Postpartum Wrist Pain – What is “Mom Thumb”?

Many people are aware of (and experience) carpal tunnel syndrome (CTS) during pregnancy, which as many as 62% of pregnant individuals reporting symptoms².  Fortunately, most of these cases resolve quickly if not immediately after delivery.

Unfortunately, there are other maladies of the wrist that are actually quite common in the POSTpartum period. For some reason, they do not get as much press.  So this article is dedicated to all those experiencing wrist pain AFTER having baby.

By far, the most common site for wrist pain during the postpartum period is on the thumb side (AKA lateral wrist or radial aspect). Some may refer to this as “mom thumb”.  Clinicians often refer to is as ‘de Quervains’.  It would be classified under the broad category of Repetitive Use Injuries. Think of the time spent in prolonged carries while feeding or rocking babe to sleep, often with wrist in flexion and thumb actively stabilizing babe or bottle¹⁵.

On a Random Personal Clinician Rant: I have found in my clinical practice that the radial wrist pain that presents in postpartum does not perfectly present as a true form of de Quervain’s Tenosynovitis, as it is often labeled in the research. In practice, I see it presenting more like an enthesopathy (i.e. a problem at the attachment on the bone) than a full blown stenosing tenosynovitis.  That being said, I do not have a diagnostic ultrasound in office to confirm and refute this suspicion. Of note, however, is that the natural history of the condition is different in perinatal patients than it is in non-perinatal patients, as demonstrated by Capasso et al in 2001⁴. In their study, after 6 months, most of the perinatal cases had resolved under conservative care, whereas 25 of 30 of the non-perinatal group went on to require surgery.  This is good new for our perinatal peeps, but it also means that we may need to take a different approach to care and understanding the mechanism of this condition when wrist pain presents in a recently pregnant person.  Rant over.

It is not all about hormones! 

People tend to enjoy blaming all pregnancy and postpartum (and female) related issues on hormones. Hormones are very powerful chemicals, but they are not the big bad wolf and they are not responsible for all your problems. For example, although the joints in your limbs are more lax during pregnancy, these changes do not perfectly correlate with estradiol, progesterone, or relaxin levels⁸. You also do not need to be the birth mother to experience wrist pain while caring for a newborn¹⁶.  So the plot thickens and we don’t get the easy out of blaming hormones and dismissing the issue.

That being said… postpartum wrist pain is more common in breastfeeding parents than in bottle-feeding dyads. Extended hormonal fluctuations may be involved in this relationship. Differences in prolonged feeding positions and maybe even the fact that it is easier to share the feeding load with others when bottle-feeding may also be contributing to this observation.

Very likely, the area that hormones are influencing is more centred around fluid retention and inflammatory control as opposed to joint laxity¹⁵. Inflammatory regulation is complex chemistry and does involve hormonal mediators. In particular, estrogen and its derivatives are well established players in both inflammatory and immune system health¹⁰. This progressive shifting of hormonal levels and its influence on inflammatory regulation and healing is one reason why we likely see a difference in the natural history of wrist pain in perinatal patients.

As a final note on hormones, wrist flexion-extension laxity does correlate to some degree with maternal cortisol levels⁸, so we could start up a whole other conversation about the connections between stress and hormones and inflammation and pain and the musculoskeletal system… but I will save that for another day. For now, take care of yourself and remember that stress influences everything.

It is not all about laxity!

Laxity is another keyword that people like to throw out there when pain is experienced during the perinatal period. But just like hormones, pain is not all about your joints being too loosey-goosey. Elasticity does not equal pain. This is being actively explored in perinatal pelvic girdle pain (which may be explored in a later blog…) and the same applies to our extremities.

Our current understanding of most MSK joint-related pain syndromes has a lot more to do with loading mechanics than joint flexibility or position. Certainly, laxity may play a role in the loading nuance and injury risk, but that does not mean that the laxity itself is the primary problem. More often than not, an increase in muscle coordination, strength, and stamina is capable of gracefully compensating for the increase in ligamentous laxity. So let us consider more how a postpartum wrist is loaded and repetitively used. Then we can attempt to build more tissue resilience and better control, which will reduce the risk of repetitive strain injuries.

Hopefully I have not lost you will all my dorky terminology and explanations.  I firmly believe that the more we understand about the mechanism of how something works - down to that delicious cellular level - the smarter we can be about how we approach solving the problem. Which leads to more success and less pain and you get to savour your postpartum experience with babe rather than being slowed down by pain.

What do we do about it?  Let’s talk about Treatment Options!

This is all you really wanted to know, isn’t it? There is no standardized care for wrist pain, but there is a lot to offer.  Each case will vary, but below is a list of different treatment options that may be included in your care plan.

Conservative Treatment Choices

• Exercise & Stretching
  • I put this one first because it is the most neglected and potentially the most important. As I mentioned above, the trend in MSK care is leaning toward improving loading mechanics, so we need to recruit and use muscles appropriate for healthy, resilient, pain-free tissues.   Stability exercises for the wrist may be done using resistance bands or weights or sometimes even just the force provided by your other hand or a bucket of rice.

• Taping
  • Taping is great because it goes with you. Either athletic tape ("white tape”) or kinesiology/elastic tape (we use RockTape) may be used, depending on the intent. On a basic level, tape provides the brain with more high fidelity information from that area of the body, so then the nervous system has improved control, stamina, and strength. A recent study showed that exercise in combination with taping was more effective than exercise alone for postpartum wrist pain⁷. It makes you look cool too.

• Splinting/Bracing
  • Splinting is probably one of the most commonly used interventions for wrist pain, but let me be very clear: bracing alone is not enough. There are individual studies that go both ways on the utility of splinting but research in this specific area suggests that splinting does not provide satisfactory pain relief by itself³. There has been no difference shown in outcomes with full-time splinting compared to “wear as you want” splinting⁹, which suggests that using a brace is palliative at best and does not modify recovery progression. However, splinting may still be useful in some cases. I often recommend splinting at night to avoid persistent flexion and for pain-relief as desired, but ALWAYS in conjunction with exercise and manual therapy. Either a thumb spica or wrist splint can be used, depending on the site of pain (or what you have at home).
• Manual Therapy
  • Joint mobilizations may be indicated, but often times there is a mix of hyper (too much) and hypo (too little) mobility at various joints in the arm and wrist (and rest of the body). Joint adjustments may help improve loading position and proprioceptive feedback¹¹. Soft tissue therapies - including myofascial cupping, IASTM, and go-old-fashion hands-on massage - are often very helpful for tissue healing and pain relief. I am partial to using IASTM (Instrument Assisted Soft Tissue Mobilization) around the wrist and thumb^5,6,13. These techniques improve the “slide and glide” between tissues layer, as well as bring more blood flow and healing chemicals to the area.  (FYI, in our office, we have a few different tools and trainings, including Graston, RockBlades, and FAKTR tools).  RockFloss or Voodoo Floss is another supportive technique that we might use for postpartum wrist pain. These glorified elastic bands are used for compression (which impacts feedback/proprioception and blood flow/fluid dynamics) and to improve interlayer tissue glide.
• Inflammatory Regulation
  • Inflammatory regulation and pain management could be considered their own independent department of care for postpartum wrist/thumb pain, as well as any musculoskeletal condition. Over-the-counter NSAIDs like ibuprofen may be used to reduce inflammation and pain, but depending on whether or not you are breastfeeding, you should check in with your medical doctor or midwife before taking any medication.  There are also nutritional choices that can promote either good or bad inflammatory control. In general, erring toward high healthy fats and lots of veggies and avoiding access sugar is a great start toward an anti-inflammatory diet.

NON-Conservative Treatment Options for Mom Thumb/de Quervain’s

Although these are not services offered at AltaVie Health, sometimes it is nice to know what the next steps would be if the problem remained persistent. For reference, in the decade that I have been treating perinatal patients, I have had 2 cases which I ended up referring out for non-conservative support. The first case was a woman with pre-existing chronic pain issues. The second case was unfortunately delayed in initiating care due to the COVID shutdown.  In all other cases, there has been complete recovery without external referrals.

• Cortisone Injections
  • Local steroid injection is generally quite effective at reducing inflammation and pain in patients with de Quervain’s tenosynovitis¹². However, it is not considered a good first line of defence for tendon injuries due to the list of potential adverse effects, including loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties¹.  Because of the possibility of tendon degeneration⁴, most physicians do not recommend corticosteroid injections at the wrist unless other treatments have been unsuccessful.  Because of a strong positive natural history in postpartum wrist pain, it is generally not recommended in this population.
• Medication
  • There are medications stronger than ibuprofen that may be used to reduce pain and/or inflammation. Many of these are not recommended while breastfeeding, so please connect with your medical provider prior to taking any medications for your wrist pain.
• Surgery
  • There are surgical methods of “releasing” de Quervain’s stenosing tenosynovitis - if that is determined conclusively via ultrasound to be the cause of your wrist pain. However, surgery should be considered only if conservative measures implemented for 4 to 6 months have failed⁴. Fortunately, surgical interventions are generally not recommended or required for postpartum patients because of their positive natural history (meaning it usually goes away over time).
• “Other” Injections
  • Although steroid injections are most common, there are other injection therapies that may be used in sports medicine, naturopathic, and pain clinics. Although I am sure there are several others, prolotherapy, PRP, and neural therapy injections are the three that I see done often^14,17. These are all separate treatments with different mechanisms of actions, so I will leave it to the practitioners who provide them to determine their appropriate use. Although there is less published literature on these compared to steroid injections, there is still some decent research and an adverse response profile that most patients are much more comfortable with. As I mentioned above, the 2 cases under my care that did not resolve with conservative management did resolve with neural prolotherapy injections.

At AltaVie, we take a multimodal approach to most musculoskeletal conditions for our perinatal patients. Postpartum wrist pain (or mom thumb) is no different. Although most of the research is looking at one intervention at a time or comparing a single intervention to another, our clinical care blends the best of as many worlds as we can reasonably combine. Typically, a conservative care trial period for postpartum wrist pain will include manual therapy (usually including IASTM), kinesiology taping, exercise rehab, and ergonomic advice specific to infant handling.  We are also likely to sprinkle in some nutrition recommendations to promote healthy inflammatory control and soft tissue healing. We take this multi-angled approach because we want what is best for babe, and that is you at your best!

It is difficult to “rest” your wrist or hands (or brain) because the care demands of babe are constant. That being said, there is a form a repetitive loading that you can take a break from that is likely to help tremendously. That is: get off your phone.  “Tech Thumb” or “Text Thumb” presents in a very similar way to lateral wrist pain and the two conditions often overlap. Take a 2 week trial break OFF your phone, as much as humanly possible.  Use your fingers to type and swipe rather than your thumbs, when it is absolutely necessary to use the phone.

Certainly, there are other forms of wrist and thumb pain that can present during the postpartum period. On the medial (or pinky or ulnar) side of the wrist, the most common condition is TFCC Syndrome, which requires an all-together different approach.  You can also still experience carpal tunnel syndrome and other neurodynamic syndromes in the upper limbs during the postpartum period, so please, seek out a clever practitioner to receive the appropriate diagnosis before creating your treatment plan.

I hope this blog helped and that you are able to find a full and quick recovery for your wrist pain so that you can get back to focusing on the more important things in life.  <3

REFERENCES

1. Abate M, Salini V, Schiavone C & Andia I. Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies. Expert Opinion on Drug Safety. 2017; 16:3, 341-349, DOI: 10.1080/14740338.2017.1276561
2. Ablove RH, Ablove TS. Prevalence of carpal tunnel syndrome in pregnant women. WMJ. 2009 Jul;108(4):194-6. PMID: 19753825.
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4. Capasso G, Testa V, Maffulli N, Turco G, Piluso G. Surgical release of de Quervain's stenosing tenosynovitis postpartum: can it wait? Int Orthop. 2002;26(1):23-5. doi: 10.1007/s00264-001-0302-8. PMID: 11954843; PMCID: PMC3620858.
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