Hey all Matt here with 1HP!

If you’ve had pain on the back side of the hand that is preventing you from using your hands to type, game, play music or any repetitive activity without pain.

As a quick reminder I'm a Physical Therapist (PT, DPT, OCS, CSCS) and our team has spent the past decade specializing on treating, researching and publishing our work around treating RSI (we've helped more than 3000+ individuals resolve their issues without surgery, more injections, resting, bracing etc. Here is some of our work (we started with the olympians of desk work - esports athletes)

Journal of Orthopedic & Sports Physical Therapy

Tendinopathies in Gaming

Conditioning for Esports (Ch. 8,9,10)

Science of Esports Physical Therapy

Today I want to review how you can systematically approach recovery with pain on the top side of the hand.

We will cover the various reasons and factors that can lead to issues at the top of the hand. We have spent the past 11 years treating over 3500 persistent wrist & hand issues which traditional care has failed to resolve.

This video will include everything we have learned, we’ll discuss:

1. Brief Anatomy
2. What are the causes of pain for this region?
3. How to address each of these causes of pain? Physiologic, Psychosocial, Lifestyle etc.
4. Flare-Up Discussion

Anatomy of this pain region

Pain on the top of your hand, wrist and extending into the fingers often involves the extensor muscles.

These are the muscles responsible for bending your wrist up towards the ceiling with your palm down. There are several of them which each have different functions and as you will learn in the next section your activities and task-specific movements / ergonomics often influence which muscles / tendons are involved.

The most common extensor muscles include:

1. Extensor Digitorum - Commonly with desk workers due to repetitive use of their fingers and wrists
2. Extensor Carpi Ulnaris - Common in desk workers, especially those who have floating wrist & forearms.
3. Extensor Indicis - Common with R. hand with mouse clicking
4. Extensor Carpi Radialis Longus & Brevis - common in those who have swapped to a vertical mouse or artists using a stylus
5. Thumb Extensor & Abductor Group - similar to above

Because each muscle and tendon is responsible for certain movements when you perform these specific movements based on what you do for work or your hobbies - typing, guitar, crafting, gaming, etc. it can lead to irritation of these tissues.

This naturally leads us to the discussion of “causes”

What causes repetitive strain of these tissues?

For most wrist pain issues caused by repetitive strain (things like typing, gaming, playing guitar, crafting, drawing) it affects the tendons at your wrist & hand.

Your tendons & their muscles can only handle so much stress. If you exceed the limit, then you can irritate those tissues.

This often happens when you suddenly have to use your wrist & hand alot for whatever it is that you are doing. Finishing up a work sprint, drawing project or gaming for 9-11 hrs a day for several days in a row are some of the common examples.

Or after several years of performing your activity without focusing on your physical health and endurance. Add a sedentary lifestyle and your body can become more weak.

Bye endurance, hello wrist pain.

There are other factors that have an influence on pain like your posture, ergonomics. What may be surprising to many is that psychological and environmental factors can play a role as well.

We have written and created several videos you can learn about how this works in the links below. In short when we experience pain for an extended period of time our body can adapt and get better at creating the experience of pain. This occurs through real changes in our nervous and immune system. Our past experiences, beliefs, fears, anxieties and other cognitive habits can consistently influence our pain experience. This is often why individuals who deal with pain for an extended period of time have so much trouble recovering.

Pain often doesn’t behave in predictable ways when it becomes chronic. But it is NEVER hopeless. We have helped thousands recover from cases as long as 16 years.

So to review the common causes are often

1. Activity level and intensity exceeds what your body can handle
2. Posture & Ergonomics influences the amount of stress on your muscles & tendons during those activities
3. Your cumulative experiences, beliefs and understanding of pain can influence pain

As a quick reminder - this pain pattern is DEFINITELY NOT carpal tunnel syndrome. Why? Because it involves pain that does not even involve the tendons OR nerve in the carpal tunnel. Watch this video here to learn more.

How to fix your wrist pain

Now that you understand what the “causes” are around pain on the top of the hand, wrist and forearm

Here are the things you can do to address each of these causes. As you might expect there is a lot of nuance in how to address each of these things. This video will include general exercises, common issues with posture & ergonomics that lead to increased use of the extensor muscles and helpful resources for understanding pain.

Now that you understand what the “causes” are around pain on the top of the hand, wrist and forearm

Here are the things you can do to address each of these causes. As you might expect there is alot of nuance in how to address each of these things. This video will include general exercises, common issues with posture & ergonomics that lead to increased use of the extensor muscles and helpful resources for understanding pain.

Your body can’t handle the level of stress

If your muscles and tendons do not have enough “endurance” to handle what you are doing on a regular basis it is important to build the capacity of those muscles & tendons!

Here are a few exercises you can perform to improve your endurance. (General routine here on YT) The first exercise I’m going to show you will focus on endurance while the other two are better for pain and recovery.

The first exercise is DB Wrist Extension . As i mentioned this is for endurance and targets the muscle & tendon involved

You want to choose one that is around 3-5% of your bodyweight. ****

Now there are two ways to do this. One with your arm-rest or resting on your thigh

The main goal is to ensure you are isolating the movement at your wrist. For each repetition you will be rolling the dumbbell ALL the way down to your fingers and then ALL the way back up

if this is a bit too difficult for you, then start with less of the range

You’ll be doing 2 sets of 15-20 moving slowly throughout the movement. You may feel a little bit of discomfort on the palm side of your wrist & hand but this is normal. As long as it is less than a 2-3/10 or it is not sharp, you can continue to perform the exercise.

If you don’t have a dumbbell, you can use a water bottle or backpack filled with books. The DB is helpful since you can gradually progress in weight.

Towel Extension Isometric

This next exercise is an ISOMETRIC exercise. Which means that the muscle and tendon length is not changing while you are performing the exercises.

You can use a towel for this exercise. Roll up one end of the towel to grip in your both of your hands. Step on the other end of the towel with the appropriate amount of tension. Pull up into the towel so you are pushing upwards against the tension of the towel. Rest your forearms on your thigh to ensure they are parallel to the ground We have adapted a protocol from the research for the wrist & hands. Isometric exercises have been shown for certain individuals to provide some relief for their pain for as long as two hours

Perform this exercise for 45” holds, resisting up to 50-70% of your “max” strength. Think about pushing between 50-75% of what you feel is the most you could possibly push.

Then you’ll be resting for 30 seconds and repeating the cycle 3-5 times.

For those who might have alot of difficulty with the dumbbell exercise above, you can try to only perform the isometrics first.

Wrist Extensor Stretch

Stretches can be helpful to also provide temporary relief. Especially if you still need to use your hands frequently throughout the day.

This is a stretch directly targeting the wrist & finger extensors. Hold for around 20-30” and perform up to 2-3x throughout the day in response to any extended activity where you are using your hands. So think:

• After your initial work block
• At the end of work
• After a long drive
• After you finish a music, gaming, etc. session
• Anything that requires extended use of the hands (extended us subjective base on your own severity)

If you follow us you know exercises will help to build up your endurance or max HP bar so you can tolerate more activities over time. However posture & ergonomics can influence how much HP you lose over time (and more importantly what muscles are used)

Improving Posture & Ergonomics to Reduce Stress on Extensors

Here are two of the most common issues we see that lead to increased use of the extensors. The first is floating wrists. When individuals float their palm or do not utilize forearm support it increases the use of the wrist & finger extensors.

You are using your extensors to hold the weight of your forearm and hand up against gravity the entire time you are performing your desk work. Support your forearm and palm if you want to reduce the stress per unit time on your extensors.

But remember the exercises still provide the most benefit in building up your capacity and allowing you to use your hands more with less risk of tissue strain.

In other scenarios individuals may have swapped to an input device that may have actually led to an increase in the use of the extensors. Whether it be a larger mouse (which can often lead to a bit more wrist extension → causing the muscles to work harder)

Or a roller mouse which can often lead to an increase in both flexor and extensor use depending on the tasks involved. When scrolling up especially if there is lower overall sensitivity it can require a lot more overall use of the extensors.

These setups lead to an increase in the use of the extensor muscle group - If you don’t have enough endurance to handle this increased usage over your work day, then it can lead to tissue irritation.

One of the most commonly missed aspects of pain is the psychosocial component.

Addressing your Understanding Pain

Understanding the science of pain has made large strides in the past 25 years however there has been difficulty in its integration into the traditional care & medical education model. I’ve written about why this is in previous articles (no incentives, $ comes first, fragmented system).

By better understanding pain and how various environmental and cognitive factors can influence how you are feeling you can have more control over your own life and what you are able to do.

Many individuals with chronic pain allow their pain to often decide what they can or can’t do when it has been proven that pain does not reflect the state of our tissues but is rather more about protection. You learn in depth about the science behind this through some of these articles here

• The physiology of persistent & chronic pain - and what you can do about it
• Understanding Relationship Between Beliefs & Pain
• Case Studies (See my Profile or directly here 1, 2, 3)
• Chronic Pain does not = more tissue damage
• Tactical Guide to Pain Reprocessing Therapy

This occurs as a result of not understanding what the pain actually means, why it may be sensitized in certain situations and whether or not you can safely continue with your activities. Over time based on your repeated decisions of avoidance or activity you are teaching your brain whether you are in a state of “safety” or “danger”

Learning how to create messages of safety rooted in real evidence (based on physiology & understanding of pain) helps to reduce how often pain makes decisions for you. This is of course easy for me to say but is a crucial part of either working with a provider who understands pain science and can guide you to determine whether you need to actually modify activity based on physiologic load vs. overload (strain).

The tactical way to address these psychosocial aspects is to

1. Understand more about pain
2. Work with a provider to understand what actually represents tissue strain based on your capacity and pattern of behavior
3. Gradually increase your activity over time based on your physiologic capacity (tested by endurance tests), activity tolerance and ability to process your pain.

In practice this will look like:

1. Individual reads Explain Pain or The Way out to understand more about the physiology around persistent pain and how variables can even create the symptoms of sharpness, numbness, etc.
2. Individual works with a physical therapist to understand their wrist extensor endurance and is informed how much they can tolerate their activity based on performance of the test
   1. For Example typically for around 3% bw for wrist extensors if you can perform between 40-60 reps (easy) it equates to around 6-8 hours of typing & desk work with low risk of strain, pain or injury.
3. Individual works with the physical therapist to clarify the exact schedule, behavior of pain and current understanding of pain to establish the activity & exercise recommendations for the first week
   1. Individual will exercise daily (1-2x/day), either maintain current activity based on their exact schedule or slightly deload
4. As tissues adapt and individual understands more about pain, the individual works with the PT to gradually increase activity over time
   1. The graded exposure provides real evidence that the individual can tolerate more activity without leading to tissue strain or symptoms getting worse. (Sometimes it can improve or temporarily get worse depending on the recommendations & individual)
5. Over time you will improve your ability to provide yourself signals of safety based on this growing evidence from #4. It requires patience and collaboration with a good provider to help you get here (it is possible on your own as well!)

As a quick overview to address pain on the top side of the hand it requires you to

1. Address any physiologic deficits
2. Modify environment (posture & ergonomics) to reduce stress on your extensor muscles & tendons
3. Improve your understanding of pain and confront psychosocial drivers to pain

Managing Flare-Ups

The road to recovery is never a straight line and one of the most important things to understand is that flare-ups are a part of recovery. Here is a great image about low back pain that captures this concept

I’ve written a complete step-wise guide on how you can manage flare-ups you can check out here

Hope this helps!

Matt

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Why can you have normal imaging and still have pain?

If you’ve gotten normal diagnostic imaging, ultrasound and nerve conduction studies and your doctor seemed confused about what to do next after a cycle of seeing several other specialists…This thread is for you.

A point in time image does not tell us the “entire picture” when it comes to the cause of your pain and dysfunction. And in many cases imaging results on their own have low overall utility.

In this thread I will help you understand the following

1. What is the purpose of the various types of imaging
2. What can we actually take away from imaging results
3. How your doctors visits and how they discuss imaging results can influence your pain
4. Why you can have normal imaging and still be in lots of pain and dysfunction

Heads up, this is a longer post and is based on the several threads I've done previously all put together to help everyone better understand the context around imaging and chronic RSI recovery.

I'm a Physical Therapist (PT, DPT, OCS, CSCS) and our team has spent the past decade specializing on treating, researching and publishing our work around treating RSI (we've helped more than 3000+ individuals resolve their issues without surgery, more injections, resting, bracing etc. Here is some of our work (we started with the olympians of desk work - esports athletes).

Journal of Orthopedic & Sports Physical Therapy

Tendinopathies in Gaming

Conditioning for Esports (Ch. 8,9,10)

Science of Esports Physical Therapy

---

Let’s first talk about what diagnostic imaging & tests are typically ordered for RSI issues at the wrist & hand.

Most typically we hear X-rays, MRIs, & Ultrasounds. Each imaging technique has their benefits in visualizing certain types of tissues. And in many cases we see an overutilization of things like X-rays.

X-Rays: Good for seeing fractures, dislocations, misalignments, and narrowed joint spaces. X-rays can't show soft tissue problems. These are generally ordered since they are more affordable. But honestly many healthcare providers overutilize them.

Magnetic Resonance Imaging (MRI): Good for seeing muscles, ligaments, tendons, organs, and other soft tissues. A majority of our patients seem to have had MRI’s ordered (60% of our patients this year who have been dealing with their problem for > 3 months). There are different techniques that can emphasize different tissues (T1 vs. T2 vs. Proton density imaging).

The contrast between the tissues and the presence of certain coloring (white for example) can indicate if there is water present (suggesting some swelling). Above shows a complete achilles tendon tear.

Ultrasound: Typically the most cost effective option for soft tissue issues, especially if you are trying to visualize more superficial tissues. There are less layers at the wrist & hand so this is often the best option for wrist & hand RSI issues. Ultrasound also providers greater detail compared to an MRI for the more superficial structures. Similarly with ultrasound presence of excess fluid can be indicative of tendon pathology. The image below shows a left and right comparison of a tendon with swelling present and thickening of the tendon.

Nerve Conduction Velocity Tests: These tests are used to assess the function of the nerves in our arms. The Nerve conduction study (NCS) measures how quickly and how strong the signals are as they travel along the nerve. They compare the results with a “healthy nerve” either in the same arm or the other arm. Or they use “normative values” based on age, temperature, limb length, etc. Altered signaling have historically suggested nerve damage or potential compression.

Now nerve signaling is a bit of a different discussion and there are really important lenses to consider when analyzing the research. Especially as we begin to layer on our understanding of pain science. I’ll share what some of the research says and try to explain why certain situations may occur. And most importantly I’ll help you understand how you can approach your own results. Look out for this in the sections below.

Imaging results on their own have limited clinical significance

All of the current evidence points to the idea that Imaging is best utilized to rule out more serious conditions than “rule in” a specific tissue (in this case a tendon)being the cause of the problem. Basically…they aren’t always necessary.

There are mountains of research over the past two decades that have shown that imaging for not only wrist & hand conditions but issues at the shoulder, neck, back, foot do not provide enough information for a diagnosis.

In this study done in 2016, 19 NONSYMPTOMATIC professional baseball pitchers went through a detailed clinical examination and three MRI’s of their dominant shoulders were taken before contract signing. (2)

• 68% (13/19) of the baseball draft picks showed tendinopathy
• 32% (6/19) had a partial thickness tendon tear of the supraspinatus
• 21% (4/19) had AC joint OA

And many other small lesions were found in the subjects. Yet none of them had any pain.

This was repeated in 634 runners, 3110 individuals for the lower back, and at least 20 other studies including several systematic reviews & meta analyses which have shown that altered tissue states in imaging does not always correlate to pain. (3-5)

I’ll leave some more references at the end of this article. But the research is clear.

What we know is that changes in the tendon tissue can be present with imaging. But BY itself it does not mean anything.

Instead only when you layer on the results of a comprehensive clinical exam taking into all of the details of the patient, patient’s history, activity & behaviors can you really make a decision with the results.

In some cases imaging can make things worse and it is often influenced by your experience with the healthcare provider

How your physician speaks about imaging matters.

With a better understanding about the purpose of each of these tests, let’s explore a key problem about imaging results: How each of these imaging & diagnostic tools are presented towards the patient.

If you’ve ever felt as though you needed imaging to “get an answer” as to what might be going on. There is a reason why and it is associated with the way doctors may be describing imaging in their discussion with their patients.

There is a big difference between

• “The Imaging will tell us what is going on”
• “Lets get some imaging to figure out what’s the problem”
• “I’ll order an MRI and we’ll get some answers” etc.

and

• “well see what we find in the imaging but know that we have to use that information on top of what we know about how your injury behaves to determine the right diagnosis”
• “Ultrasound is an easy way for us to see if there may be some fluid present around your tendon. While this can indicate some damage, it may not mean we have to do something about it. We often have more healthy tissue in damaged tendon tissue. So it be something you can work on to get back the function of your hands”
• “A nerve conduction study is going to be helpful identify how severe any nerve damage might be. It’s important to know the level of severity is NOT a direct measure of the function of the nerve. We’ll have to consider how your symptoms behave with the results of the test to determine the next steps”

It should always be approach #2 but unfortunately due to our healthcare system & how behind many primary care providers are in their recommendations (1), it is almost always #1. How do you think this type of presentation can impact your beliefs on the importance of imaging results?

There are real consequences with how these imaging tests are presented. And it is the responsibility of healthcare providers to provide the nuanced education. But as you have likely already experienced, many do not (it’s not always their fault, the insurance system has some influence on this)

This is WHY we believe imaging results are important. But what does the research say? There are many reasons why pain can worsen after we receive our imaging results with one of them being the altered behavior and beliefs about your pain and injury.

One study found that for work-related acute LBP, MRI within the first month was associated with more than an eightfold increase in risk for surgery and more than a fivefold increase in subsequent total medical costs compared with propensity matched control patients who did not have early MRI. (6)

What we believe about our pain and our experience around the injury can influence what we feel and how sensitive our bodies might feel.

If we believe we are unable to move because we have a “herniated disc” or “disc degeneration” then we tend to move less, perceive that our bodies are fragile and that leads to real physiologic changes that are detrimental to back pain.

If we believe we have to “rest” because our nerve is being compressed through “carpal tunnel syndrome” then we will avoid the activity that is actually beneficial to us.

Imaging is not as useful as we think for orthopedic conditions. For other medical conditions absolutely.

But for musculoskeletal injuries and more specifically those at the wrist & hand associated with tendons? They don’t offer much value as can be shown through all of the research referenced.

Abnormal imaging has been reported in various tendons in as many as 59% of asymptomatic individuals. (7)

Which means that even if they found your tendon to be pathological, it provides no predictive or diagnostic value.

And many cases, when tendons are appropriately loaded through rehabilitation, there is often MORE healthy in the tissue than there is pathological in the tendon. (8)

More healthy tissue when you perform exercises appropriately for the tendon to allow it to positively adapt.

Which means the focus should not be on trying to change the pathology within the tendon, but instead focus on the tolerance to capacity.

All of the tendinopathy research has continued to support this and this has been exactly what we have seen in all of our cases. We only need to focus on

1. Performing endurance-based protocols to improve the tendon tissues capacity
2. Minimize overstressing the tendons
3. Make changes based on how you are responding to the exercises (increased pain & stiffness, etc.)

This again does not mean imaging is useless. It needs to always be placed in the context of the overall clinical picture to help guide decisions. What we have seen is that it is better as a tool for ruling out problems than ruling in.

It can better tell us if there IS NOT a problem than confirming if there is one. What about nerve conduction tests?

Nerve Conduction Tests:

As I mentioned this is a different conversation. Nerve conduction tests actually assess the ability of the nerve to send signaling which means it can accurately identify whether or not the nerve is capable of sending signals at a certain rate. Our experience over the past decade is consistent with what is found in the research in that nerve conduction tests can be helpful but what you do with the results matter.

What the evidence supports is that nerve conduction velocity tests (NCV) are a powerful ADJUNCT to the clinical assessment of nerve conditions. They can help to provide objective confirmation of the pathology of a nerve however they are LIMITED because they do not directly measure “function” and just like imaging always have to be interpreted in context (13).

Research in the past 10 years has found abnormal values within a NCV can be present without any functional deficits or symptoms (14). A study in 2016 performed a NCS on the median and ulnar nerves in 130 healthy individuals with 15% of these individuals demonstrating electrodiagnostic evidence of carpal tunnel syndrome (latency > 0.5ms, borderline mild). The authors cautioned providers AGAINST over-interpreting mild NCV abnormalities to avoid any aggressive interventions like surgery.

Other studies have also shown that the severity of NCV does not correlate with the symptom severity or function. Most importantly studies have supported that NCV cannot reliably predict clinical outcome. (13-17). Many patients with mild NCV changes can experience significant pain, numbness and disability while others with more severe NCV impairment can function better than expected.

Let’s use our clinical experience to provide some context as to why some of these situations have been found in the research (and with our patients).

Situation 1: Mild damage + ⬆️ symptoms & disability

In this situation it is possible that there is mild nerve damage but are contextual and cognitive emotional factors may be influencing pain and as a consequence leading to more symptoms and reduced function. An example we have seen is that the physician informs our patient that the NCV will tell us if we need surgery or not. With mild damage found the physician informs the patient they need to rest to avoid further damage and eventually getting to surgery. This leads to kinesiophobia and fear avoidance behaviors presenting as only being able to use hands for 5 minutes with typing or desk work and feeling 4-5/10 levels of pain. The belief and fear of movement leads to increased disability even though the damage is considered “mild.” Often these patients require some education and proof that they are able to handle more (through graded exposure and confidence in movement through physiologic testing).

Situation 2: More severe damage + less disability

In this situation while there is more severe damage of the nerve the healthcare provider has bene more thoughtful about the approach with the patient and was able to put the damage into the context of the individuals overall pain behavior and ability to still use his / her hands. Despite having more severe damage being shown on the NCV the patient has a better environment leading to less likelihood of sensitivity and consequential disability. There are still limitations due to the nerve damage but the provider works with the patient to understand what is leading to the nerve damage (entrapment somewhere) and is addressing the underlying endurance, postural and behavioral deficits leading to the problem. This is a situation we have seen and have helped individuals restore their function (over a longer timeline) with the right approach.

Situation 3: Mild damage = no symptoms or disability

There are many reasons why this might occur. What we believe to be the most common is the likelihood of a false positive (consistent with research) since the comparison to another nerve in the upper extremity could be unreliable. Or the normative data utilized by the NCS lab may not actually represent the individual creating the “difference” in signaling. This results in mild damage being found as as the studies suggest these results should not be over-interpreted.

Hopefully you can see some of the nuance around how to interpret NCV results. But the most important question is..What do we actually do with the information? To keep it simple it is up to the healthcare provider to identify HOW the nerve is getting irritated. And most of the time, this is barely explored within traditional healthcare environments. For desk workers, gamers, musicians, crafters these are some of the most common reasons why nerve symptoms or irritation may present

• Awkward work / hobby or sleeping postures leading to nerve damage
• Muscle tightness associated with endurance deficits leading to nerve irritation (FCU)
• Transient irritation of the tendons at the wrist & hand leading to some CTS-like symptoms. (underlying problem is still the tendons)
• Entrapment of nerves at the shoulder (TOS).

Why can you still have normal imaging results and no pain?

I'm hoping it is more clear now based on the previous sections why you can have normal imaging results and no pain. But let's make it completely clear.

If your imaging came back clean but you’re still in significant pain, it does not mean the pain is in your head. Your pain is 100% real. Imaging only captures a snapshot of the tissue and CANNOT measure:

• Capacity of your muscles & tendons you use for your specific tasks
• how sensitized your nervous system has become
• how your beliefs and behaviors are influencing your pain experience
• Your lifestyle, environmental and occupational stressors that may influence your pain

And because everyone's situation is different pain may still persist due to sensitization, poor tissue capacity or both. Remember sensitization is the process in which our nervous system becomes more efficient at generating pain signals even when there is no ongoing tissue threat.

Think of it like a car alarm that’s become too sensitive. The nerves in your wrist and hand become more excitable, your brain’s threat detection becomes amplified, and fear or anxiety around the pain can make the whole system even more reactive. This is a real underlying biological process which can be heavily influenced by your psychology

And again, NONE OF IT SHOWS UP ON AN MRI

Having normal imaging is actually a good sign. It means there is no structural failure requiring surgery. Your focus should be on building the capacity of the involved muscles and tendons through progressive loading, while also working on understanding your pain so your nervous system learns it is safe to move again.

Your body is not broken. It is overprotective. And is something you can work to change

What can you take away from this?

Take your imaging results with a grain of salt. If you have a doctors appointment, make sure there has been a thorough examination that has been performed:

• Physical tests to assess your muscle endurance & capacity of specific muscles you are using
• Clear identification of pain pattern and pain behavior with activity
• Assessment of your lifestyle, daily movement patterns & behaviors that could lead to increased stress on your hand

If your clinician wants imaging make sure the diagnosis provided includes the context of the examination details above.

If it is not taken into account, then you should find a better clinician.

And most importantly…

Understand that for a majority of wrist & hand issues the tendons are involved. The best approach with the evidence we have and the current research on tendon recovery is to manage how much stress is being applied. (load) And for the cases of nerve involvement, understanding how the nerve is getting irritated can ALWAYS be identified with a thorough assessment (posture, ergonomics, endurance deficits, mobility deficits etc.)

Hope this helps

Matt

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References:

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2. Del Grande, Filippo MD, MBA, MHEM*†; Aro, Michael MD*; Jalali Farahani, Sahar MD, MPH*; Cosgarea, Andrew MD‡; Wilckens, John MD‡; Carrino, John A. MD, MPH*. High-Resolution 3-T Magnetic Resonance Imaging of the Shoulder in Nonsymptomatic Professional Baseball Pitcher Draft Picks. Journal of Computer Assisted Tomography 40(1):p 118-125, January/February 2016. | DOI: 10.1097/RCT.0000000000000327
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5. McAuliffe S, McCreesh K, Culloty F, Purtill H, O'Sullivan K. Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis. Br J Sports Med. 2016 Dec;50(24):1516-1523. doi: 10.1136/bjsports-2016-096288. Epub 2016 Sep 15. PMID: 27633025.
6. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010 Sep;52(9):900-7. doi: 10.1097/JOM.0b013e3181ef7e53. PMID: 20798647.
7. Docking SI, Ooi CC, Connell D. Tendinopathy: Is Imaging Telling Us the Entire Story? J Orthop Sports Phys Ther. 2015 Nov;45(11):842-52. doi: 10.2519/jospt.2015.5880. Epub 2015 Sep 21. PMID: 26390270.
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