What is the next step in managing wrist pain, likely related to repetitive use, with partial improvement after two months of bracing, ice, and ibuprofen (ibuprofen) therapy, despite a negative X-ray?

From the Guidelines

For persistent wrist pain with partial improvement after conservative measures, I recommend continuing the current brace use while adding physical therapy focused on wrist strengthening and stretching exercises for 6-8 weeks, as this approach is supported by the most recent and highest quality study 1. Physical therapy can address underlying muscle imbalances and improve joint mechanics. Consider switching from ibuprofen to naproxen sodium (220-440mg twice daily with food) if tolerated, as it may provide longer-lasting relief. Topical NSAIDs like diclofenac gel 1% applied to the affected area 4 times daily can also help with localized pain while minimizing systemic side effects. Key points to consider in management include:

• Relative rest to decrease repetitive loading of the damaged tendon, as suggested by 1
• The use of manual therapy as an adjunct to other evidence-based treatments, as recommended by 1
• The appropriateness of imaging studies, including MRI, for diagnostic evaluation and treatment planning in patients with chronic wrist pain, as outlined in 1 and 1 If symptoms persist after these interventions, obtaining an MRI would be appropriate to evaluate for soft tissue injuries like TFCC tears or ligament damage that wouldn't appear on X-rays, following the guidelines for chronic wrist pain management 1. Corticosteroid injection might be considered if a specific inflammatory condition is identified. These next steps follow a graduated approach to treatment, addressing both symptom management and potential underlying causes while the healing process continues.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Carefully consider the potential benefits and risks of ibuprofen tablets and other treatment options before deciding to use ibuprofen tablets. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals [see WARNINGS] After observing the response to initial therapy with ibuprofen tablets, the dose and frequency should be adjusted to suit an individual patient's needs. Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain.

The patient has been using ibuprofen for two months with some improvement in pain. The next step would be to review and adjust the dose as required. Since the patient is still experiencing some pain, the dose of ibuprofen could be adjusted, but not to exceed 3200 mg total daily dose. Additionally, consideration of other treatment options should be taken into account, as the patient has been using ibuprofen for an extended period. 2

From the Research

Wrist Pain Management

The user's wrist pain, likely related to repetitive use, has shown some improvement with the use of a brace, ice, and ibuprofen. However, the pain still persists.

• The current treatment approach has been partially effective, but additional steps may be necessary to further manage the pain.
• There is limited direct evidence in the provided studies to guide the next step in management for wrist pain related to repetitive use.
• However, studies on other conditions, such as adhesive capsulitis 3, neck pain 4, rotator cuff injuries 5, osteoarthritis 6, and spinal disorders 7, suggest that a multimodal approach to treatment can be beneficial.
• Combining different conservative treatments, such as physical therapy, medications, and exercise, may offer additive benefits for improving pain and function.
• The use of corticosteroid injections, hydrodilatation, and suprascapular nerve block may be considered for certain conditions, but their application to wrist pain related to repetitive use is not directly addressed in the provided studies.