I had a good case referred from a local primary care provider to come through the door the other day. I would like to hear your thoughts/feedback and treatment approach.
She is a 19 year old, right-handed Division I golfer who is home from school for the summer. Since she has had more time off, she has been playing more golf. She started having symptoms in her right wrist 2 weeks after playing. No prior history of wrist/hand pain; or injury in itself. She denied any other trauma (such as falling on outstretched hand).
The location of the pain was at the anatomical snuff box. The symptoms were only present at the complete end of the follow-though stage of golf swing. She had no pain otherwise, even with continuing to lift weights (doing pushups, etc) and carry through with daily activities.
The clinical exam was in most part unremarkable in that the patient had full, pain-free ROM in all directions of the wrist and hand. No reproduction of symptoms with manual muscle testing of all major groups, including the extensor pollicis longus and abductor pollicis brevis. Finkelstein’s test was negative (even with overpressure). No noted deformities, swelling or bruising. No pain at rest and in no distress.
Palpatory examination revealed tenderness deep at the snuff box. But, when I say deep; I mean quite a bit of pressure. I palpated the same on the other wrist and no difference in discomfort response (basically did not reproduce concordant symptoms). I would suggest this pain gave very little clinical utility. Try this on your own and it just isn’t comfortable…
I was able to reproduce her symptoms by getting her to swing at the golf club. As she described, a focal pain in the anatomical snuff box at the end-range of follow-through (from a PT standpoint: the involved wrist in full radial deviation and wrist extension).
What are some differential diagnosis? Should imaging be ordered? What else would you look for? How would you treat?