Middorsal Wrist Pain in Athletes

Study Title: 

Middorsal Wrist Pain in the High-Level Athlete: Causes, Treatment and Early Return to Play

Authors: 
Hanson, ZC and Lourie, GM.. 

Publication Information: 
Orthopaedic Journal of Sports Medicine (2022) Vol. 10: 4. 
​
Background Information: 
Wrist injuries in high-level athletes, although common, often lack the attention or urgency for care as do injuries in the shoulder, knee and ankle. The evaluation, triage and management of these injuries are relatively standard, particularly those sustained acutely. And unlike radial and ulnar sided wrist injuries, an understanding of middorsal injuries could be improved. Wrist injuries specific to this location often  present as early insidious discomfort that, with examination and care that lack detail, leads to lingering pain and inability to perform. This open access paper reviews the differential diagnoses of middorsal wrist pain in high-level athletes, along with treatment and return to play and is summarized below.

Do note that this summary does not include my own personal thought processes (i.e. assessment upstream) and choices for plan of management (i.e. manual therapies and/or exercise rehabilitation strategies). Summarizing this paper was simply a means for me to keep myself abreast of the multitude of possibilities when presented with athletes experiencing middorsal wrist pain.

TRAUMATIC AND OVERUSE INJURIES

Scapholunate Ligament Injuries

• The Scapholunate Interosseus Ligament (SLIL) is the main stabilizer of this intercarpal region, a key component in normal wrist kinematics and force transmission.
• SLIL injuries often result from falling with impact in wrist extension and ulnar deviation.
• If untreated or mismanaged, these injuries may lead to instability, carpal collapse and early degeneration. 
• Pain is often local to the dorsal side, 1 cm distal to the Lister tubercle.
• In addition to weakness, a click is often reported, particularly with axial loading such as in a push up or press.
• Provocative test include the Watson test and the SL Ballottement test, both identifying pain, crepitus and/or a palpable clunk.
• Radiographs demonstrate a widened SL interval and increased SL angle on P-A and lateral views respectively. MRI may be necessary.
• While mild injuries may be managed conservatively, more significant injuries (presence of instability) may require repair or reconstruction.
• Depending on the nature and demands of the sport, protected RTP may be as early as 3 months while unprotected RTP may be as early as 5 months.

Second and Third Carpometacarpal Injuries

• Together with the trapezoid and capitate, these to carpometacarpal (CMC) joints form a pillar of arch-like support for the hand and wrist to move about.
• Natural minimal joint motion about this quadrangular joint however, lends itself to increased susceptibility to injury, including sprains and avulsions.
• Carpal bosses, easily visible in flexion, are native to this region and a result of bony hypertrophy secondary to chronic stress or injury. *Note: An accessory ossification centre, os styloeum may be present.
• Symptomatic carpal bosses may result from acute injury, overuse, bursal irritation/inflammation, and tendon (ECRB/ECRL) sliding over the bony prominence. Ganglion cysts are also commonly present in this region.
• Pain is often exacerbated by forced wrist extension and laxity/crepitus may be present with the CMC Shuck test, torque test and Kleinmann compression test (see paper for descriptions) but diagnostic lidocaine tests are confirmatory. 
• Radiographic investigations should include a "carpal boss view" - 30deg of supination + ulnar deviation.
• NSAIDs, injections, and immobilization are common in this region though some have managed operatively of non-united acute bony injuries to preserve ECRB/ECRL tendon mechanics. Carpal boss excisions have also been performed though instability and subsequent CMC fusion are potential concerns.

Distal Radial Physeal Stress Syndrome

• Commonly known as "Gymnast's Wrists" as this diagnosis is most prevalent in this population, particularly between the ages of 12 and 14.
• Radiographic findings are generally seen in longer standing cases, demonstrate a widened physis with irregularity and abnormal mineralization. A positive ulnar variance is seen in the most advanced of stages.
• Rest is necessary for initial management with progressive re-integration of load warranted for continuation of sport. (*Note: Optimization of mobility and strength upstream should be considered.)

Avascular Necrosis of the Lunate

• Also known as Kienböck disease and most common in men aged 20-40.
• This differential should be considered in young adults with insidious wrist pain with no (acute or repetitive) mechanism of injury.
• Diagnostic imaging is confirmatory.
• Management often consists of cast immobilization and may require surgical intervention (vascularization and/or joint-levelling). Advanced conditions may require interventions to prevent carpal collapse. 

TENDINOPATHY AND TENDON INSTABILITY

Extensor Pollicis Longus Tenosynovitis

• Secondary to chronic, repetitive wrist hyperextension (drummers, gymnasts, etc)
• Thought to involve impingement of the EPL between the 3rd metacarpal and Lister's tubercle resulting in irritation and inflammation of the tendon compartment.
• A small percentage may present similarly following a minimally/non-displaced distal radius fracture. Abnormal blood flow may result in swelling of, or within, the extensor compartment or decreased perfusion.
• Passive stretching and resisted load of the muscle may be painful upon testing. Clicking or snapping may be reported.
• Radiographs may reveal bony enlargement and MRI may demonstrate high signal intensity surrounding the tissue or of the tendon proper. Ultrasonography is also often utilized for diagnostic purposes.
• Surgical interventions, injections and aspirations have been performed but conservative care done well can be favourable.

Extensor Carpi Radialis Brevis Insertional Tendinitis

• Secondary to repetitive, forceful contraction in load bearing (i.e. gymnastics, weightlifting) and racquet/stick sports.
• Includes all differentials within the tendon pathology continuum - tendinopathy, tendinosis, tenosynovitis, etc.
• Pain local to the base of the 2nd and 3rd metacarpals with resisted extension and passive flexion.
• Carpal bosses may be present here.
• Conservative care done correctly is typically sufficient, although injections and tenosynivectomy may be warranted.

Fourth-Compartment Syndrome: Anomalous Muscles and Tenosynovitis​

• Extensor Indicis Proprius (EIP) is located within the 4th compartment, deep and ulnar to the Extensor Digitorum tendons.
• Anomalous muscles (i.e. aEIP) may increase intracompartment pressure when present and lead to tenosynovitis and PIN irritation. Think muscle belly within the tendon sheath.
• Extensor Digitorum Brevis Manus (EDBM) while rare, originates from the distal radius periosteum, dorsal carpal ligaments and inserts on the ulnar aspect of the MCP joint extensor hood of the index finger. Hypertrophy of this muscle in manual labourers may lead to tenosynovitis and subsequent impingement against the extensor retinaculum.
• Extensor Digitorum tenosynovitis also falls within this family of diagnoses.
• In some cases, the above may be identified by a fusiform soft tissue mass distal to the extensor retinaculum mimicking a ganglion cyst or lipoma.
• The EIP test is performed by resistance to extension of the index finger in flexion. The same for the other structures respectively.
• Radiographs are unnecessary but MRIs may be confirmatory.
• Compartment decompression and tenosynovectomy may be warranted in troublesome cases resistant to conservative care.

DORSAL IMPINGEMENT SYNDROMES

Dorsal Capsular Impingement

• Attributed to capsulitis or synovitis of redundant capsular tissue impinging between the ECRB tendon and the Scaphoid.
• Innocuous causes are common though recurrence and re-aggravation are as well.
• Osteophytosis of the dorsal scaphoid, lunate and dorsal rim of the distal radius may present challenges in chronic cases.
• Pain is local to the ECRB as it crosses the scaphoid and noted with loaded and/or unloaded wrist extension at end range.
• Typically identified via diagnosis of exclusion though MRIs may demonstrate thickening.
• Again, beyond conservative care lies surgical intervention. In this case, possibilities include synovectomy, capsulectomy, osteophyte debridement and excision of the dorsal ridges of the scaphoid and/or lunate.
• Postoperative RTP is reported to be around 6 weeks.

Occult Dorsal Carpal Ganglion

• Cysts that may lead to dorsal impingement syndrome.​
• Most often originating from the SL ligament and existing between the EPL and ED tendons.
• Causative injuries often go unnoticed and/or difficult to recall.
• Pain upon palpation over the wrist in line with Lister's tubercle, exacerbated by passive hyperextension.
• Ultrasonography or MRI may assist in diagnosis.
• While resorption is common, injection and (relative) immobilization may be of assistance in management.
• Surgical excision (with or without PIN excision) does take place, though care must be taken not to disrupt the SL ligament.

Dorsal Posterior Interosseous Nerve Syndrome

• The Posterior Interosseous Nerve is the terminal branch of the Radial nerve. It traverses between the two heads of the supinator and travels along the radial floor of the 4th extensor compartment and ulnar to the Lister tubercle.
• Again, often secondary to forceful hyperextension of the wrist, although those with hypermobility may be at more risk of impingement of the PIN.
• In addition to clinical history, diagnosis is aided by pain on maximal dorsiflexion with tenderness at the 4th compartment along the course of the PIN.
• Conservative care is generally successful though neurectomy of the PIN may be warranted.

Personal Thoughts:
It is clear that structures within this region are numerous and nuanced. It should also be clear that specificity of management warrants specificity of diagnosis. As such, it is incumbent upon ourselves as clinical practitioners to have a detailed understanding of the differential diagnoses within this region regardless of our scope of practice. And although many more differentials exist in the areas surrounding the middorsal region,  as well as those pertaining to non-traditional orthopaedic pathways, this paper provides us with a good overview to help maintain a vast array of possible scenarios when presented with wrist pain in high level athletes.