Courtesy: golfcoachblog.com

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?

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12 comments

  1. Has she ever has a history of wrist trauma – even when younger? Navicular instability can cause a SLAC/SNAC wrist and that can cause early OA at the radial styloid process- thereby causeing pain with radial dev and ext. Any pain when pressing/compressing the radial styloid process just above the snuffbox?

    1. AE,
      No, no prior history of any type of trauma, first onset of wrist pain. I did not specifically drive the stolid process in, but no symptoms or any pain with manual provocation to this area.

  2. Harrison, whats going on man! It’s mitch from ODU PT. I’d be interested to see what her FMS score is. I’ve been working a lot with Gray Cook’s functional movement screen and find it extremely helpful with my athletes especially with distal extremity issues. If you’re unfamiliar with the screen, I’d see if another therapist in the area can screen this athlete. Let me know the scores.

    1. Hey Mitch! Good to hear from you man. I have read some of Gray Cook’s work but I haven’t taken any courses so do not know her score. As far as I know, no one around me does FMS formally.

      Any tips that I sold look t more proximal?

      Harrison

  3. Harrison,

    Probably more lunate dissociation/ligament injury if there is no history of navicular fracture. Any tenderness at the lunate level? You can try a scapholunate shear test, Watson Test (scaphoid shift) to assess further. Other differential dx, besides OA could be a scapholunate ganglion or just synovitis (overuse).

  4. Hey man,

    My name’s Mark and I’m a PT in Savannah, GA. I randomly found your blog online and I really enjoy it. As far as this case I know it’s rare, however it could be some type of nonunioned fracture or perhaps AVN from repetitive trauma instead of macrotrauma such as a fall. With her history of golfing, repetitive swinging theoretically could subject the wrist and scaphoid to extensive repetitive loading which could create a problem. I’d maybe recommend imaging if symptoms did not improve after a couple weeks of therapy. I’d be curious to see how she responds the rest of the way.

    Take it easy,

    Mark

    1. Thanks for the kind comments and reading Mark! I really appreciate it and your response to this post.
      Those differential diagnoses definitely went through my mind, especially AVN. I’m going to post the 2nd part of this post next week and I’ll like to hear your feedback about what I thought and how she is doing.

      Harrison

  5. Does the pain come early in the round of golf or late? Could it be trigger points in brachioradialis. She is a student and perhaps she has been studying hard with her elbows flexed and produced a shortening adaptation? This muscle can refer pain to the snuffbox region

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