If you are just tuning in, check back to part 1 and part 2 of this series to catch up.

Going through with a functional diagnosis, rather than simply a pathological diagnosis, I opted to tape the patient’s wrist in a specific, driven direction mainly because she had no pain at rest and only way I could assess my hypothesis was to tape, then get her to swing the club.

I could not find a great picture to show arthrokinematics of the radiocarpal joint with the wrist going into extension, radial deviation and pronation; but I hope you get the point with the picture below showing the need of the scaphoid volarly gliding on the radius (or the radius dorsally gliding on the scaphoid).

Photo courtesy: http://www.pt.ntu.edu.

Knowing this, I opted to tape the radius from an anterior to posterior direction (or dorsally). The patient went out back and an immediate change, no pain with the same swing.

A/P Glide of Distal Radius (note first wrist crease is radiocarpal joint, second crease is midcarpal joint)
Finished product of radius gliding dorsally.

Treatment from here consisted of seeing her 4 visits over 4 weeks:

1st week. I educated the patient to hold off on playing for an entire week (which worked well since she was going on vacation).

2nd week. The next visit (over a week later), she returned and said she had an x-ray to be sure and it was negative for any findings (just inflammation via MD). This aided in our functional diagnosis and made the patient (and parents) less concerned overall. I performed mobilization with movement applying anterior to posterior glide on the radius with active pronation and extension. Otherwise, HEP consisted of wrist flexion/extension, circles and MCP flexion/extension AROM. I educated her on an interval program to return to golf (basically try all wedges at 50% intensity and work her way up letting pain be the guide).

3rd week: Same manual program and incorporated FlexBar exercises for wrist strengthening. She was returning to her swing coach so I encouraged her to ask him of anything specific that she is doing wrong with her swing (the swing coach has a high speed camera and honestly, I am not a good golfer so wanted to ask a professional!). Interval program continued letting pain be the guide.

4th week: Patient participated in the interval program and has worked her way up to drivers without pain. She was feeling good and just wanted exercises to help strengthen her wrist (long story short, she opted to by a red and green FlexBar by TheraBand). The swing coach taught her to follow through higher up over her head, rather than across the chest. May be tough to see, but this does make sense as it decreases the amount of pronation her wrist has to have at the end of the swing. Fore!

Hands more across the chest.
Hands higher than chest

I shared this case based on a physical therapist’s ability to incorporate a functional diagnosis into practice and use of a mechanical treatment approach to help in ruling-out a more pathological reason for pain. It did help that she eventually had an x-ray but the positive change that occurred after a plausible approach simmered down probability of something more serious.

I hope you enjoyed. Thanks to my wife for letting me tape her and for the pictures of me in very hot heat here in North Carolina. Let me know what you think and if you would have done something different.

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2 comments

  1. Good Job HV! I have a similar case for elbow pain from a golfer at end range I’m going to post on Wednesday! I would suggest also, other than form, there is a reason why she even developed this pain at end range. This is what the SFMA is useful in finding out, especially in athletes. She may have thoracic, GH, hip, or tibial rotation issues, that up the chain causes her wrist compensation and closed packed loading positions. This is also why I developed DeQuervain’s when doing KB snatches on my right side, which has a restricted TC joint, hip, thoracic spine, and GH joint.

    1. Thanks E! Yeh definitely had some swing issues and more than likely had proximal involvement. I do want to take some formal SFMA courses as I have done this instinctly over the years with just naked eye observations.

      My only concern with addressing this so early on in treatment is that most of the population doesn’t understand these components so avoiding the wrist and just talking and observing proximal segments could potentially send the patient out the door. Not in this case but you know what I mean?

      I like incorporating OMPT principles to help in Dx and immediate treatment and relief; and then provide superior outcomes with the swing mechanics.

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