What is the likely diagnosis and management for a 31-year-old male (M) runner with acute hand and wrist pain that began yesterday morning, improved with ibuprofen (ibuprofen), and has no signs of fever, redness, swelling, or gross deformities, but has a history of numbness and tingling that has resolved?

Acute Hand/Wrist Pain in a Young Runner: Likely Diagnosis and Management

Most Likely Diagnosis

This clinical presentation is most consistent with a repetitive strain injury (RSI) or overuse tendinopathy, though an occult fracture (particularly scaphoid) must be ruled out given the acute onset and severity of pain. 1, 2

The key diagnostic consideration here is distinguishing between:

• Repetitive strain injury/tendinopathy (most likely given the runner status, transient numbness/tingling suggesting nerve irritation, and improvement with NSAIDs)
• Occult fracture (must exclude given acute severe pain upon waking, even without clear trauma—sleeping in awkward position can cause stress fractures in athletes) 2

Immediate Management Algorithm

Step 1: Complete the X-ray Evaluation

• Ensure a minimum 3-view series is obtained: posteroanterior (PA), lateral, and 45° semipronated oblique views 3, 4
• Add a scaphoid view (4th projection) to increase diagnostic yield for both distal radius and scaphoid injuries, as this is critical in a runner who may have sustained repetitive microtrauma 4
• Relying on only 2 views is inadequate and can miss significant pathology 4

Step 2: If X-rays Are Negative

Do not assume the absence of fracture based on negative initial radiographs alone. Conventional radiography misses up to 30% of scaphoid fractures 2. Given the severity of morning pain and the patient's athletic status, you have three evidence-based options:

1. Conservative approach: Place in short arm cast/splint and repeat radiographs in 10-14 days 3, 1
2. Immediate advanced imaging: Order MRI without IV contrast (sensitivity 94.2%, specificity 97.7% for occult fractures) if clinical suspicion remains high 3, 4
3. Alternative advanced imaging: CT without IV contrast if MRI unavailable (provides high-detail bone imaging, easier in casted patients) 3, 4

For this 31-year-old runner with severe acute pain, I recommend immediate MRI without IV contrast rather than waiting 10-14 days, as delayed diagnosis of scaphoid fracture can lead to nonunion, avascular necrosis, and post-traumatic arthritis—outcomes that would significantly impact his running career 4. The transient numbness/tingling also warrants evaluation for concomitant ligamentous or soft tissue injuries that only MRI can detect 3.

Acute Phase Treatment (Regardless of Imaging Results)

Immediate Interventions

• Apply ice for 15-20 minutes every 2-3 hours to reduce swelling and pain 1
• Immobilize with wrist splint in neutral position during acute phase 1
• Compress with elastic bandage and elevate wrist above heart level 1
• Continue ibuprofen for pain control and anti-inflammatory effects (already showing benefit in this patient) 1, 5

Activity Modification

• Avoid running and weight-bearing activities with the affected hand until imaging is complete and diagnosis confirmed 4
• This is critical to prevent displacement of any occult fracture 4

Subacute Management (If No Fracture Identified)

Transition Phase (Days 3-7)

• Gradually transition from complete rest to controlled movement to prevent stiffness 1
• Begin gentle range of motion exercises when pain allows 1
• Implement functional support (braces, tapes) which reduces recurrent sprains (RR 0.30,95% CI 0.21 to 0.43) 1

Exercise Therapy (Week 2 Onward)

• Start exercise therapy as soon as possible to prevent recurrence and promote healing 1
• Include coordination and balance training to prevent recurrent injuries 1
• Incorporate proprioceptive training as part of neuromuscular rehabilitation 1
• Focus on eccentric strengthening exercises which reduce symptoms and promote tendon healing 1

Return to Running

• Delay return to running until no pain with resistance is achieved 1
• Returning too soon may lead to prolonged symptoms or reinjury 1

Red Flags Requiring Specialist Referral

Refer to hand surgery or orthopedics if:

• MRI reveals scaphoid fracture, ligamentous injury requiring repair, or other surgical pathology 4
• Worsening pain despite appropriate conservative management 4
• Persistent symptoms after 4-6 weeks of well-managed conservative treatment 1

Critical Pitfalls to Avoid

• Do not rely on negative initial radiographs alone in a patient with severe acute wrist pain—up to 30% of scaphoid fractures are missed 2
• Do not allow prolonged immobilization (beyond what's necessary for fracture healing), as this leads to stiffness and contracture 1
• Do not skip the scaphoid view on initial imaging in an athletic patient with acute wrist pain 4
• Do not permit early return to running before achieving pain-free resistance testing, as this increases risk of chronic injury 1

Special Consideration for Runners

Patients with spontaneous onset of wrist pain who have activities consisting of repetitive loading (like running with arm swing mechanics) could be suffering from carpal bone stress injury or early avascular necrosis 6. The fact that this patient is a runner makes occult stress-related pathology more likely than in sedentary individuals, further supporting the recommendation for advanced imaging if initial radiographs are negative.