Wrist and forearm pain from desk work: a clinical guide

Desk workers with wrist and forearm pain are usually experiencing one of three things: carpal tunnel syndrome (median nerve compression at the wrist), De Quervain tenosynovitis (extensor tendons of the thumb at the radial wrist), or lateral epicondylalgia / extensor tendinopathy (overuse of the wrist extensor tendons at the elbow). Each has a distinct mechanism and distinct management.

Carpal tunnel syndrome is compression of the median nerve at the wrist, producing tingling and numbness in the thumb, index, middle, and radial half of the ring finger. It is worse at night and with sustained wrist flexion (typing, phone use). Tinel's test (tapping the carpal tunnel) and Phalen's test (sustained wrist flexion) reproduce the symptoms.

Management: wrist neutral splinting at night, workstation height assessment (keyboard position below elbow height increases wrist extension and carpal tunnel pressure), median nerve glides, and wrist flexor strengthening. Persistent severe cases warrant surgical opinion.

De Quervain involves the tendons of abductor pollicis longus and extensor pollicis brevis, which run in a narrow canal at the radial wrist. Pain is at the radial side of the wrist, worse with gripping and thumb movement. Finkelstein's test (thumb in fist, wrist ulnar deviation) is strongly positive.

Common in new parents (repetitive lifting of infants) and intensive keyboard users. Management: activity modification to reduce provocative loading, soft tissue work to the first dorsal compartment, and graduated loading of the thumb extensors.

Extensor tendinopathy at the lateral epicondyle (common extensor origin) presents as outer elbow pain, worse with gripping, typing, and resisted wrist extension. The cause is repetitive low-load wrist extension, exactly what sustained keyboard use produces.

Management follows tendinopathy principles: reduce provocative load, introduce isometric wrist extension (pain management), progress to heavy slow resistance through the wrist extensor range. Grip strength asymmetry is a useful outcome measure, symmetry to the unaffected side is a return criterion.