Wrist Osteoarthritis and ligament injury
In this article Ross Hauser, MD discusses wrist osteoarthritis, the problems of diagnosing various forms of wrist pain and long-term non-surgical options including the use of Prolotherapy.
Doctors have noted that arthritis of the wrist is a painful disabling condition that has various causes and different presentations at the doctor’s consultation. The traditional treatment has been a total wrist fusion at a price of the elimination of movement. However, forms of treatment which allow the preservation of movement are now preferred. Various wrist replacement techniques are still not sufficiently robust to meet the demands of many patients, nor do they restore the normal movements of the wrist.1
Despite the concern of researchers three wrist surgeries are favored for the following:
- Total wrist fusion: The procedure is performed in young patients who have arthritis in one wrist and high physical demands on the wrist. The operation will lead to good pain relief but loss of movement of the wrist.
- Total wrist replacement: Performed in patients with arthritis in both wrists but with relatively low manual demands. The operation results in good pain relief and a functional range of movement.
- Wrist denervation: In this procedure, nerve branches that take sensations from the wrist to the brain are cut, which will reduce pain perception and improve symptoms temporarily.2
The wrist represents one of the most complicated regions of the musculoskeletal anatomy. It is made up of 15 bones and 27 articular surfaces, that is, surfaces related to a joint, all in a sea of ligaments. Stability of the wrist is provided by the tight-fitting anatomic design of the individual carpal bones and by the ligamentous interconnections that control movement of one bone on another. Each bone within the wrist is joined to the one next to it by one or more ligaments. Tough bands of ligament connect the wrist bones to each other and to the forearm bones and hand bones. This results in a large number of ligaments, an elaborate system that maintains these bones and articulating surfaces in proper relation to one another. Two of the largest ligaments of the wrist are the medial (ulnar) and lateral (radial) collateral ligaments. The MCL passes from the distal end of the ulna and crosses the wrist to attach to the triquetrum and pisiform bones. The LCL passes from the end of the radius, across the joint to the scaphoid.
Weakened ligaments are a common cause of chronic wrist pain. They may also make an individual more susceptible to injuries. Because of its complexities, the wrist is one of the most common areas where ligament injury occurs.
Wrist instability results from a disruption of the ligamentous support between the individual carpal bones (intrinsic ligaments) and between the radius and the carpus (extrinsic ligaments). Once the normal soft tissue constraints are lost, the carpal bones assume a pathologic orientation based on the remaining ligamentous forces. If the ligamentous injury is incomplete, the bones can assume a normal alignment at rest, but collapse under applied load. This is termed dynamic instability of the wrist. Static carpal instability occurs when enough restraints are lost that the bones assume an abnormal alignment on standard x-rays of the wrist.
When weakened ligaments allow the wrist bones to become unstable and shift positions, wrist instability results. In addition, any one of the ligaments may be torn due to an injury and become a source of pain.
In sports there are four principle mechanisms of injury described: throwing, weight-bearing, twisting, and impact injuries.
- Throwing injuries to the wrist are associated with throwing, racquet sports, and often overuse injuries.
- Weight-bearing injuries are seen in gymnasts and weight lifters who experience high compressive forces on the wrist.
- Twisting injuries may occur in any sport, whereby the wrist undergoes a rapid rotation, which disrupts the ligaments and stability of the wrist.
- Impact injuries are the most common injury, and result from falls.
In search of an alternative to wrist surgery
Wrist replacement failure can have a high rate of failure as attested to Dutch research appearing in the medical journal Acta Orthopaedica. This includes 25% of replacements needing revision and 2/3 of the implants becoming loose.3 But other research said you can sill get a fusion! “A failed wrist arthroplasty still leaves the option of a well-functioning arthrodesis.”4
We not only disagree with wrist fusion after wrist replacement, we disagree with wrist replacement in the first place! Yes, there may be rare cases where wrist replacement is needed, but Prolotherapy can save a wrist pain patient for the complications of surgery
Rest, activity modification, and support braces are frequent initial recommendations in traditional medicine. It is important to note that rest and immobility of a joint can cause more problems in the long run.
Anti-inflammatory medications are some of the most commonly prescribed medications. Along with cortisone injections, another common recommendation for wrist pain, these medications eventually inhibit healing and have adverse effects on long term health of the joint.
Arthroscopic wrist surgery is actually used for both diagnosis and treatment of wrist pain. MRI and standard x-rays are not yet sensitive enough to show ligament injuries in the wrist. Therefore, arthroscopy is an option used by orthopedic physicians to examine the wrist and obtain a diagnosis.
Prolotherapy for Wrist Pain
Rather than surgical arthroscopy to diagnose wrist pain, it is better to examine the wrist and apply gentle pressure to the painful area with the thumb to reproduce the pain. The painful structure has then been located and the diagnosis is made. The diagnosis of wrist instability or wrist ligament injury is best done by direct palpation. The wrist bones are very superficial, and thus the weakened ligament(s) can be easily palpated and positive “jump signs” elicited. Once the injured wrist ligaments are located and a diagnosis is made, Prolotherapy treatments would be recommended. Prolotherapy to the injured wrist ligaments causes a strengthening of the ligaments and a stabilization of the wrist joint.
In research conducted, Prolotherapy showed itself to be very effective in eliminating pain, stiffness and improving the quality of life in this group of patients with unresolved wrist pain.
This included patients who were told that there were no other effective treatment options were available or that surgery was their only option.
Current conventional therapies for unresolved wrist pain include medical treatment with:
- non-steroidal anti-inflammatory drugs,
- anti-depressant medications,
- steroid injections,
- trigger point injections,
- muscle strengthening exercises,
- massage therapy,
- education, and counseling.
The results of such therapies are typically short term and often leave the patients with unresolved pain. When these treatments fail, the surgical procedure most often recommended for those with chronic unresponsive wrist pain is wrist surgery.
Prolotherapy is the injection of a solution for the purpose of tightening and strengthening weak tendons, ligaments, or joint capsules. Prolotherapy works by stimulating the body to repair these soft tissue structures.
One explanation for the lack of response of chronic wrist pain sufferers to traditional conservative therapies is that their underlying problem, ligament laxity, is not being addressed. Typically in the early stages of wrist arthritis, the problems are mainly caused by carpal instability from ligament injury. Prolotherapy has been shown to decrease pain by stimulating tissue repair in degenerated tissues such as ligaments and tendons.
In this research, thirty-one patients with an average pain duration of 52 months, were treated quarterly with Prolotherapy . Included in this group were nineteen patients (61%) who were told by their medical doctor(s) that no other treatment options for their pain were available or that surgery was their only option. Patients were contacted an average of 22 months following their final prolotherapy session and asked questions via telephone interview regarding levels of pain, stiffness, other physical and psychological symptoms, as well as questions related to activities of daily living, before and after their last prolotherapy treatment.
Improvements in many quality of life parameters were achieved in this patient population who received the Prolotherapy for their wrist pain.
- Ninety percent of patients had 50% or more pain relief and 88% felt improvement in their stiffness levels. All patients who were taking pain medications prior to receiving prolotherapy were able to reduce the frequency of required medications after receiving prolotherapy.1
Prolotherapy treatment for wrist pain
To halt the arthritic process, stabilize the carpal joints, and reduce wrist pain, Prolotherapy can be used effectively. Prolotherapy injections represent a regenerative medicine treatment that addresses the genesis of the problem: ligament laxity.
You can read our study on patients using Dextrose Prolotherapy for Unresolved Wrist Pain, published in the journal Practical Pain Management.
1. Logan JS, Warwick D2. The treatment of arthritis of the wrist. Bone Joint J. 2015 Oct;97-B(10):1303-8. doi: 10.1302/0301-620X.97B10.35717.
2. Biswas S. Persistent Wrist Pain. Eplasty. 2015 Jul 28;15:ic43. eCollection 2015.
3. Harlingen D, Heesterbeek PJ, J de Vos M. High rate of complications and radiographic loosening of the biaxial total wrist arthroplasty in rheumatoid arthritis: 32 wrists followed for 6 (5–8) years. Acta Orthop. 2011 Dec;82(6):721-6. Epub 2011 Nov 9.
4. Krukhaug Y, Lie SA, Havelin LI, Furnes O, Hove LM. Results of 189 wrist replacements. A report from the Norwegian Arthroplasty Register. Acta Orthop. 2011 Aug;82(4):405-9.