What are the treatment options and exercises for a patient with persistent wrist pain due to overuse?

Management of Wrist Overuse Pain: Patient Information and Exercise Protocol

Initial Conservative Treatment (First 3-6 Months)

Begin with relative rest, ice therapy, NSAIDs, and eccentric strengthening exercises, as approximately 80% of patients with wrist overuse injuries fully recover within 3-6 months with this conservative approach 1, 2.

Relative Rest Protocol

• Avoid complete immobilization – this causes muscle atrophy and worsens outcomes 1.
• Modify activities that reproduce your pain, but maintain some wrist movement to prevent deconditioning 2.
• For athletes or manual laborers, modify technique to minimize repetitive stresses on the wrist tendons 2.

Ice Therapy Application

• Apply melting ice water through a wet towel for 10-minute periods 1.
• Repeat as needed for pain relief and to reduce swelling 2, 3.
• Ice therapy provides short-term pain relief and blunts inflammatory response 2.

Pain Management Options

• NSAIDs (oral or topical) provide effective acute pain relief 2, 4.
• Topical NSAIDs are preferable because they eliminate the risk of gastrointestinal bleeding associated with oral NSAIDs 2.
• Important caveat: NSAIDs only provide temporary symptom relief and do not modify the underlying tendon condition or alter long-term outcomes 1.

Wrist Splinting

• Splinting helps protect and immobilize the affected joint during the acute phase 5, 4, 3.
• Use wrist splints to reinforce and unload tendons during activity 2.

Exercise Rehabilitation Program

Eccentric Strengthening Exercises (Primary Treatment)

• Eccentric exercises are highly effective and may reverse degenerative changes in the tendon 1.
• These exercises stimulate collagen production and guide normal alignment of newly formed collagen fibers 2.
• Begin eccentric strengthening after the acute pain phase subsides 1.

Stretching Exercises

• Stretching exercises are widely accepted for tendon rehabilitation and should be incorporated into your program 2.
• Perform gentle wrist flexion and extension stretches regularly 2.

Deep Transverse Friction Massage

• This technique can reduce pain when combined with eccentric exercises 2.

When to Seek Further Evaluation

Persistent Pain After 3-6 Months

If pain persists despite 3-6 months of well-managed conservative treatment, return for further evaluation 1, 2.

Diagnostic Imaging Considerations

• Plain radiographs should be obtained initially to evaluate for bone abnormalities, calcifications, or occult fractures 1.
• MRI without IV contrast is usually appropriate when radiographs are normal or equivocal and symptoms persist with an unclear diagnosis 6.
• MRI or ultrasound may confirm the diagnosis and extent of any tendon damage 2, 5.

Second-Line Treatment Options (If Conservative Measures Fail)

• Corticosteroid injections may provide more effective acute-phase pain relief than NSAIDs, but do not alter long-term outcomes 1, 2.
• Limit to 2-3 injections maximum, as they may inhibit healing and reduce tendon strength, potentially predisposing to rupture 1, 2.
• Extracorporeal shock wave therapy appears safe and effective but requires further research 1, 2.

Surgical Referral Criteria

• Surgery should be reserved for carefully selected patients who have failed 3-6 months of well-managed conservative therapy 1, 2.
• Surgical techniques typically include excision of abnormal tendon tissue and release of scarring 1, 2.

Critical Pitfalls to Avoid

• Do not rely on NSAIDs or corticosteroid injections as disease-modifying treatments – they only provide temporary symptom relief 1.
• Avoid complete immobilization – this causes muscle atrophy and deconditioning 1.
• Do not mislabel this as "tendonitis" – wrist overuse represents chronic degenerative tendinosis, not acute inflammation 1.
• If multiple tendons are symptomatic or systemic inflammatory signs are present, evaluation for underlying inflammatory arthritis is necessary 1.