For some of us the most pressure our wrists will experience over winter will be pushing ourselves up out of a comfy armchair, twisting the cap off a jar of hot chocolate, and thumb swiping the phone for the warmest holiday destinations. Others will heed the call of winter sports, where pressure on the wrist will be less subtle, like falling on an outstretched hand whilst snowboarding or taking a rugby tackle.
Whether pursuing a winter sport or not, the wet conditions of the cooler months, increases the chances of a falls, and subtle repetitive strain injuries are a threat to wrist stability, no matter what the season.
As one of the more flexible, yet delicate parts of the body, the wrist provides a vital link between the power of the forearm and the hand, while being essential to supporting the structures needed for finger dexterity and touch. It enables us to carry out complex motions, and enhances the ability to generate power, for example when using a hammer or swinging a racket. Without this mobility though, limitations are placed on the hands and simple daily tasks become more of a chore. Before things can go awry, understanding its structure can at least help in avoiding motion or force that has the potential to result in injury.
A complex joint
Although a very complex piece of anatomy, in simple terms the wrist is made up of eight small bones known as carpals. These bones are connected by ligaments and each of the bones are supported by a joint capsule, that surrounds the joint and contains a lubricating fluid. The muscles that support the wrist start further up the arm, with the tendons of these forearm muscles crossing the joint to help control the actions of the hand.
The carpal bones also support a relatively well known tube that runs through the wrist, the carpal tunnel. Whilst these bones cup one side of the tunnel, the rest is covered by ligaments on the palm side of the wrist, that hold tendons and nerves in place. The tendons of the arm slide back and forth through this narrow passageway, and the tunnel also accommodates the median nerve.
The other nerves of the hand take a different course, with the ulna nerve running between two bones known as Guyon’s canal. This is still on the palm side of the wrist but further towards the little finger. The last of three nerves of the wrist, the radial, runs on the back of the hand, where the anatomical ‘snuff box’ is situated at the base of the thumb. This nerve activates the muscles that straighten the fingers.
Another structure, the Triangular Fibrocartilage Complex (TFCC) on the little finger side of the joint, plays an important role in stabilising the bones of the wrist. Other than allowing smooth movement of the hand, the TFCC contains a small cartilage pad that acts as a shock absorber for forces concentrated at the base of that side of the palm. It also suspends the bones of the forearm over the joint and gives the hand greater mobility.
As far as mobility of the wrist is concerned, there are six motions of the wrist. Flexion and extension, which is up and down like a diving flipper. Radial movement and ulnar movement, created for example by waving from side to side. The last two are supination and pronation, or in other words a twisting motion. All these ranges of motion add to the ability of the arm and hand, yet this complexity also increases the chance of injury.
Wrist injuries great and small
Whether it is a ball sport like rugby, or a trip skiing up at the snow, the first type of injury caused by impact, can be best avoided by one’s skill level. For those not as adept at these sports, these sudden injuries can occur when falling down during a tackle or misjudging a steep slope, as this naturally prompts the body to put out a hand for support. These types of falls can then lead to wrist injuries involving dislocation, fracture, breaks, sprain or strains, as well as nerve or tendon damage.
Although not technically a bone of the wrist, the bones of the arm where they join this joint, are at most risk of fracture when falling and will generally fall under the category of a wrist injury. The carpel tunnel bones can be fractured as well from this type of fall, with swelling of the wrist and pain during movement as indicators. Similarly, shock absorbing areas of the wrist such as the Triangular Fibrocartilage Complex, are mainly injured due to this type of fall.
As the function of the wrist plays a major part in our daily lives, it is no surprise that this delicate structure can suffer from a second type of injury, overuse. Repetitive wrist actions can set up strain injuries locally in the wist or in associated structures further up the arm in the elbow, for example tennis or golfers elbow. One of the most common locally occurring, wrist strain injuries is carpal tunnel syndrome. This is when the median nerve that passes through this narrow tunnel, becomes compressed due to tendon degeneration or swelling.
This inflammation is generally due to overuse or an underlying medical condition. Overuse can be from excessive vibration of hand tools, as well as poor hand positing or any repetitive movement that overextends the joint, such as typing or playing the piano. Medical conditions that can bring about carpal tunnel syndrome include diabetes, joint trauma or fluid retention, for example in pregnancy.
The ulna nerve can be irritated, like the median nerve, resulting in Guyon’s canal syndrome. Once again, the cause is over use, such as repeated twisting, or from constant pressure on the little finger side of the joint, caused by weight bearing on cycling handlebars or gripping during weight lifting.
Rheumatoid and osteoarthritis, like any other joint, can be another cause of wrist pain, and the degeneration of cartilage is one of the most common conditions seen by hand surgeons. Wrist tendonitis is degeneration of a different kind, this time affecting the tendons that cross the joint. Also as the wrist contains so many joints, the joint capsules, ligaments, or tendon sheath may weaken leading to a ganglion cyst. This is a fluid-filled sack that although usually painless, may press on a nerved or impede joint movement.
The wrist is a complex and delicate piece of anatomy, where pain is commonly experienced. Like the other joints of the body though it is possible to take some simple measures in decreasing wear and tear, or preventative action in avoiding impact type injuries. After all this is a sound investment, considering that wrist health is critical to the function of the hands and what we do we do for a living.
Wrist strengthening and care
Unless ambidextrous, we tend to use one hand more than another. A starting place for being proactive with our wrist health, would be to use both hands for tasks that only require one. This would then maintain strength, co-ordination and flexibility of the hands for simple tasks such as brushing our teeth, stirring or using a manual screwdriver. There is also the dual benefit of sharing the work load, while ensuring that if one hand is injured, the other is better trained to take over.
Other preventative measures to injury, would be to invest in shoes with quality soles that grip, or if unsteady on the feet, for example after surgery, to use a solid walking frame during recovery. If healthy and taking on a sport that you know involves falling, learn how to fall. For example mastering a well executed tumble roll forward and backwards, will see that the most is made of a lift ticket at the snow, as opposed to an expensive ambulance bill.
If injured though, resistance can be part of a physiotherapy plan for recovery. This generally is with the use of small hand weights to flex and extend the wrist and forearm, or with the use of a wide elastic bands that vary in their level of resistance. These are generally performed with the other hand supporting the wrist, with the elbow at a ninety degree bend while held against the body. The hands are then slowy curled palm facing up (flexion), and then down (extension) in sets of three, with ten repetitions of each set. These weight or elastic band exercises can also be performed in the ‘thumbs up’ position, or in other words with the wrist sideways. Stretches to increase joint flexibility can be as simple as bending the fingers backwards or forward with the other hand, or against a surface like a table or wall, with either palms or the back of the hands facing down.
Building wrist strength to increase its capacity to lift and enhance performance in sport will also help in the prevention of carpal tunnel syndrome and other injuries. The exercises to achieve this are relatively simple and some can be done whilst sitting at work. Doing ten repetitions at a time and using a small weight means that you can build up strength gradually over time, this being especially so if performing as part of a post injury rehabilitation routine.
Note that the use of weights that strap to the wrist like a cuff, are more applicable to weight training as opposed to cardio workouts. Although these weights are used for cardio exercise to increase the burning of calories, there is a pay off in the stress placed on the joints and muscles of the wrist, arm and shoulder. Careful consideration should be given to your level of physical fitness, plus the type and intensity of exercise performed while using these or any other resistance devices.
Other general wrist strengthening exercises include squeezing a tennis ball as hard as possible but without pain for five seconds and repeat each of these sets, ten times. If this places too much stress on the wrist then a memory foam ball may be more suitable. Wrist rolls can be performed using a small weight tied to rod, such as a piece of dowel, using about 1 one meter of rope. Hold the rod out in front and let the weight hang on the rope, with a palm down grip on either side of where it has been tied. Then using a motion like revving a motor bike handle, wind the weight up with both hands, and then down making sure the arms stay up during the exercise.
Indirect improvement of wrist strength can be improved through exercises like pull ups, bicep curls, lat pulldowns and chest or shoulder presses. One unconventional method of building the wrists and forearm strength, is by placing the hands in a large container of rice. Once submerged, making wrist curls with open or closed hands, opening and closing the hands, and moving them up and down, can offer an alternative to resistance or weight training. If unsure of any of these methods or exercises, please consult your physiotherapist for more information or exercises that may better suit your goals.
For sports that involve swinging a racquet, club or bat it is good to appreciate that there is a tremendous amount of power transfer from the feet through the body. The wrist and its small tendons and bones lie near the end of this kinetic chain, and so the release of power from the body at this point can cause injury. If pursuing sports such as golf or tennis where the wrist is integral to generating this power, then it is worth using some strengthening techniques. Most simply the racquet, club or bat can be used to slowly working through the range of motion, to build up wrist strength and even improve technique.
For injury prevention or protection during recovery, a range of wrist guards and braces are available. Guards are common in snowboarding as fractures to the wrist are common, and according to one study ‘wrist guards reduce the risk of hand, wrist, or forearm injuries in snowboarders by up to 85 percent’. Wrist guard designs are specific to the needs of the sport, so those used for skating will vary in features to those in snowboarding.
Wrist braces are more for support in the recovery of injury or rehabilitation of a chronic condition, as they keep the wrist in a resting position. They are also used to provide general support, or to assist in sports such as gymnastics, where the wrists bear the full body weight. As weight bearing is something that the wrist was not designed for, sports that require this have a higher likelihood of injury.
Once again these braces come in a range of designs, the choice of which wrist brace to use for your condition, can be made easier by what your physiotherapist recommends. Your physiotherapist will also be able to educate you on how best to strap your wrist, specific to the activity or sport, and recommend the types of tape to be used. The same will apply to work based injuries, looking at the ergonomic set up of workstations and work tasks, in an effort to reduce the causes associated with an overuse injury.
Anti inflammatory medication may be considered, where swelling is impeding the body’s ability to recover. In severe cases more direct intervention may be required, such as referral to a specialist and the consideration of a steroid injection or surgery. For the most part though, physiotherapy treatment and strengthening exercises should be enough to restore proper function to the wrist.
Finally, consider how many references we make to hands, and it’s not hard to see why the wrists are overlooked. Phrases like ‘all hands on deck’ or ‘gain the upper hand’ illustrate our reliance on the hands and that which supports them. So next time you give a hearty clap, uncork a bottle of wine or swipe that holiday destination on your tablet, note that although a quiet achiever, the wrist deserves some care and respect of its own.