2 years chronic wrist pain

[AJDux1502]

Ill try and be as to the point as possible, however Id like to give as much info as well as its a bit of a long story..... I have been to multiple doctors, a surgeon and 2 physiotherapists and the issue is only getting worse, and I honestly dont feel a correct and full diagnosis has been made. I have given up golf, guitar and am finding work now very trialsome and painful.

Initial injury - Scaphoid fracture and malunion about 8 years ago, worked for 5/6 months in this condition before MRI scan revealed the problem. Scaphoid was pinned with bone graft from hip. Next 6 years or so were OK, movement pretty good, wrist a little susceptible to pain and srain than other hand but overall no complaints.

Recent - About 2 years ago I took up golf, after a few months realised my wrist was playing up more and more, seemed to centre around TFCC area, did a lot of research, used wrst widget to treat. After 6 months this specific pain had eased, however other wrist pain and problems had started to develop. Januaury '14 I had the pin removed from scapphoid, no improvement, however surgeon found no physical signs of damage or trauma on examination or Xray, so sent me on my merry way telling me it may be years before it heals on its own (felt like a palm off im in honest, sorry to say).
Saw physiotherapist who couldnt give any answers or help, gentle exercise of wrist and gentle stretching may help.....

Current - Wrist pain is gradually increasing over time, have been back to doctor who referred me back to physio. Physio this time felt more beneficial, the lad was a lot more thorough in trying to find the issue and has given me exercises to try and help the ulnar nerve glide more freely, this still feels like an incomplete diagnosis to me though, as I have a lot of pain all around the wrist and no wastage or weakness. The rest of the day and day after physio my wrist is as bad as it has been, and Im concerned the stretching exercises for the ulnar may be aggrevating another issue, of which I am sure is there.

As I am a window cleaner I am concerned now if I am going to be able to work today, something I can barely afford to start doing, really need some advice and help now.

Symptoms (in general order of frequency) - Dull ache mainly on left side of wrist and hand extending up through pinky finger, sometime extending up forearm. More accute pain on left side of wrist around TFCC area that is worse with more use. Occasional pain in centre of back of hand/wrist, quite acute especially after yesterdays physio. Very slight tingling on left side (pinky and side of 3rd finger as), woke up this morning with both fingers numb and pins and needles.
Wrist will pop and crack with more use, sometimes it will even seem to 'lock' with acute pain, and will pop past with a bit of effort leaving it achy.
Pain at base of thumb which is acute and passing, made worse by gripping.
Occasional pain at base of palm in the centre, very acute but fairly infrequent thankfully.
Currently today left hand is useless, picking up kettle, gripping tap or door handle is painful, constant clicking and cracking with movement.

Is it possible there is some ligament damage/instability? If so will the exercises from the physiotherapist for the ulnar nerve aggrevate the condition? The surgeon had mentioned a possible MRI but after the operation seemed very reluctant, would an MRI possibly pick up something that is being missed?

Many thanks in advance


Andrew

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[physiobob]

Hi Andrew, thanks for your post. The first thing that strikes me is you collective symptoms of fatigue etc. This might well indicate a physiological system that is overloaded/over stressed and the result of this is that the precking order for the bodies normal repair is upset. By that I mean the body will repair essential things first and often the connective tissue system is pushed down the queue. This means that normal repair after activity does not happen and we can get persistant soft tissue pain and discomfort. I battled with a neck for 18 months and tried everything I knew to fix it. No result at all. Then I talked with my osteopath colleague who was also a naturopath and applied kinesiologist. She assessed me and determined that I had some intollerances in my system which we then addressed with some dietary changes. In 10 days my pain was gone and I had not had any manual treatment at all.

A fracture scaphoid is often a persistantly painful condition. You need to consider how it was broken, what else was sprained/strained/torn in the process (i.e. ligaments), what is therefore now slightly unstable, and if the result is a non-normal tracking of the wrist. This is most likely and a job like window cleaning would perhaps not be the most recommended! That aside the scaphoid could also not be the issue and it is more one of longterm overuse and gradual soft tissue degradation, eventually resulting in pain. Rest will provide only short term respite if the connective tissue repair system is not doing its job.

I would lay off the exercises myself when things are painful. It is not likely that you need specific ulnar nerve stretches at the wrist but it could be indicated if someone can assess your neck, especially the cervicothoracic junction (where the neck attaches to the rib cage). Releasing this area (in fact the entire thoracic spine) is important to reduce any overuse and blocking of the neck vertebrae (where the ulnar nerve originates).

In terms of assessment you would only want a skilled hand therapist looking at you, maybe one with an interest in musicians (who often have persistanly problematic overuse injuries). If you are open minded have an assessment from an applied kinesiologist with a dietary view on any possible contributing factors in the issue. An MRI has already shown to be clear so I don't think it's of much use unless it is done with a contrast medium (called an arthrogram). A bone scan would be if you are more worried about the pain eminating from the scaphoid itself.

And as your job is your job, ask your treating therapist for the appropriate wrist support to wear when window cleaning. There are also specific surgical options for an instable TFCC (often seen in tennis players and gymnasts) which you could discuss with a hand surgeon if persistant TFCC is considered a major contributing factor.

I hope this helps a little with some new ideas.

regards

[physio0907]

Hi Andrew,

I don't think it's unreasonable that further investigation is needed at this stage, although you will need an MRI arthrogram to determine the full extent of your problem - it may well be a TFCC problem like you stated or else ligamentous instability - the ulnar neural exercises you are given may well help with some of your symptoms, but they won't cure what interface is causing the nerve to become tethered, and to be honest the physios treatment should not be very painful consistently. Either see a clinical specialist Physio in hands, or else see an ortho surgeon with a view to getting an MRI arthrogram. I know it's easier said than done, but you should look into different career paths based on the history you have with your wrist, and the potential existing problems you have, best of luck!