Recently (2 weeks), I began treating a young woman between the age of 25-30 for a 1.5 year history of bilateral wrist and hand pain with insidious onset. Besides pain, her biggest complaint was significant numbness in her ulnar nerve distribution on her left hand. Her flexibility in her bilateral wrist flexors and ulnar deviators is fair, with significantly increased tissue density in her superficial and deep anterior forearm musculature. She is left handed.
She notes 8/10 pain in her left wrist at worst, with a constant 2-3/10 at rest. She is a computer programmer who spends roughly 6 hours a day at the computer. She notes pain with continued computer work and general pain at the end of the day. She has had EMG studies as well as MRIs with no significant findings. The following is a list of special tests.
Negative: UQS, Finkelstein, Roos, Phalens, Reverse Phalens, Ulnar Tinels
Mobility: Distal Radial-Ulnar (Right:4/6, Left: 5/6), Proximal R-U (4/6 bilaterally), Carpals (4/6 bilaterally)
Strength: Grip (Right 5/5, Left 4+/5), Wrist flexion (Right 5/5, Left 5/5), Wrist extension (5/5 Bilaterally)
Endurance: 5# Repeated Repetitions (Wrist Flexion): Left fatigue with 23 reps, Right fatigue with 39 reps
Current POC:
- Soft Tissue Mobilization to proximal wrist flexors
- Ultrasound (Continuous, 1.0 Hz) x 7 minutes bilaterally, followed by
- Wrist flexor stretches 3-5 x 30 seconds
- 3# wrist flexion/extension/radial and ulnar deviation with eccentric focus
- Alternating isometrics for stabilization of distal R-U joint
- Basic wrist stabilization taping
- Recommended wrist/forearm padding while working at computer
I should also let you know the MD prescription was “Tendonitis; Eval and treat” (I love these scripts). The patient has also been on a certain corticosteroid for the past month which is now being tapered.
Progress to date: Pt notes decrease of L wrist pain to 4-5/10 pain and right to 2/10 pain with occasional (less than once a day) spike to 6/10 in left.
So Mike, why the hell are you writing this? I find the most interesting part of this case is that she has no positive tests, special or diagnostic imaging, for anything but continues to present with a specific pattern of pain, and in my opinion NOT tendonitis. My thought process leads me to believe ulnar nerve entrapment, but what are your thoughts about anything I have written here? In particular the script from the MD and the POC.
(Obviously certain info has been changed to keep the patient’s identity safe)
Mike Scott, DPT 
Hey Mike,
I’m obviously not a PT and some of the tests you mentioned might as well be greek to me. But I can certainly agree that when it comes to MDs, very few have a solid understanding of injury (especially when diagnostic imaging comes up short).
I do commend him/her though for at least sending the patient to you. Many would just treat with NSAIDS. The corticosteroid may have been overkill.
My most major thought though…if you patient continues the pattern that brought on the injury is it not just apt to return?
Hey Mark,
I wrote a very long response then lost it. somehow. So here goes attempt #2. “Eval and treat” can be a frustrating script to get, but because as PTs we can sit with our patients for an hour at a time and get to know their condition, we can usually get a good feel of what directions to go in.
I do not mind the corticosteroids in this case, because they tell me that there is some inflammation SOMEWHERE, but they do not tell me where. So for now, I am addressing her faults (hypermobility and decreased flexibility) and educating her on proper mechanics (even though she had an ergonomic assessment prior to seeing me).
Even though this patient is going to continue to do what most likely caused her pain in the first place, there is hope. It’s like a competitive long distance runner with knee pain. You aren’t going to tell them to stop running for good. You are going ot find their faults, fix them, and prevent them from returning by changing their mechanics, etc. The same goes for this patient.
For the time being, her POC is working, but she does continue to have some discomfort day-to-day, but her pain levels continue to improve. As Kory suggests below, I think I am going ot dive a little deeper into her neurtal tension, even though her initil neural tensions tests (ulnar, radial, madian) were all negative. Thanks for your comments Mark, and I hope all is well.
Hey Mike,
For some reason your response didn’t reach me and I happened to check in today to see what you’re up to.
In any case, thanks for the thoughts. I agree with your analogy of the distance runner not giving up running. Despite proper mechanics, the parts eventually wear down (as with a car). I always try to stress this to those who won’t change behavior in the face of pain.
Mike,
You may want to look at some neural tension tests for the upper extremity as well as some more cervical tests to make sure not a cervical problem that is referring to the wrist and hands.
Also if you are not familiar with the book Explain Pain by Lorimer Moseley and David Butler, I would highly recommend it. Remember that pain is an output of the brain and noiception is not needed to produce pain. So negative tests tell us nothing to probably cause noiception, but patient can still have pain (i.e. phantom limb pain in amputees).
Kory,
First, thank you for your reply. I did some initial Ulnar/Radial/Median neural tension tests during the upper quater screen which were all negative, but I do want to implement some nerve flossing into her program, just to see if I can get a favorable reaction, and possibly provide her with more symptomatic relief when she does have pain.
I have not heard of Moseley and Butler’s book, but I do know that she does have mechanical symptoms, which lead my to believe they are not psychosomatic in nature. Thanks for reading and replying Kory!
Mike
Hi Mike!
Have you tried soft tissue work on the scalenes, in particular the posteriors as well as pterygoids? Also sub. scap and pec. minor?
How is her serratus anterior strength/scapular stability? Is her G.H. joint at 90*? That slight misalignment could create a constant low grade tension on the ulnar nerve, in particular if she’s got her elbows too far away from her midline while typing. Hope that gives some food for thought! Best, Kevyn
Kevyn,
Thank you for the input. I did not look at her sub-scap, and her scalenes are suprisingly “Normal”. Her pec minors are a little tight, and I will dive deeper into it when I see her next, along with her neural tension, to hopefully pinpoint where, if any, restrictions are occurring.
Mike
Mike,
I would also implement some exercises for her posture and thoracic spine. The position of the thoracic spine, controls the position of the cervical spine which changes the tension of the neural tissue. I like a sitting, active thoracic extension or a supine towel roll stretch. Both help to mobilize the thoracic spine and allow for better cervical positioning.
Thanks for responding Bridgit. I have given her a doorway stretch and some chin tucks (supine and seated, the latter to be done at work). Her thoracic mobility is good, as she is hypermobile systemically. She did get reproduction of symptoms with some different neural tension tests later this week; therefore, I added some nerve glides for the UE. I appreciate your comments and hope to hear from you again soon.
Mike
Follow up to Part 1. Case Study: Wrist/Hand Pain – Part 2 http://wp.me/pGet4-8Y
I would look more at the work environment and habits.
My general plan would strongly emphasize the need for frequent wrist mobilization, stretching, and some strength breaks throughout the day. Every ten minutes would not be too much, however the break can be very short, maybe ten seconds. This can be done while sitting and looking at the computer screen, so with a reminder software application it can become a habit. Once or twice an hour(or more) stand and do some other anti-sitting down movement.
Also she could switch the hand with which she holds the mouse. I did this myself back when I had a desk job and it’s not that hard- nothing compared to brushing teeth or throwing a ball with the non-dominant hand.
Great script- the doctor is just saying “I have no clue, you deal with it.”
Let us know what happens.
Hey Steven,
We have discussed taking breaks, even as little as 15 seconds from her work to quickly give her wrists/forearms/shoulders/neck a break. I have recommended the reminder software, and now we just have to see what she does with it all. I did see her again later this week, and even with being weened from the corticosteroids, she continues to do well. I do believe that it is the constant state of her work environment that is truly leading to this problem, coupled with her hypermobility in her wrists.
-Mike-
Pingback: Case Study: Wrist/Hand Pain – Part 2 « Mike Scott, DPT·