What is the likely diagnosis and treatment for a patient with unilateral wrist pain that worsens upon extension?

Unilateral Wrist Pain Worsening with Extension

The most likely diagnosis is lateral epicondylosis (tennis elbow) or intersection syndrome/wrist extensor tendinopathy if the pain is localized to the wrist itself, with initial management consisting of activity modification, NSAIDs, and eccentric exercises, reserving corticosteroid injections for acute phases only. 1

Differential Diagnosis Based on Pain Location

If Pain is at the Lateral Elbow/Proximal Forearm

• Lateral epicondylosis is the primary consideration when wrist extension reproduces pain at the lateral epicondyle, affecting the dominant arm 75% of the time and most common after age 40 1
• Activities requiring repetitive wrist extension (racquet sports, occupations with repetitive wrist flexion/extension) are classic triggers 1
• This represents tendinopathy with fibroblasts, vascular hyperplasia, and disorganized collagen rather than true inflammation 2

If Pain is at the Dorsal Wrist

• Occult dorsal ganglion cysts are the most common cause (76% of cases) of dorsal wrist pain with extension loading 3
• Intersection syndrome presents with radial/dorsal wrist pain and characteristic rubbing/squeaking sensation at the intersection of the first and second extensor compartments 4
• Scapholunate ligament tears cause radial-sided pain and may be identified with Watson's test 5, 3

Diagnostic Approach

Initial Evaluation

• Obtain standard radiographs (posterior-anterior, lateral, and oblique views) as the first imaging study for all patients with wrist pain 1, 6
• History alone leads to specific diagnosis in approximately 70% of cases 5
• Localize tenderness through systematic palpation of anatomic structures 5

Special Physical Examination Tests

• Finkelstein's test for de Quervain's tenosynovitis (though this typically worsens with thumb flexion, not wrist extension) 5
• Resisted wrist extension reproducing pain at lateral epicondyle confirms lateral epicondylosis 1
• Watson's test for scapholunate instability if radial-sided pain 5

Advanced Imaging When Radiographs Are Normal/Nonspecific

• MRI without IV contrast is the next appropriate study for persistent wrist pain with normal radiographs 1, 6
• MRI demonstrates dorsal wrist pathology in 84% of patients with extension-related dorsal wrist pain, with occult ganglion cysts being most common 3
• Ultrasound is equally accurate to MRI for ganglion cysts and can evaluate extensor tendon pathology, with the advantage of dynamic assessment 1, 7

Treatment Algorithm

Conservative Management (First-Line)

• Activity modification to avoid repetitive wrist extension is essential 1, 2
• NSAIDs for pain control 1
• Eccentric exercises to reduce symptoms, increase strength, and promote tendon healing 1
• Deep transverse friction massage may reduce pain 1

Corticosteroid Injections (Second-Line)

• More effective than NSAIDs in the acute phase of lateral epicondylosis but do not change long-term pain outcomes 1
• Should be reserved for acute exacerbations rather than routine use given lack of long-term benefit 1
• Ultrasound-guided injection improves accuracy for specific tendon compartments 4

Alternative Interventions

• Saline hydrodissection (ultrasound-guided injection of saline into intercompartmental space) can be both diagnostic and therapeutic for intersection syndrome 4
• Orthotics are commonly used though evidence for effectiveness is inconclusive 1
• Extracorporeal shock wave therapy has demonstrated mixed benefit 1

Surgical Referral

• Consider orthopedic referral if pain persists despite 3-6 months of well-managed conservative treatment 1
• Surgical techniques include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1
• For ganglion cysts causing severe symptoms, surgical excision has recurrence rates of 7-39% 7

Critical Pitfalls to Avoid

• Do not confuse intersection syndrome with de Quervain's tenosynovitis—both involve radial wrist pain but intersection syndrome occurs more proximally (4-6 cm proximal to Lister's tubercle) and has the characteristic squeaking sensation 4
• Do not rely solely on corticosteroid injections—while effective acutely, they provide no long-term benefit and may delay appropriate rehabilitation 1
• Do not dismiss persistent dorsal wrist pain with extension loading—84% have identifiable pathology on MRI, most commonly occult ganglion cysts that may require specific treatment 3
• Pregnancy can worsen overuse tendinopathies—consider this in the differential for women of childbearing age 4