Wrist pain: the symptoms that tell you more

The wrist is a small space with a great deal passing through it, which is why wrist pain is often not a pain problem. Numbness, weakness and a lost grip tell you more reliably than the ache does.

Where it hurts, and what that means

• Thumb side of the wrist, coming on when the thumb is used, when lifting a baby, when twisting a cloth or opening a jar, and reproduced exactly by making a fist with the thumb inside and bending the wrist toward the little finger: De Quervain's tenosynovitis, the commonest tender wrist in a new parent and in anyone who wrings, sews, weaves or types.
• Back of the wrist with a round, firm lump that changes size and aches after use: a ganglion. It is fluid from the joint, it is not a tumour, and it can be left alone, aspirated or removed.
• Numbness and tingling in the thumb, index, middle and half the ring finger, waking the person at night, relieved by shaking the hand, with clumsiness and eventually wasting of the muscle at the base of the thumb: carpal tunnel syndrome, a compressed nerve rather than a painful joint.
• Little-finger side of the wrist, worse on twisting a door handle, a key or a screwdriver, or after a fall on an outstretched hand: the cartilage disc of that side, the TFCC, which is injured far more often than it is diagnosed.
• A deep, vague ache with grinding in the joint at the base of the thumb, in someone in their fifties, worst on gripping a lid or a pen: thumb-base osteoarthritis, and it is common, and it is treatable.
• Both wrists and both hands, with the small joints swollen and morning stiffness lasting more than half an hour: rheumatoid arthritis, and this is the presentation in which early treatment prevents damage that never reverses.
• A wrist hot, red, swollen and exquisitely tender, sometimes after a bite or a cut over the joint: infection, and it is same-day care.
• A wrist that hurts after a fall on the outstretched hand, tender in the hollow just in front of the thumb tendons: the scaphoid, which is the fracture that gets missed, and which is discussed below.

The scaphoid warning

• A fall on an outstretched hand, pain on the thumb side of the wrist, and tenderness in the anatomical snuffbox. The first X-ray is frequently normal.
• A normal X-ray does not exclude it. The bone has a fragile blood supply, and a missed fracture goes on to fail to unite and then to die, which destroys the wrist in a person of thirty.
• The correct response to that pattern is immobilisation and a repeat study, not a sling and reassurance. If this happened weeks ago and the wrist still hurts, get it looked at.

What we ask

• What the hand does for a living and at home: hours at a keyboard or mouse, phone use, tailoring, machine work, washing by hand, carrying a child on the same side, gym gripping, racquet or bat sport.
• Whether it is pain, numbness, a lump, swelling, weakness or a giving way, and in what proportion.
• Night symptoms, which distinguish nerve compression from tendon and joint problems more reliably than anything else.
• Whether the neck, elbow or shoulder has been hurting first, since a wrist that is painful with numb fingers can be a nerve higher up.
• Both sides, since symmetric small-joint disease is a different category entirely.
• Diabetes, pregnancy and the postpartum period, thyroid disease, kidney disease, inflammatory bowel disease, psoriasis, and any previous injury or surgery.
• How long, and what has already been tried, including a splint, since a splint worn correctly for three weeks is diagnostic as well as therapeutic.

What we look at

• The specific tender points around the wrist, one by one, since the location is the diagnosis in this joint.
• Grip and pinch strength against the other side, and the thumb abduction muscle bulk, which is where carpal tunnel damage becomes permanent.
• Provocative tests for the nerve, the thumb tendons and the little-finger-side cartilage, and the scaphoid hollow.
• The range of the wrist and of each finger, and the presence of any swelling in the small joints of the hand.
• X-ray for any post-fall wrist, for grinding, and for deformity. Ultrasound for a ganglion and for the tendons. Nerve conduction studies when the numb pattern suggests carpal tunnel, and before an operation. MRI when a scaphoid, a ligament or the disc is in question and the films are normal.
• Bloods for the inflammatory pattern: an inflammatory marker, rheumatoid factor and anti-CCP, and uric acid where a gout attack is plausible. Anything suggesting an infection of the joint goes to a specialist immediately.

Red flags

• A hot, swollen, painful wrist with fever, or one that has become painful after a cut, an animal bite or an injection. Joint and tendon-sheath infection spreads fast and destroys fast.
• Progressive numbness, dropping objects, or visible wasting at the base of the thumb. That is a nerve losing function, and the surgery is time-sensitive.
• Pain after a fall that has not settled in two weeks, whatever the first X-ray showed.
• Both hands swollen with prolonged morning stiffness in someone under sixty, which needs a rheumatologist within weeks rather than months.
• A deformity, a wrist that has collapsed after long-standing inflammation, or a lump that is growing, hard or painful at night.
• Numbness with neck pain and clumsy feet, or with weakness above the wrist as well, which is a neck rather than a wrist.

What helps

• Removing or modifying the load, which is the actual treatment for the tendon group. A fortnight without the wringing, the phone-scrolling in bed, or the same grip in the gym, does more than any preparation.
• A properly fitted splint, worn for the hours that matter, which for De Quervain's and for night-time carpal tunnel symptoms is the single most effective conservative measure. Wearing it intermittently is the reason it gets a reputation for not working.
• For carpal tunnel: splinting, treating the diabetes or the pregnancy-related fluid if relevant, an injection into the canal, and release surgery when the nerve is losing function. The surgery is quick and reliable, and delay is what costs the muscle.
• For the tendon and joint group: progressive loading of the wrist and the thumb once the acute pain settles, since rest alone leaves the tissue weaker and the pain returns the first week the hand goes back to work.
• Ergonomics: keyboard height, a mouse that the hand rests on rather than grips, a phone held up rather than the head bent down, and a break every half hour.
• Ice after activity, warmth before it, and a topical anti-inflammatory gel for the flares.
• For inflammatory arthritis, the disease-modifying drugs a rheumatologist prescribes, started early, because the small joints of the hand deform within months of untreated inflammation.

Where Ayurvedic care sits

• Medicated oils applied over the tendons on the thumb side and around the joint, with gentle massage before activity, which is the part of the herbal contribution that patients consistently find useful.
• Dashamoola kwath as the base decoction for the aching, tolerable over the weeks a tendon takes.
• Kaishora guggulu where the joint is swollen and hot-feeling, and yogaraja guggulu where stiffness leads, in a defined course with a review date.
• Guduchi as general anti-inflammatory support, and ashwagandha for sleep where night symptoms have been breaking it.
• Triphala at night for the bowel, as with any long course.
• What no preparation does is decompress a median nerve, unite a scaphoid, or stop an autoimmune joint from eroding, and a wrist with numbness or weakness needs the specialist pathway rather than another month.

How we judge it

• Which specific movements have come back: lifting a child, twisting a cloth, opening a jar, sleeping through the night without shaking the hand awake.
• Grip strength measured against the other side, and the muscle at the base of the thumb, since those are the findings that decide whether a nerve is recovering.
• Tenderness at the exact spot, and how much the splint is still being needed.
• Whether the imaging and the nerve study that were indicated have been done, and whether the load that caused it has actually changed.