Here’s an odd thing. This has never been discussed in a scientific article to my knowledge, nor in a scientific meeting relating to hand surgery. Every week, almost without fail, a patient comes in and tells me that, for a number of years (or months) they have been unable to bear weight on the open palm of their hand because it causes pain in the back of the wrist to do so.

Typically this relates to yoga (downward dog, plank etc), burpees, push ups, hand stands, hand walking, vaulting, wheel barrow walking, or even hand-offs (rugby) or pushing off a wall (squash) or resisting punches with a pad on the hand while training a boxer. Rarely it is seen after needing to use crutches. Some physiotherapists see it in patients who need to open-palm weight bear to rehabilitate something else.

Now, lots of people do those things, but it seems to me to be more common in city workers who also do those things.

This is difficult to prove. I previously worked in King’s College Hospital, Camberwell, South London (lower socio-economic demographic) where very few patients worked in office jobs (if they worked at all). I now work in the City of London where almost everyone has an office job. Many of these patients work hard and play hard. Weekend and evening sports are done competitively in this population. Many type for more than 8 hours a day.

I very rarely saw this condition at King’s College Hospital (13 years). In my 7 years in the City of London, I cannot get through a week without the same history being presented to me as if it is an odd thing. There is little information available for the general public. The condition is generally very uncommon. Patients (rightly) suspect it is a rare condition. But not here!

So why might this be?

MRI scans usually reveal a very small ganglion (leakage of joint fluid) in the centre of the back of the wrist, surrounded by some oedema (inflammatory fluid). Usually the diameter of these ganglions is 2-3 mmm. This is directly in the area of tenderness. It is usually directly under the extensor tendons that work the fingers (‘extensor compartment 4’). Large ganglions (visible ones), measuring 4-15mm in diameter, rarely cause as much discomfort. I think that is because these are often softer, on a longer stalk, and can move out of the way when the wrist bends backwards. The small ones pinch between the small wrist bones (usually the capitate) and the rim of the articular surface of the radius. There isn’t much room for a ganglion here. Impingement is when something soft gets pinched in a joint. We see it in many joints – classically the shoulder hip, but also ankle and others.

I suspect that the combination of typing a lot, holding the wrist in gentle extension for much of the day, followed by (or preceded by) a workout in the gym, is a risk factor for developing this condition. How do I prove that?

The good news is that this condition is very benign, and often settles completely with one steroid injection. This should be supported by ergonometric considerations, wrist stability training and advice on how to prevent recurrence. Hand therapists are great at providing this help.

In my experience, about 90% of such patients are symptom free within 2 weeks, but about 20% have recurrence after 2 months. Further injection cures about 50% of this group, but hand therapy is increasingly important for refractory cases. Establishing the primary cause is of course important in preventing recurrence.

Mr Mark Phillips, Consultant Hand Surgeon