What is the best course of treatment for a patient with left wrist pain and limited range of motion upon extension?

Treatment of Left Wrist Pain with Limited Extension

For a patient with left wrist pain and limited range of motion upon extension, implement task-specific practice focusing on wrist extension movements as the core rehabilitation strategy, combined with a structured exercise program of flexibility and resistance training, while avoiding splinting and prolonged end-range positioning. 1

Initial Assessment Priorities

• Obtain plain radiographs as the first-line imaging study to evaluate for bone, joint, and alignment abnormalities, as this is the most appropriate initial diagnostic approach for chronic wrist pain 2
• Assess for specific wrist extension capability: measure active wrist extension degrees and finger extension degrees, as these measurements guide treatment eligibility 2, 1, 3
• Evaluate grip strength, which may remain preserved despite limited extension 1
• Consider Kienböck's disease (avascular necrosis of the lunate) in the differential diagnosis for any patient presenting with wrist pain and limited wrist motion, particularly with tenderness over the dorsum of the lunate 4, 5

Core Rehabilitation Program

Task-Specific Practice

• Implement task-specific practice focusing on wrist extension movements as the primary rehabilitation strategy 1
• This approach directly addresses the functional limitation and should form the foundation of treatment 1

Flexibility Training Protocol

• Perform flexibility training 2-3 times per week 1
• Hold static stretches for 10-30 seconds with 3-4 repetitions for each stretch 1
• This frequency and duration optimizes tissue adaptation without overloading healing structures 1

Resistance Training Progression

• Begin with low-intensity exercises at 40% of 1-RM with 10-15 repetitions 1
• Progress to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as tolerated 1
• Increase resistance when 15 repetitions become only somewhat difficult (Borg RPE 12-14) 1
• This graduated approach prevents re-injury while building strength 1

Critical Management Principles

What to Avoid

• Do not use splinting as it may prevent restoration of normal movement and function 1, 3
• Avoid prolonged positioning of the wrist at end ranges, as this exacerbates symptoms 1, 3
• These restrictions are particularly important as splinting has been shown to directly correlate with functional disability—even partial restriction significantly impairs function 6

Treatment Duration

• Continue rehabilitation for 9-12 months depending on return-to-work goals 1
• This extended timeframe is necessary for optimal functional recovery 1

Advanced Considerations

When Conservative Management Fails

If radiographs reveal specific pathology or symptoms persist despite appropriate rehabilitation:

• MRI without contrast is the next appropriate study for soft tissue evaluation when radiographs are normal or nonspecific 2
• MRI provides superior sensitivity for ligamentous injuries, occult fractures, and avascular necrosis compared to radiographs 2
• For Kienböck's disease specifically, staging guides treatment: immobilization for stage I, revascularization or ulnar lengthening/radial shortening for stage II, and more aggressive interventions for advanced stages 5

Functional Electrical Stimulation Option

• Consider FES for patients with demonstrated impaired muscle contraction, specifically for wrist motor impairment 2
• FES leads to short-term increases in motor strength and motor control with reduction in impairment severity 2
• However, evidence does not demonstrate increases in functional outcomes, limiting its role as a primary intervention 2

Evidence Quality Note

The rehabilitation approach is supported by high-quality guideline evidence synthesizing multiple sources 1. The imaging algorithm comes from the American College of Radiology Appropriateness Criteria 2, representing expert consensus on diagnostic pathways. The critical finding that wrist motion directly correlates with functional ability—with restricted motion significantly increasing disability scores—provides strong justification for avoiding immobilization 6.