From Diagnostic Uncertainty to a Career in Hand Therapy: One Physiotherapist’s Wrist Injury Journey
Virtual Hand Therapy Fellowship '25/'26
Written by: VHSF Fellow | Anonymous
When I started my career as a physiotherapist in Canada, I was eager to help people return to the activities they loved. I had experienced injuries myself, including an ankle surgery as a young athlete, so I was familiar with rehabilitation from the patient perspective. Seven months into my career, I injured my right wrist (my dominant hand, of course!) and embarked on a career pivot I never anticipated.
I was doing a push-up-like movement and felt a small pop in my dorsal-radial wrist. I assumed I could rest it over the weekend, but the pain gradually worsened over the next 3-5 days. I consulted a colleague who was a Certified Hand Therapist (CHT), and I wore a wrist lacer brace for 4-5 weeks, followed by AROM, proprioception, and theraband strengthening exercises. Initially, this seemed to help; however, over the next 6 months, the pain worsened along the ulnar aspect of my wrist, and I started having a shifting sensation with activities involving supination.
I consulted a sports medicine physician who suspected DRUJ instability and recommended imaging and a surgical consult. My X-rays and SPEC-CT with contrast were clear, and my MRI arthrogram showed only very mild distal ECU tenosynovitis. The imaging reports stated that there were no bony abnormalities or evidence of Ulnolunate impaction syndrome; the SL and LT ligaments, TFCC and disc, and ECU tendon and subsheath were intact; the joints were normal; flexor and extensor tendons were unremarkable; and median, radial, and ulnar nerves were normal. My imaging was reassuring, but clinically something was clearly wrong as my pain was progressively increasing and my function was progressively decreasing.
While waiting for a surgical consult, I tried a Muenster splint for 6 weeks followed by hand therapy with a CHT. During this time, I developed shoulder pain from compensatory movements, my wrist began painfully clunking, and my right forearm and hand became even weaker, further contributing to my functional decline. By the time I saw the surgeon 6 months later, I still had full AROM, but I could not turn a doorknob, dispense soap into my palm, wipe a surface, push open a door, weight-bear through my right hand, scoop dog food, or use a hand-over-hand technique to turn my steering wheel. The surgeon suspected a TFCC tear and ECU subsheath tear and advised that post-operative recovery would take about 6 months.
During the 7 months that I waited for surgery, my hand function continued to decline, and 3 months after my surgical consult, I could no longer continue working. During surgery, the surgeon discovered that my ECU tendon was frayed into multiple strands, my ECU easily subluxed over the ulnar head with a strongly positive piano key sign, my ECU subsheath had a posterior longitudinal tear, and my TFCC had a radial-sided tear. The surgeon repaired the ECU tendon and reconstructed the subsheath using an extensor retinaculum flap, and the TFCC tear was debrided but unrepairable. I was placed in a sugar tong cast for 2 weeks with the elbow at 90o, slight wrist extension, and slight forearm supination with the fingers free. Then, I had a splint fabricated with the elbow at 90o, slight wrist extension, and full supination with the fingers free for another 4 weeks. At 2 weeks post-op, I was allowed careful elbow flexion and extension AROM while maintaining the supinated wrist position and avoiding any wrist rotation.
At 6 weeks post-op, I was allowed to begin wrist AROM in all directions. The most helpful AROM exercises for me included:
- Rolling a ball on a table into wrist flexion and extension. I found the support of my hand on the ball (closed chain) to be more comfortable and allowed me to achieve better ROM than wrist flexion and extension with my hand moving freely (open chain).
- Holding a light ball (slightly smaller than a volleyball) with both hands on either side and rotating the ball into pronation. I started with my elbows slightly bent, then as I gained pronation I gradually bent my elbows until I could have my elbows near my ribs.
I had full supination from the splint position; however, I really struggled to regain pronation, which made radial and ulnar deviation exercises very difficult.
A few weeks later, my therapist then initiated PROM and joint mobilizations at the DRUJ in an attempt to promote pronation. However, this was excruciating, brought on immediate nausea, and resulted in significant pain for 3-4 days afterwards, during which I was unable to move or use my hand. After a few sessions, I declined hands-on treatment and started researching alternative ways to promote pronation.
I was also encouraged to start using my hand during daily activities to naturally promote strength. However, my pronation was limited to 10o, so I had to compensate with shoulder abduction and internal rotation to accomplish tasks such as spreading jam on toast, typing, writing, and pouring juice.
At 3-4 months post-op, I was still struggling with pronation and end-range extension ROM, and I was having great difficulty with daily tasks. I could not hold a dynamometer to test grip strength because the device was too heavy for me to hold against gravity. As a result, I decided to return to the CHT I had seen prior to surgery, who recommended a very gradual strengthening program. The strengthening program specifically targeted each wrist movement direction separately, and this approach made a massive difference for me.
At 6 months post-op, my hand strength was improving, and light ADLs were becoming easier. However, I was now facing constant right shoulder pain from compensatory patterns related to immobilization, lack of pronation, and prolonged right arm disuse. My hand was now strong enough to hold a theraband for physiotherapy exercises for my shoulder, so I started strengthening my rotator cuff and periscapular muscles. It has taken 10 months of strengthening for my shoulder pain to nearly resolve.
Ultimately, I was off work for 15 months. During that time, I registered in the VHSF Virtual Hand Therapy Fellowship because I knew I needed to pivot my career in order to make physiotherapy sustainable for me long-term. I returned to work in a new position treating clients with hand injuries. Today, my pronation is approximately 90% of full range, and I still struggle with weight-bearing and pushing through my right hand, as well as heavier gripping and twisting activities.
When I started my career as a physiotherapist, I never imagined working as a hand therapist. As a student, I found hand anatomy to be very complex and intricate, the differential diagnoses confusing and seemingly endless, and wound care made me squeamish.
My personal experience with my wrist injury altered the trajectory of my career and placed me in spaces where I could network with brilliant clinicians I may never have met otherwise. More importantly, my injury changed the way I think about diagnostic uncertainty, postoperative rehabilitation, irritability, compensatory patterns from long-standing injuries, and the importance of listening to the patient’s experience and finding alternative ways to accomplish the same goal. Altogether, this journey has shifted my perspective, and I now see hand therapy as a fascinating and unique area of clinical practice to dive into.
