What is the best course of treatment for a patient with sudden onset pisiform area pain, no history of trauma, worsening pain with splint use and immobilization, and pain upon extension?

Discontinue Immobilization and Initiate Active Movement-Based Treatment

For a patient with sudden onset pisiform area pain, no trauma history, and worsening pain with splint use and immobilization, you should immediately discontinue the splint and transition to strategies that encourage normal movement patterns and functional use of the hand. 1

Why Immobilization is Contraindicated

The worsening pain with splint use is a critical red flag that indicates immobilization is exacerbating rather than treating the condition. Splinting in this context creates multiple harmful effects:

• Increases attention and focus to the painful area, thereby amplifying symptoms 1
• Promotes increased accessory muscle use and compensatory movement strategies 1
• Leads to muscle deconditioning from immobilization 1
• Causes learnt non-use of the affected limb 1
• Directly increases pain 1
• Can precipitate complex regional pain syndrome, particularly with prolonged immobilization 1

The guideline evidence explicitly states that splinting may prevent restoration of normal movement and function, and that benefits should be balanced against potential harm. 1 In your patient's case, the harm is already manifest through worsening pain.

Recommended Treatment Approach

Immediate Actions

• Remove the splint immediately 1
• Engage the patient in tasks that promote normal movement, good alignment, and even weight-bearing of the hand 1
• Use the hand to stabilize objects during functional activities to avoid learnt non-use 1

Movement-Based Strategies

• Encourage optimal postural alignment at rest and within function 1
• Grade activity to increase the time that the affected limb is used with normal movement techniques within functional activities 1
• Avoid postures that promote prolonged positioning of joints at the end of range 1
• Demonstrate and promote therapeutic resting postures rather than immobilization 1

Pain Management

• Implement strategies that reduce muscle overactivity, pain, and fatigue 1
• Support the affected limb when at rest using pillows or furniture to take the weight, rather than rigid immobilization 1
• Address associated problems of pain and hypersensitivity 1
• Employ anxiety management and distraction techniques when undertaking tasks 1

Behavioral Modifications

• Apply local heat or cold over the painful area (not immobilization) 1
• Use techniques applied to trigger points and areas of hypersensitivity 1
• Implement stress management practices to manage symptom exacerbations 1

Surgical Consideration if Conservative Measures Fail

If the pain remains intractable despite discontinuing immobilization and implementing movement-based strategies, pisiform excision should be considered. 2 This surgical option has demonstrated effectiveness for:

• Pisiform-triquetral arthritis 2
• Tendonitis of the flexor carpi ulnaris insertion 2
• Intractable pisiform bone pain not relieved by conservative methods 2

The subperiosteal dissection technique preserves the insertion of the flexor carpi ulnaris tendon and maintains wrist strength and mobility. 2

Critical Clinical Pitfall to Avoid

Do not continue or restart immobilization in this patient. The evidence is clear that when pain worsens with splinting, continued immobilization will lead to progressive deterioration, potential development of complex regional pain syndrome, and chronic dysfunction. 1 The patient's response to the splint is telling you that movement-based treatment is required, not further restriction.