This phase is normally the first 24-72 hours of your symptoms developing.

RICE

RICE stands for Rest, Ice, Compression and Elevation. These steps are helpful for when you have an injury in the acute phase to help reduce pain and assist with the healing process. Depending on your level of function you may not need to do the compression and elevation aspect of this treatment method as it may not offer any benefit, however the others should still offer some help in reducing your symptoms.

Rest: You need to reduce the activity level you are performing and let your body have time to heal. Doing too much initially won’t allow your wrist time to heal as quickly.

Ice: This can help reduce the pain you are experiencing and also reduce some of the swelling. Using some frozen peas wrapped in a damp cloth for 20 minutes will work well here and do this every hour or two. Do not apply the ice directly to your skin, make sure you have a barrier which is preferably damp, and keep an eye out for any ice burns on the skin. If you notice this stop immediately.

What can be helpful here is having a specifically designed ice pack you can reuse over and over again. You still need to have that damp cloth as a barrier with these packs as well.

Compression: This relates to the use of the ice being compressed onto the wrist and thumb. This can be achieved by simply wrapping a cloth around your joint, but more bespoke equipment offers this which would be more comfortable and effective, such as a wrist/hand ice pack.

Elevation: Having your elbow rested on an object, with your wrist/hand raised above your shoulder will help reduce any swelling in the area. This may help reduce some of the painful symptoms you are experiencing. Aim here for a similar time frame as applying ice and go for up to 20 minutes. If you are not experiencing any swelling then you can skip this part of the treatment. Do not compress and elevate at the same time, as the volume of fluid returning towards your heart may put too much pressure on it.

Medication

In the initial phase the use of over the counter medication may be an option. Medication such as paracetamol and ibuprofen may allow this acute phase to be more manageable. Please consult your family doctor if you have any concerns with this impacting your current medication, or if any medical history may be impacted by the option of including this medication.

Brace

You may find it helpful to have the support of a thumb brace. You should only use this in the first few weeks and aim to wean off the brace gradually so that you don’t become too dependent on it. A brace can help transition as you begin to introduce your normal activities again. You don’t want to be wearing the brace when you are completing the exercises in Phase 2 as it will limit the range of movement you can produce and also reduce the load going through the tendon, which we will need to increase. Some people find that using the brace whilst sleeping is helpful for this condition.

Exercises

The aim of these exercises is to keep the joints above the wrist as mobile as possible, and encourage blood flow to and from the affected arm.

You may find it helpful to do these exercises in a circuit type fashion, where you do exercise 1 for 1 set, followed by exercise 2 for 1 set, then exercise 3 for 1 set, follow this pattern until all the movements are completed, and then restarting.

This would be roughly the first 6 - 8 weeks of your recovery.

Education

You may find you want to continue the advice from Phase 1 into this phase as well, which is absolutely fine. During this period the main focus is reducing your pain levels throughout the day and to start loading your wrist tendons progressively.

At the base of your thumb by your wrist you have two tendons which tend to be irritated with this condition, they are called abductor pollicis longus and extensor pollicis brevis. If you lift your thumb upwards you can normally see this tendon in action. These tendons help lift your thumb up and outwards away from your hand.

Tendons love load but it needs to be the right level for what they can tolerate for that period of time. You want to reintroduce load to the tendon and progressively load it so it can tolerate more. This ability to tolerate more load will mean you can perform more tasks day-to-day and eventually return to your sporting or daily activity of choice.

Tendons can take up to 12 weeks to repair and in some circumstances longer, depending on the severity and also the individuals specific activities they want to perform. Whilst you are rehabilitating your tendon you need to be cautious not to overload your tendon and cause a spike in pain and also irritation to the tendon. This may result in a backward step and delay in your recovery. Equally important is not loading the tendon enough. It is a balance to create and unfortunately you won’t get it right every time, however as long as you don’t keep getting it wrong, and each week you are loading the tendon more, then you are heading in the right direction.

You will hopefully start to notice that general daily activities become easier as you reduce the load which was aggravating your symptoms and your tendons begin their healing process. Try and avoid the temptation in the start to repeatedly poke and massage the tendons as this could potentially irritate it further.

The next question you need to start asking is “why did this occur?”. This is really important so you can understand what you did to trigger such a reaction. Sometimes this can be really obvious but other times it needs a bit more thinking. If you play a specific sport have you increased the frequency per week of doing this sport, the length of the session, or the intensity of the sessions? Did you recently change any equipment or technique? Equally some basic DIY or home activities can cause tendinopathy, even something as simple as cleaning the car.  If you aren’t used to doing the activity and suddenly introduce it into your daily life, your tendons may not have time to adjust to the demands required of them.

The ‘why’ is important so that we can adjust things accordingly when we return to the activity and make sure we don’t repeat the same thing.

You can continue any exercises from the previous phase but you may find they have less value as you progress through your rehabilitation.

A good marker of when to progress from this phase is when you can perform these all with no pain and general daily activities are less discomforting. You may still have pain with certain activities throughout the day but this should be less, and after roughly 8 weeks you can progress to the next phase.

Exercises

The aim of these exercises is to introduce some basic strength work and to load the wrist tendons without increasing your pain. Remember to start off easy and only increase the intensity each week once the symptoms have settled.

• For the first exercise you may find certain movements still irritable, especially in the early weeks. Don’t force the range but instead allow your tendon some time to heal, and just complete the movements which are not irritable. The range will improve but you need to allow your tendons some time to heal.
• For the grip strength exercise start off with the lightest putty or stress ball on the grip strength exercise, and ensure you have your wrist in a position which isn’t irritable. Initially you may be more comfortable using your fingers to generate the movement, but over time you will need to ensure your thumb is also worked during this exercise. You may find that towards the end of the Phase you can introduce a Gyroball as a way to challenge you further, along with offering a more entertaining way to strengthen your forearm.
• You may find it helpful to do these exercises in a circuit type fashion, where you do exercise 1 for 1 set, followed by exercise 2 for 1 set, then exercise 3 for 1 set, and then restarting.

Medication

In this phase you want to continue with any pain medications that are appropriate so that if you are experiencing any pain you are still able to do your rehab exercises, and also maintain a good level of quality sleep, however the general usage of the pain medication should be reduced as you move through the phase. By the end of this phase you should not be reliant on pain medication to get you through the day or to perform the exercises.

Brace

During the phase you should be weaning yourself off the brace reducing its usage throughout the day. By the end of this Phase you should not be reliant on the brace and be able to perform the exercises with ease.

Symptoms

During this phase you should start noticing more times in the day when you are pain free, however it is not uncommon for there to be sharp spikes in pain if you are doing a specific activity. This will improve and the activities which cause irritation should become less. If you continue to perform activities which consistently aggravate the wrist, it will continue to cause you pain and perhaps be affecting the end stage of healing. You need to alter the activities in some manner that are causing irritation until you have moved further along in your healing.

During the rehabilitation programme you may find that specific exercises or activities of daily life aggravate the tendon and you become sore for a couple of hours after. This is ok as long as the pain is below 5/10 on the pain scale, and as long as it settles within 2-3 hours. If you are sore for the rest of the day, or particularly sore and struggle with gripping activities the next morning this means you have done too much for the tendon to cope with at this stage. When it becomes irritable and painful like this, sometimes applying the treatment options and exercises in Phase 1 may be helpful. It's important that you don’t keep repeating activities which result in a spike in pain as this will prolong your recovery.

Pacing

At this stage you should find you can do more day-to-day activities pain free. The temptation here is to go a bit overboard. A nice reminder to pace activities so that you don’t over do it, and that you spread these activities out as much as possible throughout the day.

In this phase we are looking at between 6 to 12 weeks following the start of your symptoms.

Education

Similar to Phase 2 the timelines here are merely a guideline and may vary depending on the severity of your tendon pain.

The aim of Phase 3 is to introduce some strength exercises to the tendons of the thumb and wrist which are affected. If you find performing these movements difficult, you can simply hold the weight or contract against the band to generate tension in the tendon but without adding movement, this should be easier than performing this exercise with movement.  You should continue the wrist mobility exercises from the previous phase making sure you get full range in all directions of the wrist joint.

You should notice that you are becoming less restricted in the day and able to perform more daily activities with ease. Your soft tissue structures are still healing during this period as well.

A good marker of when to progress from this stage is when the strength exercises are easy to perform, are almost equal on both sides and do not cause pain.

Exercises

Some points to consider with the exercises:

• The first exercise is continued from Phase 2 but with a longer duration.
• For the Prayer Stretch exercises start this slowly and increase the range of motion over time, you would expect this exercise to be discomforting to start with initially as you haven’t moved your wrist this far for a number of weeks.
• For the radial deviation exercise this will be the toughest exercise of the programme to complete. Start off with a light weight and progress this slowly over time.  You can use a water bottle, dumbbell or even a resistance band for this exercise.
• The final exercise will also be tough to start. Using an elastic band or hair tie is a simple way to get some light resistance needed to strengthen the tendon. Start off with a small range of movement initially and only increase it slowly over the weeks in this phase.
• You may find it helpful to do these exercises in a circuit type fashion, where you do exercise 1 for 1 set, followed by exercise 2 for 1 set, then exercise 3 for 1 set, followed by exercise 4 for 1 set, and then restarting.

Symptoms

You should in this stage not be noticing your wrist pain with daily activities but perhaps with specific hobbies or work based tasks which require a lot of gripping. This will improve and hopefully by the end will be less limiting.

Steroid Injection

If towards the end of this phase you are struggling to perform any of the strength exercises and daily activities are still painful, it may be helpful to be reviewed by a physiotherapist or doctor who can look at the option of a steroid injection. A steroid injection can help reduce the pain which may help you perform the exercises to increase your strength. There are risks associated with this treatment option and these should be discussed in full with the medical professional who is administering the injection, and it should only be considered if all other treatment options have been explored in full.