If you are just checking in to the blog, you may want to read part 1 here first before reading this post.

I want to thank everyone for their comments and differential diagnosis.  I feel everyone of them could be right on.  To your dismay, this case wasn’t one of those where something unusual popped up that was diagnosed by a PT but a case of clinical reasoning using joint function.  Read on:

How I approached this case is how I approach every case: to be able to provoke symptoms and then find a mechanical change to nullify (or at least decrease) it through either a manual approach, education, or change in the perturbed movement pattern.  The following was my differential diagnosis (read past post for many others)

Differential diagnosis:

1.  DeQuervain’s Disease (tenosynovitis).  This is an obvious answer but negative reproduction of symptoms with soft tissue resistance and (-) Finkelstein’s test.

2. Scaphoid fracture (or any other carpal fracture). Some therapists may get some type of imaging first, but I disagree.  Considering no trauma (other than repetitive, microtrauma); insult to the scaphoid itself through a fracture was very unlikely.

3. Derangement of the radial aspect of the wrist. Quite broad yes but this is the route I normally would treat.  This can be due to many reasons but most likely overuse and synovitis. See more below.

To find a mechanical change:

I was able to reproduce concordant symptoms with the golf swing.  The pain would arise sharply, but was immediately extinguished once she took her wrist away from the position.  No longstanding effect to further aggravate the symptoms.  This calmed my fears of something more serious occurring.

I decided to delve further into the distal radioulnar joint, radiocarpal joint(s) and midcarpal joint(s).  I did notice some hypomobility (I don’t use scales very often but just minute I would suggest) in the convergence of the scaphoid to lunate and scaphoid to radius.

Photo courtesy: pt.ntu.edu.tw

This data was small, but informative.  It gave me a treatment approach even though from a diagnostic standpoint, I wasn’t exactly sure to “call it”.

I felt the patient was creating undue stress and compression forces of the radial styloid process and scaphoid from a joint derangement at mostly the radiocarpal joint (but midcarpal too).  Basically, the joints were pounding against each other repetitively when she increased her playing time.  Why?  At the follow-through phase of the golf swing, her involved wrist (right hand) was entering a closed-pack position through multiple functions.  The wrist was in radial deviation, extension and pronation; all closed-pack positions or simply high congruency between the joints.  These movements, the weight of the club, repetitiveness and altered form led to pain.

Wrist position just prior to end of the follow through

This made sense to me in my head through a 3-D analysis and also background information on arthrokinematics.  Stay tuned for later in the week to see how I treated her and the overall outcome.  Feel free to leave me comments as well on your thoughts too.

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