NSAIDs or capsaicin as first-line treatment for mild to moderate pain, combined with appropriate splinting when indicated, followed by oral NSAIDs or acetaminophen if topical agents are insufficient. 1

Pharmacological Treatment Strategy

Topical agents should be prioritized over systemic medications, especially when only a few joints are affected:

• Topical NSAIDs are highly effective for wrist/hand pain with an effect size of 0.77 (95% CI 0.32 to 1.22), equivalent to oral NSAIDs but with significantly better gastrointestinal safety (no more GI side effects than placebo, RR = 0.81) 1

• Topical capsaicin achieves clinical improvement with an NNT of 3 (95% CI 2 to 5) within 4 weeks, though minor local skin reactions may occur 1

• Oral NSAIDs (e.g., ibuprofen 400 mg every 4-6 hours) should be used when topical agents are insufficient, with doses up to 3200 mg daily for inflammatory conditions like rheumatoid arthritis, though 400 mg doses are typically adequate for pain relief 2

• Acetaminophen is recommended as part of the treatment regimen for osteoarthritis-related wrist pain 3

Splinting and Orthotic Management

Splinting is essential for specific conditions and should be tailored to the anatomical location:

• For thumb base osteoarthritis, full splints (covering both thumb and wrist) provide superior pain relief compared to half splints (ES = 0.64,95% CI 0.02 to 1.26), with NNT of 4 for improving daily activities 1

• Ulnar gutter splints or wrist splints including the ulnar aspect should be used for suspected ulnar-sided injuries (TFCC tears, ECU tendon pathology) 4

• Splints should be used when pain impedes functioning, but avoid prolonged immobilization to prevent stiffness 3, 4

• Immediately initiate active finger range of motion exercises even while splinted, as finger stiffness is one of the most functionally disabling complications and extremely difficult to treat once established 4

Physical Activity and Exercise

Exercise therapy is a cornerstone of wrist pain management with moderate-quality evidence:

• General exercise shows positive to mixed effects for hand/wrist osteoarthritis (GRADE quality: ⊕⊕) 1

• Strength and resistance training demonstrates positive to mixed effects for hand/wrist conditions (GRADE quality: ⊕⊕) 1

• Grip-strengthening exercises combined with wrist stability training significantly reduce pain (VAS scores), improve function (patient-rated wrist evaluation), and increase grip strength and muscle strength in patients with non-specific chronic wrist pain 5

• Tai chi, yoga, and qigong show positive effects for hand/wrist osteoarthritis, though evidence quality is very low (GRADE quality: ⊕) 1

Location-Specific Management Considerations

Treatment should be guided by the anatomical location and underlying pathology:

Radial-Sided Pain (De Quervain Tenosynovitis)

• Topical NSAIDs or capsaicin as first-line 1
• Thumb spica splinting 1
• Consider corticosteroid injection if conservative measures fail 6

Ulnar-Sided Pain (TFCC Injuries, ECU Tendon Pathology)

• Ulnar gutter splinting 4
• Activity modification: avoid lifting, twisting motions, and forceful gripping until pain-free 4
• Topical NSAIDs 1

Dorsal Wrist Pain (Ligament Injuries, Ganglion Cysts)

• Conservative management with splinting and NSAIDs initially 3
• If ganglion cyst confirmed, observation is often appropriate as many resolve spontaneously 3

Carpal Tunnel Syndrome

• Wrist splints (especially nighttime use) 6
• Corticosteroid injection 6
• NSAIDs and pyridoxine (vitamin B6) 6
• Reexamine in 3 weeks or earlier if symptoms progress 6

When to Escalate Treatment

Surgical referral or advanced intervention is warranted when:

• Conservative treatment fails after 2-3 weeks of appropriate management 4, 6
• Severe or acute symptoms requiring immediate resolution 6
• Conditions with risk of long-term deformity if untreated (scaphoid nonunion, Kienböck's disease) 7
• Progressive neurological symptoms in carpal tunnel syndrome 6

Critical Pitfalls to Avoid

• Never immobilize fingers along with the wrist - maintain full finger range of motion from the first encounter to prevent devastating finger stiffness 4
• Do not assume "wrist sprain" without imaging - ulnar-sided pain with a "pop" during lifting suggests TFCC injury, ulnar styloid fracture, or ECU pathology requiring specific management 4
• Avoid prolonged immobilization - early controlled motion prevents stiffness while promoting healing 4
• Do not delay diagnosis of scaphoid fractures - up to 30% are missed on initial radiographs; use specialized views or repeat imaging in 10-14 days 8