Case of the Week 3-27-12: Chemically Irritated! | Modern Manual Therapy Blog

Case of the Week 3-27-12: Chemically Irritated!

About 6 weeks ago, the patient had an acute onset of right wrist pain around the anatomical snuffbox. What was the solution?

History: 37 yo male OMPT, uses his hands all day, regularly lifts his 3 beautiful daughters, works out 3-4 days/week. The onset was insidious, worsened with grasping and lifting. Symptoms were intermittent and rated 1-3/10. All upper body workouts were stopped for the first week, however work and lifting daughters were not able to be stopped. The symptoms were not improved after the first week. A standard wrist splint, but without thumb immobilizer was worn for 5 days of the next week. This actually worsened the swelling, caused ulnar paraesthesia, and increased the wrist pain to 5-6/10 with movement/activity. Pain now 8-9/10 at worst.


  • initially minimal edema progressed to moderate edema around right anatomical snuffbox (to the point where it became quite convex as opposed to concave
  • All wrist ROM WNL except ulnar deviation, with pain during movement
  • Severe pain up to 8-9/10 with Finkelstein's test
  • Forearm, elbow WNL, shoulder grossly limited bilaterally in IR (normal for this patient), cervical ROM WNL in all planes
  • Neurodynamic testing WNL for median, radial, ulnar nerve
  • Finkelstein's test oddly more painful with elbow flexion rather than neurally loaded elbow extension

  • First 2-3 weeks focused on treatment of the neural container. IASTM to the radial bony contours posteriorly > anteriorly, lateral upper arm, lightly around the snuffbox, upper trap, levator scapula
  • JM to the cervical spine where limited, C7-T1, C5-6, T4
  • radial neurodynamics eventually used as a treatment because Sx, function, and pain worsened over 3 weeks and neurodynamic mobility was limited for radial nerve
  • self Tx was self neurodynamic mobility, and light graded movement within the pain free range
All treatments improved Finkelstein's ROM, but not pain. The ROM improvements were transient despite extreme compliance with mobility exercises. Swelling remained the same. After 3-4 weeks of rest, manual treatment to EVERY area that could be contributing to this condition, the PT decided to do the unthinkable (for him). He decided to have a cortisone injection (which was surprisingly barely felt at all). The next day pain was 50% reduced. After 1.5 weeks, all of the swelling was gone, there was only end range mild pain with Finkelstein's and all ADLs were painfree. 

My partner stated it was scandalous for me to go to the physiatrist for an injection. This solution would be the same I would recommend to any patient who was not responding to mechanical and educational treatments. I had started to even catastrophize somewhat as it was really affected my work, I was unable to do a lot of manual treatments, and I had a hard time carrying my kids. Three weeks later, I am totally pain free, back to working out, with the exception of kettlebell snatches, which I think may have caused it on my right (non-dominant) hand.

Trust me, my partner and I tried everything that we thought a patient who presents with this mechanically could respond to. We tried treating the neural container, treating the cervical spine, rest, repeated ice, joint mobs/manip to every upper half of the body restrictions we could find. EVERYTHING was transient to no improvement. For whatever reason, I had out of control chemical irritation that was fast becoming very irritating at how it affected my work and home life. I also felt like a slob for not being able to work out regularly. Sometimes a chemical problem requires a chemical solution. That's the moral of my current story.


  1. i balk at even writing this given the fact that this is an OMPT blog and there is an obvious lack of research but a trial of ionto with Dex may have been worth a shot if you were going to visit the physiatrist anyway...

  2. Did some research on ionto and phono for my doctorate. Pretty much concluded that you're better off rubbing it in for phono, and ionto had some penetration, but it may not have been a strong enough dosage. We do not even have ionto at the clinic!

  3. Glad you are feeling better, Doc!!

  4. HarrisonvaughanptMarch 29, 2012 at 1:27 PM

    Good post here!. It does come to show us that at times, we need to go towards other advancements that have been made in medicine. I think the same as you that we all want to 'avoid' all other interventions.

    Difficult to say if ionto would have worked. I have only used it, maybe once, since practicing. I am not a big fan, and certainly not with phono or just ultrasound in general. Maybe cold laser? Do you have that?


  5. Ironically, I think it was from kettlebell snatches! I haven't revisited it because I have a difficult time with the deceleration as you flip it over the wrist on my nondominant (involved) side.

  6. It may have worked, but the dosage is so low, I would have opted for a more therapeutic dose. She told me the research and stats based on a physical exam and would have ruled out scaphoid fracture if there was no improvement. She gave me a great informed consent as well, what every good practitioner visit should be like!