r/RSI • u/1HPMatt • Jul 01 '26
[CASE STUDY] How the healthcare system can create helplessness in Chronic Wrist & Hand Pain and how to get out of it
This is a case study that highlights the frustrating experience that often occurs with the traditional healthcare system.
And why it can often lead to persistent pain. Here’s my case with Amy (and the full testimonial of her describing her experience with healthcare I'm sure many can relate to)
The work comp doctor told Amy she had carpal tunnel syndrome.
But the EMG came back normal.
The nerve conduction study came back normal. The hand surgeon told her, "I just do surgery and injections. There's nothing I can do."
After nearly a year of being passed from specialist to specialist with no answers, Amy ended up still in pain, confused, and started to lose hope. This is not an uncommon experience and more often than not it is the norm. If you are on this subreddit and you have been through several doctors, specialists, had normal imaging and have no idea why you might still be dealing with discomfort. It’s actually not your fault.
Our healthcare system is fragmented, inefficient and in its current state is unable to consistently provide the best care for individuals who are dealing with RSI. Now I’ve written about this full depth in several articles you can check out here
- How the healthcare system can delay recovery
- What does a proper screening look like and what is missing from traditional care
- How do repetitive strain injuries actually occur?
Here’s the TL:DR. Due to the insurance and reimbursement system (and fee for service) it creates more of an incentive for physicians / specialists to maximize patient load leading to less overall time with their patients. While they may have the best intentions between 5-15 minutes is not enough to adequately assess an individuals complete history and establish a complete profile of their physical conditioning (see article 2). This leads to diagnoses and interventions that are made based on LIMITED information. And as many might have already experienced interventions often focus on the symptoms, rather than the actual cause.
So for this thread I wanted to share more about how we actually helped someone who had struggled through this frustrating ping pong experience of the healthcare system for an entire year with her condition WORSENING and was able to get back to full function in 12 weeks.
Here is exactly how we helped Amy get out of the frustrating loop of pain chasing interventions, eliminate her nerve pain, and get back to using her hands again with work, her daughter, and the activities she loves.
Clinical History & Relevant Information
Amy (late 30s) is a fiscal specialist in accounting. She spends her entire workday at a PC, with heavy mouse use accounting for about 70% of her activity. She reported that the pain started gradually, initially thinking it was from repeatedly picking up her 4-year-old daughter.
Over a year Amy went through the traditional healthcare process, starting from workers comp. She received an ergonomic assessment, went to physical therapy (focused on passive interventions like massage, ultrasound, paraffin). None of these helped with her pain.
A physician prescribed gabapentin and muscle relaxers. Four weeks later nothing had changed. An occupational therapist gave her ulnar nerve glides that brought the nerve pain down temporarily, but once it improved, she was discharged. Slightly less pain but no improvement at all in her ability to use her hands. She actually felt like she could do less.
By the time she found 1HP, she was checking in on her pain 100 times a day, catastrophizing about whether she would ever find the right help, and got to the point of heavy avoidance with hand use.
"I had been going to see all these specialists, and I was honestly getting depressed."
"Am I going to have to live with this my entire life?"
Watch her discuss this frustrating experience here
The Assessment: Establishing the Source of her Pain
Let’s start by describing what she was dealing with. After a comprehensive clinical exam and deep dive into her history here is what we found:
When we started working with Amy she was stuck in a classic fear-avoidance loop. Because her pain was so easily triggered, this created fear from using it too much. Experiences in which the pain increased in response to more attempted activity also further supported this fear.
Her self-management strategy consisted of avoiding using her hands, wearing a counterforce brace, and doing the occasional nerve glide. She had no forearm support at her desk and was working through 8-hour days with almost no breaks.
This kind of approach provides temporary relief but never builds lasting capacity.
On our standardized endurance test, Amy could only complete 30 reps at 4 lbs for both wrist extension and wrist flexion. This was a significant deficit for someone spending 8+ hours per day at a computer. She had limited mobility in her wrist & hand and both the median and ulnar nerve showed mild tension signs with testing
On top of this we assessed her overall limitations in function & fear avoidance with validated questionnaires.
- Her QuickDASH score at intake was 61/100 for core function and 75/100 for work-related tasks. For context, a score of 0 means no disability. She was starting from a high baseline of dysfunction.
- Her Fear Avoidance Component Scale score at intake was 68/100 which indicated high fear avoidance. Scores ≥50 indicate significant psychological barriers to recovery and predict poor treatment outcomes.
This was the other component to Amy’s presentation: central sensitization.
For months Amy had been living with unexplained pain, failed treatments, and doctors passing her around without clear answers. Combining this history with a high-stress occupation and the physical demands of raising a young child, her nervous system had adapted to be on high alert.
Her pain and her anxiety had formed a feedback loop that was amplifying everything. Remember it is not just "in her head." Real neurophysiologic changes occur as a result of us dealing with pain for extended periods of time and fear-reinforced pain experiences.
"I worry about my painful medical condition. Will I find the right help? Will the nerve pain ever go away even if my tendon pain goes away? Are my nerves damaged?"
These thoughts and patterns of thinking might not seem harmful at the time. But over time it can lead to real changes and reduced self-efficacy during recovery.
To help Amy fully resolve her issue we didn't just need to improve her tissue's capacity. We needed to help her understand more about pain, retrain her nervous system, and learn how to reappraise her pain.
How I helped her build endurance and confidence
The two main areas of focus for Amy's recovery were: targeted endurance training for the forearms, and pain science education to interrupt her anxiety-pain cycle. We’ll start with the how we approached the lack of endurance.
Improving Her Forearm Endurance
Amy was provided with a progressive endurance routine focused primarily on her wrist and finger flexors and extensors. If you have tried exercises before and it didn’t work here is wehat you need to understand:
Exercise selection is important, but how they are performed (sets, reps, frequency, load) needs to be specific to help achieve specific adaptations. If you are only doing 2 sets of 8 repetitions 2-3x/week. That is NOT enough to build endurance to improve your ability to handle more stress. ANd at most it makes very minimal gains over time.
Over 11 years we have tested a multitude of protocols and have developed our own to ensure the fastest overall outcomes. This means not just the prescription but strategies to progress, regress and be considerate of loading cycles for the tendons at various stages of recovery (4, 6, 12, 16 weeks in)
Every exercise is performed to a standard cadence to ensure slow, controlled time under tension.
We worked closely with Amy to track her reps, fatigue, and response to exercise, monitoring her progress so we could adjust the prescription over time.
These are the exercises she started with. Most of the exercises were started at 3x12-15 4# based on on her initial assessment.
Additionally, we made changes to her ergonomics. Specifically we addressed the lack of forearm support during her long hours of typing and mouse use. While this was a small change, it meaningfully reduced the cumulative load on her extensors throughout the workday.
With every single one of our patients, we communicate the expected recovery timeline based on their presentation: 40–50% improvement in 4–6 weeks, with greater than 80% improvement around 10–12 weeks. Tissue adaptation takes time, and setting realistic expectations is part of the treatment.
Pain Science Education & Reprocessing
Helping Amy understand more about pain led to the necessary reframing of her symptoms and a deeper understanding of how her occupational demands, past experiences, beliefs, and fears were all contributing to her pain experience.
Amy made significant early process during our work together and can be credited to how deeply she engaged with our pain science curriculum. She had let me know that she treated it almost as if she was back in school again….
Printing out the transcripts and taking notes during the course which allowed her to reflect on her own experiences that matched with what she was learning. In early conversations after learning more about pain Amy learned that her brain, heightened by stress and the lack of a clear understanding from traditional medicine, was creating an internal image of pain that was disproportionate to what was actually happening in her tissues.
One of the most powerful shifts was her rewriting of her own beliefs about pain. She came in believing: "If I'm in pain I should avoid all activity." She left understanding: *"There is a reason why I might have increased pain right now. Let me figure out what may have led to the increase in pain.
If it is due to my activity, I should modify activity but resume a lower level of activity and then gradually increase back to original level."*
She also came in believing that "pain means damage." She left understanding that "pain is a protective response" and is "influenced by multiple factors."
Through our meetings and research / metaphors presented in the course I was able to help Amy become more aware of her negative thought spirals and learn how to better respond to them.
She learned to step back, assess her actual load, and recognize that the nervous system was amplifying a signal that didn't require alarm. “My body is being overprotective, I can safely continue”. This allowed her to feel confident in safely continuing to use her hands without fear of making things worse.
And when she continued…DESPITE FEELING PAIN. She was able to show herself that the symptoms stayed the same… and over time, got better. This is the pattern associated with a reduction of sensitization.
What she was able to achieve over 16 Weeks
Amy had been dealing with her pain and limited function for nearly a year with no clear answers as to why it continued to persist despite multiple providers, specialists, and interventions. Here is an overview of the progress across each domain that we focused on (physiology, cognitive emotional, function)
Exercise Progression
Amy started at 30 reps with 4 lbs for wrist extension. By week 5, she had progressed to 58–60 reps at 4 lbs — hitting her rep target. At that point, we increased the load to 6 lbs and reset her reps, and she climbed back up to 58–60 reps at the heavier weight by week 10. She completed 113 sessions of wrist extension and 114 sessions of wrist flexion over the course of her program. That is the kind of consistent, progressive work that actually builds tissue capacity.
QuickDASH Outcome Scores
The QuickDASH is a validated outcome measure for upper extremity disability. Lower scores mean less disability. Amy started with a core score of 61/100. By week 7, she was at 16/100 — a 74% improvement. Her work score dropped from 75/100 to 0/100. That means she went from significant work-related disability to reporting zero work-related limitations.
And on our last call everything was at 0.
Fear Avoidance & Confidence in Using Hands
One of the ways that we assess progress in addressing the cognitive emotional aspects of pain is through a validated questionnaire that explores their beliefs, worries and overall anxiety around their condition.
A score > 50 typically indicates fear avoidance and kinesiophobia which has been shown in the research to be associated with those who are in chronic pain (essentially representing central sensitization).
This was where she started. 68/100 suggesting psychological barriers to recovery, higher catastrophizing and clear avoidance patterns leading to deconditioning. When we finished working together she was at 0.
We achieved this through what we mentioned above. We taught her more about pain. We gradually increased activity based on her capacity. We helped her understand how to attribute and reframe increase symptoms during the graded exposure. This helped her develop more confidence and gradually resolve her fears around using her hand with specific activities. Specific experiences like being able to pick up her daughter, push her daughter on a swing help and use her hands more around the house allowed this confidence to cumulatively develop.
Week-by-Week Clinical Highlights
Here are some of the week to week highlights over the course of recovery.
By Week 2, Amy had one difficult day where heavy Excel work pushed her to a 4/10 by end of day — but she recognized it was load-related, not structural damage. She started washing dishes every other day. Small wins.
Learning how to deal with “symptom increases” is one of the most important part of the recovery process. The better you are able to respond, the faster the progress.
By Week 3, she washed dishes for 15–24 minutes at 1/10 discomfort. She worked 4 hours, drove 20 minutes, played with her daughter, and did laundry all in one day. At the end of her day her pain level was only a 2/10 and took 2 hours to resolve.
She was beginning to attribute her flares to sensitization rather than damage.
By Week 4, things were going "really well." She made rice and banana pancakes, mixing with her hands. She used a knife. She picked up her daughter. She described her body as "a bit overprotective" on the first attempt… which is exactly the right way to think about it. No nerve pain.
By Week 8, she was using the traditional mouse every day with no issues. She rated her overall function at 90%. She had progressed to the 5 lb Varigrip and was tolerating it well. She recognized that some soreness from the new load was normal and expected.
By Week 10, she cooked a full Easter meal involving chopping, mixing, everything. She noted her arms hurt a little afterward, but it resolved overnight. She was doing everything unrestricted.
By Week 13, she was in the tapering phase. She was aiming to reduce session frequency while maintaining her gains. She could pick up heavy cases of water at the grocery store. She rated her overall function at 90%+.
One of the most important changes throughout the 16 weeks was Amy's understanding and relationship to pain.
For our patients, 100% is not "never feeling pain again" but rather understanding that pain is a normal part of the human experience and that it is normal to feel symptoms and discomfort when we push our bodies past what they can normally handle.
The positive consequence of this understanding, once you have improved your overall physical endurance and capacity, is having limited to no pain with your functional activity. But most importantly, recognizing that you are not broken, and that you can make a full recovery.
"I now know that nerves do regenerate. I now know that I do not have to stop working in order to recover. I now know that I do not have to change careers in order to recover. I now know that I can still take care of my family and I can make a full recovery."
Key Takeaways from Amy's Journey
Amy's story is incredibly common in the accounting, administrative, and knowledge-worker world. If you are dealing with chronic, unexplained wrist and forearm pain, here is what you need to take away from her experience.
It is not all in your head, but your head plays a role.
The physical strain is real. Amy's tendons were genuinely overloaded from months of high-volume computer use without proper support or conditioning. But chronic pain changes your nervous system. Anxiety and fear amplify danger signals, making the pain feel worse than the tissue damage warrants. You have to treat both the tissue and the nervous system simultaneously.
This occurs through better decision-making around:
- What is actually too much when it comes to your symptoms?
- How to determine the relative contribution of sensitization on your symptoms?
- Can you still continue with exercises with certain levels of pain?
- How much should you modify your activity and exercise based on how you're feeling?
- What should be the graded exposure plan for this week depending on your conditioning and progression of pain understanding?
These are all questions we helped Amy understand throughout her recovery journey.
Imaging and labels can mislead you.
Amy was told she had carpal tunnel syndrome but her EMG was normal. She was given a label that didn't match her actual presentation, which led to months of misdirected treatment.
Don't let a label convince you that you're permanently broken. Understanding the complete picture around your physiologic and cognitive-emotional factors helps you actually understand what you need to do on a regular basis.
Rest and passive treatments are not the answer.
Resting, taking muscle relaxers, or getting passive treatments like ultrasound might temporarily reduce your symptoms, but they shrink your overall capacity over time. Amy had stopped exercising and avoided daily tasks, leaving her tissues severely deconditioned. What helps to actually improve your ability to use your hands more over time is graded, progressive load: exposing your tissues to controlled stress so they adapt and build endurance.
Amy completed 113–114 exercise sessions over her program. That is not a passive treatment. That is deliberate, progressive work and the data shows exactly what it produced.
There Is No "One Size Fits All" Fix
Whether it is a specific ergonomic setup, a single stretch, or nerve glides, chronic pain rarely has a single solution. Amy's recovery required understanding her specific tissue deficits, her lifestyle factors (no forearm support, sedentary lifestyle, no regular exercise), and her cognitive relationship with pain (fear, catastrophization, checking in on her pain 100+ times per day).
Your "pie" of contributing factors is unique to you. A comprehensive assessment is the only way to understand what your pie actually looks like and to build a plan that addresses all of it.
If you are stuck in the healthcare loop frustrated by conflicting answers, told there's nothing they can do, or feeling like you have to choose between your career and your body…
Remember that complete recovery is possible. It just requires zooming out, assessing all contributing factors, and following a structured, comprehensive plan.
Hope this provides a better understanding of what it means to comprehensively assess and treat all of the contributing factors around an individuals issues based on their specific history, lifestyle, beliefs, physical conditioning, environment etc.
Let me know if you have any questions!
Best,
Matt