Chronic Wrist pain...help!!

So the patient is myself!
I am a recent grad and experiencing left wrist pain since Sept.
I was stretching a patients heel chords and noticed the pain shortly after and since the pain has been pretty much constant. I cannot seem to find the cause of the pain. There has been no swelling and no paresthesia.
Pain present with passive flexion and extension, moderate pain with resisted flexion and extension. Grasping large objects such as a melon are difficult and carrying heavy objects such as grocery bags etc. Pain with palpation on dorsal surface of the wrist predominately around the capitate region.
I don't find much relief with ice either.
This problem has become quite troubling as I am starting work soon and need both my hands! I have consulted other PTs and no one seems to have an answer for me.

Any advice is much appreciated!
Thank you :)

I have had what sounds like similar problem and it was subluxed carpal bone I got it reduced and hasn't been a problem. since...good luck

Dear Patient,
Chronic wrist pain might be intra-articular or extra-articular origin.
Like soft tissue injury, Osteoarthritis, Carpal instability, Space occupying lesion...

We should differentiate the root cause of pain.

Can u tell me, did you had any history of injury, swelling, rise in temp, loss appetite,
your job nature, intensity of pain, is pain radiating or localized?, any numbness down to hand, neck pain?, when does u r pain aggravates and which position of u r wrist relives pain.

:)
Suresh Mani

Hi Mira

The majority of pains like this are soft tissue related, but not necessarily soft tissue where the pain is! If you have pain on flexion/extension resistance, this may mean the muscles of the forearm are unable to perform fully as their fascial sheathing may be tight around them. This has the effect of 'strangling' the muscle and as a muscle needs all it natural space to work in, it will become weak to a degree if not. What you feel in the wrist is often the compensation for this weakness, ie overuse of local intrinsic muscles and muscles not normall used for flexion/extension. This overuse stresses these muscles and related fascia thus pain occurs. If you have limited ROM in flexion/extension this will be further proof of fascial tightening. You will need some myofascial release done to the forearm fascia to release this, thus allowing muscles to work correctly, which then reduces the need for compensation, thus no pain. It will be very unusual for a joint to be the cause in something so acute...remember joint movement depends on soft tissues giving them the space in which to work.

Try that

Hope it helps

Pete

could be a torn tfcc (triangular fibro cartilidge complex), I tore mine several years ago falling into my wrist. I had a MRI scan to confirm it....the pain has pretty much gone now and I decided not to go down the sugery route as the tear was very small..I also got pain on extension/ulnar deviation type movements

Thanks for the input guys. I am going to see someone about this tomorrow..hopefully i'll find some answers...or have to wait 4 months for an MRI...
I'll keep you updated!

Okay, so we discovered the lunate doesn't sit properly, it seem to keep subluxing. Also my wrist extensors are tight and there is a slight thickening and area of tenderness on the dorsal wrist primarily around the lunate.

I am splinting my wrist for the next two weeks. I am taking it off at night doing gentle AROM. I find when I flex after extending, my wrist clicks (centrally and slightly ulnarly). I think it's a tendon clicking..perhaps the extensor dig. communis.

Do you think the extensor retinaculum or an extensor tendon is tights and therefore pulling on the lunate causing this subluxing?

Any thoughts?

Thanks!

having ur pain on both resistance flexion and extension suggests a muscular component however u did not mention anything about ulna and radial deviation resistance.I think you have a classic capitate subluxation but you have not reported any abvious deformity. having pain on both passive flexion and extension and equal pain on resistance takes my mind of muscle and focuses it on joints. so I think its a capitate subluxation may be what u have is sparin of the ligaments surrounding the capitate bone. You may require some manipulation to reset it, and possibly frictions around it, but the history resembles the diagnosis justy mentioned.

sorry dint read ur follow up texts so it was a subluxation afterall but not the capitate,look at the ligaments holding the two carpal bones ok.

Hi,
Thanks for the reply. Regarding the painful movements, it seems to be all directions hurt with passive and active movements, it varies through the day and depends with what i am doing. The main area of pain is the scapholunate interval with extension. I seem to get some clicking (seems tendon-like) with movements such as flexion following extension.
My PT tried to manipulate the lunate back into place, but he says it's not staying put. I have no obvious deformity, but he mentioned it was "sitting high" when he palpated it.
I had a simple wrist xray done and they said everything looks normal.

I have been splinting for almost a week now. Yesterday I experienced a lot of discomfort with the splint and removed it. I was having pain with opposition and any movements. It seemed as through the extensor tendons were very irritated. I was also having some knee swelling (separate issue) so i took an Ibuprophen and massaged the extensors and did some ROM and the pain seems to have diminished.
I have pain with palpation around the scapholunate interval. I'm not sure what this might imply other than an instability of the carpals.
If I have no obvious deformity could it still be a torn carpal ligament?
I am getting very stressed out and concerned that I am going to require surgery of develop arthritis. It's very concerning as I"m just starting my career and my body seems to already be falling apart!
Thanks for all the advice! :)

Oh, and regarding some of the other questions..

I had no specific injury. I have no neck pain, no numbess or shooting pains through the arm. Pain is absent if my wrist is static. No night pain. No swelling. No loss of appetite. And no appearance of a ganglion cyst.


Thanks

how old are you madam?

haha..sorry forgot to mention..
i'm 25

First of all, I think we need to be sure that the knee problem and wrist problem are two seperate issues.Which I think they must be since you are laughing happily...anyways if you are not getting any freedom from any treatment, consider getting an injection dose.But I would really like you to reassure me that the knee and wrist are not the same thing, maybe you want to tell me about the knee etc. and possibly if anyone in ur family has had a similar case.

Hi Dr. Damien,
Well i'm not certain they are separate issues..the onset was around the same time. They are both mystery cases as well, so i shouldn't be so sure to dismiss them as being related..but I'm not sure how they would be.

I noticed both around September of 07. I have no incident to pin point either to. I think the knee pain started after a game of tennis (or this is just what i'm thinking it's related to..not sure). It is my right knee. I have pain with extension (ie terminal extension in walking) as well as with straightening it after prolonged flexion (ie coming out of cross legged sitting etc). I tend to cross my legs a lot and sit with them crossed under me while sitting at my desk or on the couch etc. The pain and swelling was mostly localized to the posterior lateral aspect of my knee. This past weekend however I noticed some anterior lateral and medial swelling around the patella. I iced and took an ibuprophen and the swelling has gone.
I find all the muscles in my right leg seem to be weak and unsteady. In sept a friend tested the ligaments, and we didn't find any major findings. I did however notice my popliteus is quite thick and tender. As well, when I strengthen my gastrocs (heel raises) I get quite a bit of posterior lateral knee pain.
I notice discomfort with closed chain internal tibial rotation as well as placing my right heel on my left knee and allowing the right knee to hang freely. Recently I've also noticed the pain around the lateral joint line. Again things tend to appear vague and they come and go so it's hard to pin point the problem.

I haven't been doing anything particularly irritating lately. In fact I haven't been exercising much at all..so that might be the issue..but I've been trying to let this issues rest and resolve, but it doesn't seem to be helping..

Is there any other info you'd like about the knee or wrist? Do you think they could be related?
(just to clarify, it's the left wrist, and right knee. I am right handed)


Thanks again!

Well I do not want to say anything that might scare you so take my thoughts with a pinch of salt, ok? your symptoms may very well be coincidental however joint problems starting with small joints then large joints suggest systemic inflammatory problems e.g rhematoid arthritis I'm sure you know that. but since you are in good health I do not think thath is a problem anyway, just good to have it at the back of the mind.If I was to disregard that, and I look at your knee pain exclusively, I would say its possibly almost not abnormal for a woman to have these symptoms.YOu need to check your abductor strength and any iliotibial tightness on that side. you could easily do dat by standing on one leg.You are presenting with symptoms that are more joint related than muscular. Do a quick blood test to rule out subtle rhematoid problems just to be sure...I am not saying there is so do not be alarmed.All these need to be clear before before you consider the injection dose. like I said since nothing appears to be helping its the last option but I think injection will help immensely.

By Injection, do you mean corticosteroids?

Thanks for the info..i will look into the blood test.
If it was RA, wouldn't there be redness/swelling present pretty consistently?

yes, dats why I wouldnt give it too much thought and ur case may just be purely coincidental.
yeah corticosteroid injections, a few shots around the area nothing fancy, sample other opinions if you wish and let me know ok?

Thanks for the advice..i think i'll pop by the doctors tomorrow.
I"ll keep you updated!

MRI Results:
High grade partial tear of the ulnar attachment of the TFCC with adjacent ganglion/synovial cyst. 3mm ulnar negative variance with no edema identified in the lunate.

So my question is..now what...
My GP is referring me to a surgeon but he said it will be a while. Any suggestions on how to be more functional (esp at work) without irritating this further. At this point it's been 7 months and little things such as putting on a seat belt, carrying groceries, twisting open the gas tank etc are all aggravating.

Anyone with experience treating these injuries, what do you suggest? Do you recommend surgery or not? From googling I read a lot of people had increased pain and decreased function post surgical intervention. Any treatment ideas?
Seeing as how this injury has occurred over 7 months ago, are there chances pain will decrease with further time without surgical intervention?

Thanks!!:)

Yep, sounded a lot like my TFCC tear so good to hear the MRI confirmed it:)

I can only really go on my own personal experience, my tear is smaller I think which may be why mine hasn't been so problematic and the pain which was as bad as you seem to be having did die down after 3 or 4 months....though recentley it has been flaring up every now and again:mad:

It's been nearly 7 years since I tore mine and its certainly got a lot better, but it's obviously something thats never totally going to go away, the main aggs are holding a book with my wrist in extension/ulnar deviation for a minute or so and pushing down through the wrist (which does make mobs difficult!). I decided against the surgery a year ago as its really not that bad now, I've sort of adapted... I wear a wrist support (a band that goes around the wrist) for exercise/heavy lifting and if its been bothering me during the day I'll sleep with a wrist splint on at night (not the most glamorous of things for night wear but never mind!). I would suggest you try and get a second opinion on the surgery though, specifically a hand specialist rather than an ortho consultant before making any decisions. I'd also try wearing a wrist splint at night to rest and immobilise it and a wrist strap/support for lifitng etc...

Sorry I can't be more helpful but from personal experience it does get a little easier with time (talking years rather than months), but may never really be 100% given the tear- saying that though the surgery could result in even less use out of it!:( It's probably going to be a case of getting around it and adapting what you do which ever route you go down....

Thanks for the advice Oscar, I will try to learn how to adapt to it. I haven't tried the wrist strap, I'll try taping it and see if that helps.
Was your pain mostly on the ulnar aspect? Mine is more dorsal and central around the scapholunate area. The tear on my MRI says its ulnarly located but I dont' have ulnar pain. I don't have any experience with TFCC tears so I'm basically clueless...
Thanks!

my pain is also dorsal, but more ulnar and when its really aggrivated the pain can spread up the ulna on the dorsal side:)

I've been googling to find out what is wrong with my wrist and this seems similar. I injured it July 2010, I don't know how I injured myself as well. I was placed in an orthopedic wrist brace for 2 months. I've seen an ortho, had MRI and had some type of shock test to rule out carpal tunnel and doctor says everything is fine.
But almost 1 year later I'm still in pain! The only other thing I suffer from is reynolds phenomenon in both hands. Wrist clicks as well and randomly likes to get real red/hot with extreme pain.

Sounds like the test you had was needle electromyography (EMG). Also sounds like the Raynaud's phenomenon may be your culprit. Sorry couldn't be of more help.
Denver Chiropractor

2 things you mention there could be caused by the same thing, ie poor circulation control. I have successfully treated both Reynaud's and chronically painful wrists. In both cases, the sympathetic nervous syetem is at fault, as it is in a state of fatigue. This system controls the tone of your blood vessels, hence the rate of blood flow. If the rate is poor, usually due to lax arteries, then the supply to the periphery of the body, ie hands and feet (in your case hands), is sluggish and symptoms related to poor circulation occur, eg, Reynaud's, pain, stiffness, weakness, etc. I would definately see if you can find someone who treats the sympathetic nervous system, and someone who will assess your biomechanics from the shoulder to the wrist. Wrist pain, esp of a non-traumatic nature, is usually a result of ongoing mechanical dysfunction usually as high up as the shoulder. If these 2 systems can be treated, then you will most likely solve your problem. Good luck

Yes, I suffer from Raynaud's phenomenon and the test was indeed an EMG. I followed up with my primary today. She asked if I was wearing my wrist brace still. I told her I do but the metal in it makes my wrist go numb (pins & needle) feeling. My wrist goes numb exactly where my wrist sits against the metal in the brace. My doctor really feels strongly that it is a sign of carpal tunnel so she's sending me for a second opinion as my problem is still here and it just might have progressed where it can be detected. Hopefully I can get this under control or fixed...1 year is too long.

I am finding this to be very interesting because Raynaud's affects both my hands & feet. I suffer no pain or issues with my feet (currently). When you mentioned the shoulder. I am currently suffering from some type of lump under my arm pit *can only be felt not seen (I'm still under going testing to find out what it is...suspected to be scar tissue so far but I don't know of any injuries to this area) My shoulders also pops (like when you crack your knuckle) often just by extending past my ears. I also suffer from a lot of neck pain & sometimes pinches in my neck at times. My doc is sending me out for a second opinion as she feels strong that I am indeed suffering from carpal tunnel, but I will also bring this info with me as well.

To get one thing straight, carpal tunnel syndrome ONLY affects the thumb, index, middle and half (thumb side) of the ring finger. It is very specific, and will not affect the little finger. It is often mis-diagnosed, and symptoms in the hand are often given the diagnosis of carpal tunnel syndrome when they are merely soft tissue tigfhtness in the forearm, and can easily be relieved with soft tissue release massage techniques. It also includes numbness in the above mentioned areas, and does not go above the wrist, as the trapped nerve is in the wrist, not in the forearm. It is worth doing some research on the net, and if you are unsure, get a 2nd, or 3rd opinion. It is your body, take charge of it...

Scar tissue is another overrated diagnosis, even if scar tisue is evident, it is a normal part of repair. Only if it repairs abnormally is it an issue, but this is rarely the case. Find someone who knows about myofascial release massage, or at least understands the nature of fascia (the soft tissue of the body).

Good call on the carpal tunnel affecting half the ring finger PhysioMitch!
Denver Chiropractor

I never knew that the pain in my fingers was connected with my wrist. I have constant pain in my thumb, index and middle. (I haven't experienced any problems yet with ring finger) I find myself massaging my hand often mostly at the base of the thumb all the way to my index and middle. Sometimes it makes it feel a little bit better sometimes I think I aggravate it more. I am hoping my second opinion appointment comes soon. Because I'm currently a student going to graphic design and multi media and I use my hands/computers a lot. Even more now that finals are due in three weeks and I'm not sure if I can make all my deadlines for all my work without ending up crying every night from pain.

Hi Jenlemoine,

Your problem doesn't sound like the OP's (Mira's).

It really sounds like a referred neck problem, possibly affecting the radial nerve...

The lump in your armpit can be many things but assuming it isn't a fatty tissue lump, quite often it might be a tender rib from the Serratus Anterior (which goes all the way to rib 1)...

If EMG has ruled out carpal tunnel then it is unlikely to be carpal tunnel syndrome where the carpal tunnel is too narrow...more likely that pressing on the carpal tunnel irritates the symptoms (like from your brace etc).

From listening to your story, i am going to put my money on a neck problem or a thoracic spine (in particular a thoracic ring) problem.

Let us know how you get on :)

Cheers!

I had to google where the thoracic spine actually sits because I didn't know if it was high or low. Once I seen where it is located my mouth dropped. I have constant pain exactly in the same area everyday. Standing for too long hurts this area and same with sitting unless I have one leg resting on something higher it feels like it almost takes the pressure/pain off. I have been in at least 2 pretty good car accidents over the last 8 years (both not my fault) One was someone cutting in front of me so I ended up hitting them going about 40 MPH. The other I was stopped at a red light and a Mac truck rear ended me since that accident I can tell you I've never been the same. I've only had xrays and no MRI's on my back but will bring this to the attention to my doctor as soon as they get the referral let's see if they want to do a full MRI of my spine it would make seance tho.
As for the arm pit...I've had Mamo & Ultrasound they think its some type of scar tissue but now that I noticed its disgustingly noticeable I'm wondering if it could be a lymph node. I've been noticing by the time 2 in the afternoon hits everyday I feel like I could literally take a nap and Im young, but feel at least 20 years older than what I am! I don't know all I know is I do have the pain in my wrist/hand, back, neck and shoulders but the pain that bothers me the most right now is the wrist/hand probably because its the most used thing being a graphic designer/photographer. Thank you everyone for advice, if I find out anything I will post.

Quote:

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Originally Posted by alophysio

Hi Jenlemoine,

Your problem doesn't sound like the OP's (Mira's).

It really sounds like a referred neck problem, possibly affecting the radial nerve...

The lump in your armpit can be many things but assuming it isn't a fatty tissue lump, quite often it might be a tender rib from the Serratus Anterior (which goes all the way to rib 1)...

If EMG has ruled out carpal tunnel then it is unlikely to be carpal tunnel syndrome where the carpal tunnel is too narrow...more likely that pressing on the carpal tunnel irritates the symptoms (like from your brace etc).

From listening to your story, i am going to put my money on a neck problem or a thoracic spine (in particular a thoracic ring) problem.

Let us know how you get on :)

Cheers!

---

hi,

I am glad that the symptoms and the "story" fit each other.

I would take an educated guess and say that you have some pretty clear signs of thoracic spine trouble and you need to find someone who can help you improve the way that it all coordinates.

if you email [email protected], they might know of someone in your area who can help - they are in my opinion the world's experts in thoracic spine care and treatment. Otherwise keep us posted.

Cheers

Finally almost 1 year and I have an answer! Had my second opinion appointment today and am really lucky to have a doctor that sat down and listened to me & my symptoms. I failed a test miserably where my hands were up like a football style goal post, head looking at ceiling & while opening & closing hands. Within 15 seconds my right hand was ghost white & my wrist didn't have a pulse. My arm also felt almost fully tingly & felt like 3 lbs. heavier. (Yup that's the blood that's stuck there) Thoracic outlet syndrome is my official d/x. Now I have at least 6 months physical therapy ahead of me, praying that it solves the issue. You nailed it...

In a way this brings tears to my eyes to finally know what is wrong with me & that I can finally start to get better because my case isn't pretty and it hurts more than ever.

That's great news jenlemoine! Thanks for letting us know :) Glad to have helped :)


A diagnosis is so important to moving forwards.

Glad you found someone who listened to you - that is important as well.

Now you have to find someone who can treat it well...have fun :)

Let us know how you go and what treatment they are giving you.

Again,. i am so happy you have a diagnosis :)

Cheers!

So I'm back again. After confirming my TOS shortly after the diagnosis I was also involved in a MVA which someone hit me & totaled my car. In that accident my right forearm was just resting on the center console until the force of her car hit mine where my arm snapped back then forward hitting the steering wheel.

After going through my full treatment of PT I thought I was on the road to recovery. I was doing semi well for a month or two but I also wasn't doing much of anything at the same time.

In October I found a new job and on my 4th shift I got stuck folding clothing for 7hrs!! I was in so much pain I wanted to cry. I know pain is not normal so I decided to go see my orthopedic Dr. again. Now this is very similar pain I had way back in 2010 but also hurt on the outer side of my forearm now too. Well my orthopedic Dr. basically says he wants me to see a specialist in Boston to rule out a TFCC tear.

First I have a normal MRI of my forearm since I still have a lump that hurts and still looks bruised (MVA happened on 6/23/11) MRI showed a 4mm focus of heterogeneous signal in the subcutaneous soft tissue adjacent to the marker I had placed on my arm. Says it can be a small resolving hematoma, or a tiny lymph node. But then says something about correlation with physical exam for whether this is the site of a recent trauma...guess the guy didn't read the notes on why I was having the MRI. But also mentions within the differential would be a tiny subcutaneous hemangioma.

Well I don't understand any of that...other than if you touch it....it hurts really bad still.

The specialist in Boston then orders a 2nd MRI an arthrogram of the wrist and this is what my results are...I don't understand any of it...can someone put it in English for me? I don't go back to see the specialist until 12/19 and I want to understand a little more about what's wrong before I see him.


It says that my radiocarpal joint & distal radioulnar joints are distended with contrast.
I have a full-thickness tear of the proximal radioulnar ligament on its palmar aspect with dorsal subluxation of the distal ulna.
Also a tear of the lunatoriquetral and/or pisiform attachment of the triangular fibrocartlidge. Scapholunate ligaments are intact with mild fraying on the palmar aspect.

Thanks jenlemoine,

English translation...

Quote:

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It says that my radiocarpal joint & distal radioulnar joints are distended with contrast.
I have a full-thickness tear of the proximal radioulnar ligament on its palmar aspect with dorsal subluxation of the distal ulna.
Also a tear of the lunatoriquetral and/or pisiform attachment of the triangular fibrocartlidge. Scapholunate ligaments are intact with mild fraying on the palmar aspect.

---

Looks like a wrist sprain. The "distended" joints are basically seen to be wider than what would be considered "normal" (but i am guessing)
You have a tear of the ligament that holds your "chicken wing" bones together. Also a TFCC tear.

Did the PT look at your thorax during the MVA treatment? What has your physical therapy been?

Thanks

PT did not look at my thorax during the MVA treatment. They did notice my right shoulder blade was a little off but they said that could be because of the TOS. Anyway during my PT my physical therapist said I probably have an underlying wrist problem as well because when I had to do progress evaluations she had my hand in hers and had me try to resist her turning my hand outward (almost like arm wrestling...without my elbow being down) I told her that it hurt. But she didn't mention to me or pressure me to go see my ortho again. I was in PT from July to mid August and we really only focused on my TOS and neck from MRI.

October 2011- is when I had pain again while working and was like ok that's not right and I followed up with my ortho Dr. again that's when he mentioned I could have a possible TFCC tear. When I read about a TFCC tear I knew right away that's what I had.

Now back in July 2010 I complained of right wrist pain after photographing a portrait session at work. I was laying on my belly taking photographs & when I was done I pushed myself up off the floor using my palms of my hands. I'm assuming that's exactly where/when I injured myself because right after is when I had pain. This pain was closer to the thumb side on the palmer side but after the car accident I noticed pain closer to the pinky finger palmer side. I have also been complaining of popping/clicking for 19 months!!!...I still suffer from Raynolds and my hand/wrist sometimes feels like its burning (also gets red...but I'm assuming its just from inflamation)

Where can I find wrist pictures/diagrams online of where my MRI says what's wrong with me? I tried googling but haven't found exact wording to match up with what the MRI says.

Hi,

The wording refers to little bones in the hand...try:
1. Scaphoid,
2. Lunate,
3. Triquetral
4. Pisiform
5. Trapezium
6. Trapezoid
7. Capitate
8. Hamate

Together they are referred to as the carpal bones

The bottom row articulates to the radius (radmainly and the ulna. The radius and ulna also shar a joint proximally and distally called the radio-ulnar joint.

Joints are named by the bones that form them - scapholunate is scaphoid and lunate etc.

As for not treating your thorax during rehab for MVA - they should have a look at it because you no doubt had a seat belt on...

Look up Reynaud's as the red is not likely inflammation ;-P

Cheers!