Wrist Pain From Overuse: Detecting and Relieving Intersection Syndrome
Jane T. Servi, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 12 - DECEMBER 97
In Brief: Intersection syndrome is tendinitis or tenosynovitis in the first and second dorsal compartments of the wrist. This overuse syndrome has been reported in rowing, canoeing, racket sports, weight lifting, and, as in this case report, skiing. Physical exam demonstrates tenderness and crepitation or squeaking several centimeters proximal to Lister's tubercle. Therapy may consist of rest, ice, nonsteroidal anti-inflammatory drugs, wrist splinting, corticosteroid injection, rehabilitation, and, for recalcitrant cases, tenosynovectomy. In skiers, changing grip diameter on ski poles and using pole straps may relieve symptoms.
Wrist pain can have many sports-related causes. The following case report highlights a common overuse injury that often goes undiagnosed (1): intersection syndrome. Physicians who treat active patients need to be aware of its classic signs and symptoms and how best to treat it.
A Skier's Case Report
A 32-year-old right-handed, healthy woman went on a long-weekend ski trip to Utah. At the end of her first day of skiing she noted a dull ache on the dorsoradial aspect of her right distal forearm. Exacerbating maneuvers included wrist extension and radial and ulnar deviation. She had experienced no acute injury and had no history of wrist injury. She iced and taped the wrist and continued to ski the remaining 2 days, despite worsening symptoms. She noted increased pain when dragging her ski pole, as well as with pole planting.
By the second day of the ski trip, she had developed swelling over the distal dorsoradial wrist, as well as palpable grating with wrist movement, but no audible crepitation. She had no paresthesias and no pain at rest.
She returned to work the day after the ski trip and noted sharp pain in the same area with the wrist movements described above and with writing, removing jar tops, and lifting objects 3 lb or heavier. She initiated nonsteroidal anti-inflammatory drug (NSAID) use without relief. She visited her physician 5 days after the onset of symptoms.
On exam she had edema at the distal dorsoradial aspect of the wrist, extending proximally four finger breadths in length. There was palpable grating with both active and passive motion, maximal in this area but extending proximally to the midforearm. She had full range of motion, but pain on active wrist extension and ulnar and radial deviation. Because of pain, strength was slightly decreased on resisted testing of the same motions, as well as on supination and grip testing. The hand was neurovascularly intact.
Classic Presentation, Optimal Treatment
This patient had a classic presentation of intersection syndrome—a common condition that is infrequently diagnosed. It has also been referred to as "squeaker's wrist," "bugaboo forearm," "oarsmen's wrist," "peritendinitis crepitans," and "abductor pollicis longus bursitis (1,2)."
Intersection syndrome is a tendinitis or friction tendinitis in the first and second dorsal compartments (figure 1) (3). The muscle and tendons of these two compartments traverse each other at a 60° angle, two to three finger breadths proximal to the wrist joint on the dorsal aspect (several centimeters proximal to Lister's tubercle) (2). Intersection syndrome has also been described as a stenosing tenosynovitis of the sheath of the second compartment (the radial extensors) where it traverses the muscle bellies of the first compartment (the abductor pollicis longus and extensor pollicis brevis) (1).
This traumatic tenosynovitis had an 11.9% prevalence in one group of Alpine powder skiers (1). The injury in these patients was attributed to repetitive dorsiflexion and radial deviation of the wrist as skiers withdrew their planted ski poles against the resistance of deep snow. Advanced skiers may be more at risk because of their more aggressive style of pole planting.
Intersection syndrome has also been described in rowers, indoor racket players, canoeists, and weight lifters who overuse their radial extensor of the wrist by excessive curling. It also presents an occupational hazard.
Physical exam reveals point tenderness on the dorsum of the forearm, two to three finger breadths proximal to the wrist joint, as well as crepitation or squeaking with passive or active motion and visible swelling along the course of the affected tendons.
Therapy consists of 1 or more weeks of wrist splinting, avoidance of exacerbating activities, icing (ice massage with water frozen in a foam cup works well), NSAIDs, corticosteroid injection, and rehabilitation consisting of range-of-motion exercises and wrist extensor strengtheners. Symptomatic relief may also be obtained in the skier by using a smaller pole grip diameter and using a pole strap (1). When conservative treatment fails, a tenosynovectomy and a fasciotomy of the abductor pollicis longus muscle can be performed (4).
Prevention in Alpine skiers includes instruction in powder skiing pole technique such as avoidance of deep pole planting and pole dragging. Decreasing the pole length by 2 in. and downsizing the basket diameter to 2.5 in. may also be prophylactic (1).
Good Nonsurgical Outcome
In the patient described above, the diagnosis was made from the history and physical alone. Because the patient had already been using rest, ice, and NSAIDs, she received at that first visit a corticosteroid-xylocaine-hydrochloride injection and wrist splinting. She noted immediate relief on injection while the anesthesia was present. She also continued her icing and NSAID therapy.
The patient had 75% improvement in symptoms 1 week postinjection and was able to resume skiing within 2 weeks with her wrist splinted. Four weeks after the injection, she had complete resolution of symptoms and an entirely normal exam. She remained asymptomatic throughout the remainder of the ski season.
Dr Servi is a primary care sports medicine physician in private practice in Ft Collins, Colorado. She is a member of the American Medical Society for Sports Medicine and the American College of Sports Medicine. Address correspondence to Jane T. Servi, MD, 1136 E Stuart, Suite 3100, Ft Collins, CO 80525.