Hey all,

Matt here! Today I wanted to post another case study of an individual who had deal with pain for around 16 years. I will go into full depth into his case and how we were able to help him address the contributing factors that led to his dysfunction and chronicity over the years.

Like every case study, I was given approval to post his story (along with his video testimonial you can check out here).

For those who don't know I'm a Physical Therapist (PT, DPT, OCS, CSCS) and our team has spent the past decade specializing on treating, researching and publishing our work around treating RSI (we've helped more than 3000+ individuals resolve their issues without surgery, more injections, resting, bracing etc. Here is some of our work (we started with the olympians of desk work - esports athletes)

Journal of Orthopedic & Sports Physical Therapy

Tendinopathies in Gaming

Conditioning for Esports (Ch. 8,9,10)

Science of Esports Physical Therapy

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Brief Overview

Julian spent 16 years trying to fix his hands. He saw multiple doctors and specialists. Tried occupational & physical therapy. And through all of these he also tried every device he could find: a vertical mouse, a foot mouse, dictation software (we'll go over some of this later). He even tried seeking AI (ChatGPT) to get some guidance.

Throughout the years and visits every MRI came back normal. Every EMG came back normal. Every specialist told him some version of the same thing: "We don't know what's wrong” and kept him a loop of care that never yielded any results. At his worst, Julian could not hold a mouse for five minutes.

Julian is a trader and lifelong gamer and over the years of dealing with his wrist pain he saw his ability to work and play games steadily disappear. He was pretty hopeless after this many years of dealing with his wrist & hand pain.

This is when he came to us and with 16 weeks of hard work and commitment to understanding what led to his level of functional limitation (physical, mental, lifestyle related) he was able to get back to full function in 16 weeks. In this time Julian went from full dictation with NO mouse use to a full day of work with the mouse and six-hour gaming sessions (same day).

I'll do my best to help you understand how we helped him achieve this.

Clinical History & Relevant Information

Julian is a full-time crypto trader. His entire workday is spent at his PC for trading, researching and monitoring his positions. On top of that, he is an avid gamer who would spend several hours after work gaming.

His daily schedule at intake looked like this: 8–10 hours of PC use split across trading and gaming, with walking as his only physical activity (ONLY DICTATION)

The pain started gradually and spread. By the time Julian found 1HP, he described it as pain "from my fingertips down to my forearm on both arms in a dozen different spots." He could not point to a single trigger. This is important to point to as we get into the later sections around sensitization. The pain was moderate to severe every day, with limited moments of relief.

Over the 16 years that Julian had dealt with the pain he spent more than $15,000 going throuhg the full gauntlet of traditional care. He saw a hand specialist who ordered X-rays and an EMG (which both came back negative). He had an MRI which was “normal” and after all of these his specialist’s only options were to try pain management and cortisone shots (he declined).

During this time he also attempted two courses of physical therapy which had caused him too much pain to stay consistent. He would perform them for a few days and felt an increase in symptoms. During these moments he was never...

• educated on how how to best respond to any increase in symptoms.
• How to determine what is actually irritating tissues or what is actually considered strain. Because of this every “flare up” would lead to resting for a week and repeating the cycle.

Ultimately after trying everything he became fearful of using his hands, adopted alot of avoidance patterns and was not able to use his hands at all. This is when he found us on reddit.

The Assessment: What Was Actually Going On

Here is what we found after our initial full clinical assessment to understand everything about his injury. We explored pain regions and behavior, complete medical history, his daily activity patterns, his ergonomics, understanding of pain and our standardized endurance test

Pain Regions: Bilateral wrist and hand pain (right dominant), extending into both forearms. Thumb involvement bilaterally. Pain at a dozen different sites, with no clear single diagnosis from prior providers.

Baseline Endurance Test (Right Hand):

• Wrist Flexion: 26 reps at 1.5 lbs, 1.1% of his bodyweight before pain onset (FCU involvement)
• Wrist Extension: 24 reps at 1.5 lbs
• Thumb Flexion: 25 reps before pain

For someone spending 8–10 hours a day at a computer, this was a significant deficit. His muscles simply did not have the capacity to handle what he was asking of them.

https://preview.redd.it/kry215q8bzjh1.png?width=393&format=png&auto=webp&s=cfdc869e297886af81482d802cea83eb3aed7a49

Overview of Pathomechanics, Baseline Endurance Test & Functional Deficits

The Fear-Avoidance Component

Julian was stuck in a classic fear-avoidance loop that developed as a result of his experiences with healthcare and what he had been exposed to online for 16 years. Every time he tried to push through, the pain spiked. So he stopped. He rested. He avoided. His hands got weaker. The next time he tried, the pain came back faster. He rested again. And the cycle continued, year after year.

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He had tried at-home exercises multiple times. But because he had no guidance on how to dose them, he would do too much, flare up badly, and stop for a week. And again he was NEVER educated on what his pain meant, what was actually too much and why it can be normal sometimes to feel an increase in symptoms. This led to an inconsistency in how often he performed his exercises (often also prescribed with too low overall volume) which also meant he never built any real capacity.

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These repeated cycles were a result of 16 years without any clarity from any healthcare providers about

• What is actually going on with his wrist & hand
• Why certain interventions will allow him to begin to use his hands more over time. Not just reduce the pain
• How to understand what he is feeling in response to the exercise and load-based interventions at various stages.
• Why it is normal for him to feel pain considering his poor endurance and overall lifestyle
• What it meant for his pain to spike in response to specific activities but also considering his entire clinical picture (conditioning, sensitivity, lifestyle)
• many other important aspects of recovery that need to be understood to make progress.

This lack of clarity and understanding led to maladaptations in his nervous system. His brain had learned that hand use equals danger. And of course his directed experiences of rest and passive interventions would reinforce this. Every time he tried to use a mouse again he would feel pain that would last for hours to days. Even lower loads of wrist & hand activity were being interpreted as threatening. This is called central sensitization. We have covered this endlessly in our content and to be clear

it is not "just in your head."

Real neurological changes occur when pain persists for this long without resolution.

His fear of re-injury was not irrational. It was a learned response to 16 years of failed treatments and no clear answers. But it was also the thing keeping him stuck. This was an essential cognitive pattern we had to address.

The Recovery Plan

Julian’s program was focused on

1. Addressing his limited endurance (20-30% of what was considered normal for his bodyweight)
2. Improving his understanding of pain to better reprocess his pain experiences

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Phase 1: Building the Foundation (Weeks 1–4)

We started conservatively with his exercises (specific to Julian, may not be conservative for others depending on their starting point). Three sets of 12–15 reps for wrist flexion and extension, targeting the specific muscles that were failing him. We kept the load light at the 1% of bodyweight and focused on consistency over intensity.

The key instruction: some discomfort during exercise is normal and expected. It does not mean damage.

This is likely the sticking point for many individuals when they try load based program. Without an understanding of pain it can feel scary to feel “safe” or understand that you aren’t damaging anything when you feel an increase in symptoms after performing some exercises challenging your endurance.

It was absolutely NECESSARY to teach Julian how to distinguish between the pattern of sharp, alarming pain with associated weakness of true tissue strain and the dull, achy discomfort of muscles being asked to work harder than they are used to. This is not EASY to understand and took consistent education and reassurance based on REAL evidence (normative values & sensitization established through the fear avoidance component scale).

We also addressed his how he was managing his overall schedule. During his work periods he would have no structured breaks for a duration of up to 10 hours of PC use. We gradually exposed him to more overall load that we knew he could handle each week. Starting with 75/25 (Dictation / typing) to 50/50 with movement breaks.

Phase 2: Progressive Loading (Weeks 4–8)

As Julian saw progress it helped motivate him to stay consistent with his programming. Since day 1 Julian committed to every aspect of the program from the high exercise volume to the daily and weekly pain reframing work. This was a large reason why Julian was able to make such great progress throughout this phase despite his long-standing chronicity.

By week 4 Julian was tolerating the exercises well which allowed us to progress him to 3 sets of 20–25 reps and increased the extension load to 5 lbs. We added thumb-specific exercises using a variable-resistance finger device to target the functional strength he needed for gaming and trading. The combined reps across the prescribed for each of the muscle groups were up to 240 PER DAY.

Yes, this sounds like a lot but with the lower % bodyweight and focus on endurance Julian was able to handle this and promote faster overall adaptations to his endurance. Keep in mind that this volume is NOT what everyone can handle but is only representative of what Julian’s specific case, history, understanding of pain, tolerance to discomfort and other environmental variables allowed him to handle. For everyone we work with we have to establish the volume that works best considering these specific variables and continually modify based on the response to that volume (for others it can be once a day or once every other day to start depending on their status)

By week 7, Julian completed a 4.5-hour gaming session which was something he had not been able to do in years. This was a major accomplishment for him after years of not being able to use his hands to actually game.

We also introduced conditional deloading during more aggressive pushes. After any day where we pushed the overall activity, due to the increase in real load we intentionally reduced the load the next day by 30-40% to allow adaptation (physically and mentally).

In many cases fear holds individuals back more than the actual physical capacity. (Fear in the form of increased symptoms as an individual plays longer, AGAIN WITHOUT ANY REAL STRAIN OR DAMAGE TO TISSUES).

Phase 3: Reintegration & Self-Management (Weeks 8–16)

By week 8, Julian was typing 3–5 hours per day and gaming 3–4 hours with manageable symptoms. As he developed more overall confidence in the hands we also shifted focus to building his overall conditioning by integrating walking 60–90 minutes daily, general strength work, and gradually expanding his activity tolerance.

The goal in this phase was to continue to help him build confidence in using his hands for more overall activities and show himself (and his brain) that he has built the capacity to handle more than he realizes. Graded exposure with integrated cognitive behavioral therapy helped to ensure Julian knew how to better process any symptoms as he introduced more activity.

It was important for us throughout this process to work on his response to flare-ups. In week 8, Julian had a pain spike after a longer gaming session. (cognitive behavioral therapy & other pain reprocessing exercises). In the past for Julian this would have meant a week of rest having to “stop gaming” for an extended period of time.

Instead through everything he learned and our cumulative work in building confidence in using his wrist & hands, he recognized it as an elevated symptom not a setback.

He was able to reflect appropriately to determine the actual variables that led to the increase in symptoms (a sharp increase in the volume of his gaming over a short period of time) and continued his program. With relative deloading while STILL doing the exercises, the pain resolved within a few days.

This was a milestone during his recovery because it showed him that his response and understanding of pain was crucial in helping him better navigate the natural ups and downs with recovery.

Pain Science Education

https://preview.redd.it/hnzbcthdczjh1.png?width=782&format=png&auto=webp&s=3170c5f876b7b7429a95884922541f741b2f18ee

Alongside the physical programming, Julian worked through our pain science curriculum (partnered with a researcher to build a course specific to RSI injuries). The module on fear-avoidance was the one that really helped him better understand how to respond to pain.

"Learning how to respond to pain was the big thing. I would always think, 'Oh, I'm feeling pain, let me stop.' After going through the module on pain and the fear-avoidance response, I realized… okay, I'm not damaging myself just from feeling pain. It's okay to continue with my activity, and I'll be fine.”

This shift in mindset… from "pain equals damage" to "pain is information, not a stop sign" is what allowed Julian to stay consistent for the first time in 16 years.

The Results

Let’s go over how he did in the latter part of his recovery. Remember he had been struggling for 16 years with this issue.

By week 12, Julian reported approximately 90% recovery. Occasional aching after prolonged activity or on waking but nothing that limited him.

By week 16, Julian was completing 3 sets of 20–25 reps at 7 lbs for wrist extension and flexion, with rubber band exercises at 3 sets of 30 reps. He was gaming 4–6 hours per day. He was working full days as a trader. He was using a mouse without a second thought.

https://preview.redd.it/ypbksi9nczjh1.png?width=931&format=png&auto=webp&s=1c96638f2d749c6c488a563642f64c9ac6e054f0

https://preview.redd.it/wji4o0coczjh1.png?width=805&format=png&auto=webp&s=1defa0d55ae804f4122aeb191cef2f40e4d1ebf0

In his own words: (see video testimonial)

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I wanted to include this quote for a reason. Julian at 16 weeks was able to handle EVERYTHING he wanted to functionally yet on only SOME days he did have some pain, not all days. The frequency of this scenario was reducing gradually over time but what was more important was his shift in his mental model of pain.

Our goal is actually NEVER just to “get rid of the pain.”

Yes the pain will go away eventually with higher volumes of activity but the goal with our work is actually to help individuals recognize that pain is actually a normal part of the human experience.

When you consider all of the variables around any time where you feel pain, you can determine why it makes sense you would be feeling some level of discomfort.

If you got back to doing everything you wanted then tried bowling 3 days in a row, 4 games each on those days with a 10 lb bowling ball it would make sense that you would have some soreness in the forearm.

You would not think “oh my injury never healed” but rather “it makes sense that with the amount of physical load I placed on my hand, my body couldn’t handle that.” This mental shift IS the goal. And this only represents a scenario around increased physical load. Stress, poor sleep, high occupational stress can also lead to increased symptoms. This is why we work together over the course of recovery to expose the individual to more overall physical load situations but real increases in activity and environmental stressors (naturally as they get back to work or start work) to understand how to best respond to those situations and feel safe.

>"The first couple times I was able to play for six hours and wake up the next day with minimal pain and when I did feel pain, my response to it was different. I was able to continue the next day as normal, as opposed to falling back into that cycle once again. That gave me a lot of confidence and hope."

Key Takeaways

There are so many things you can take away from this case study. And i’m sure depending on your own individual circumstances one may be more meaningful than another. Here are some of the larger lessons you can takeaway from Julian’s case

Normal imaging does not mean nothing is wrong.

Julian's MRIs, X-rays, and EMG all came back normal. That is actually very common with chronic tendinopathy and sensitization. The absence of a structural finding does not mean the pain is imaginary. And in many cases physicians do not know how to help you actually understand why you may still be in pain or functionally limited.

This is often what creates so much anxiety and stress around results and how you are feeling after being told you are “normal”. Your pain is REAL and there is ALWAYS a reason for it whether it be the physical, mental or environmental stressors. Being able to work with someone who can provide you this clarity only after assessing EVERYTHING is how you can feel more safe in using your hands more over time.

This is also why all of the interventions directed at the “tissue” even when nothing is wrong still does not help and often can make things worse as the continuous rest cycles can lead to deconditioning but also reduced self-efficacy. This leads to the the next big takeaway

Avoidance is not rest. It is deconditioning.

Every time Julian stopped using his hands to "protect" them, he was making the problem worse.

Tendons need progressive stress to adapt and handle more repetitive stress over time (endurance). When we continually avoid activity and load the tendon has been consistently shown to weaken and have altered structure. But as we highlighted throughout this case study this can also lead to more sensitization through

• Increased fear of pain and damage with certain patterns of symptoms
• Reduced self-efficacy or belief that you can use your hands for daily and functional activities
• Anxiety around what is actually causing the problem since no “solutions” have been able to help with both function and pain
• Repeated past experiences of elevated pain reinforcing the belief that using hands for a certain period of time is “dangerous”

The goal is NEVER to rest but to find ways to load appropriately for both your physical and mental curls.

Consistency beats intensity every time.

Julian missed at most two days of exercises over three months. This was 190 days sessions of his exercise program which often involved the 120 reps per muscle group per day all the while increasing the overall resistance and reps over time.

This discipline and consistency (not just the physical and mental exercises) was what drove the main results. This is NOT easy to do but I cannot emphasize more how important it is to fully commit on the understanding of why you can perform a certain amount of repetitions for your specific case AND how to understand your symptoms as you increase activity and exercise.

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I’ve repeated this multiple times throughout the case study and all of our other pieces of content but i’m hoping it is clear that your response to pain.. can change.

The pain response is trainable.

Julian did not just fix his hands. Through consistent work to better understand pain and why his symptoms would be elevated in certain scenarios he was able to rewired how his nervous system responds to discomfort.

This is the part that makes the results last. Without changing the fear-avoidance pattern, the physical improvements would have been temporary. Without understanding why you are safe despite certain levels of pain it can make it difficult to make progress as you push with your specific activity that may be associated with pain.

Through his disciplined effort and collaborative work to help him reprocess certain scenarios with elevated pain throughout his recovery he was able to build a better internal framework for managing musculoskeletal / orthopedic issues for the rest of his life. I want to emphasize here that this takes time for every individual. But it is something that NEEDS to be addressed for long-term lasting recovery and better overall quality of life in response to pain.

If you got all the way down here, I appreciate your taking the time to read through this and hope itw as helpful in some way. Feel free to let us know if you have any questions around anything relating to this case.|

And remember Julian came to us after 16 years and $15,000 in failed treatments. He was skeptical. He did his research. And once he committed he was able to show himself he could get back to the life he thought was impossible to have again in 16 weeks.

Hope this helps anyone that is struggling. It's possible but it takes actually addressing the underlying physical, cognitive emotional and lifestyle components that lead to continued sensitization of pain and functional limitations.

Best,
Matt, PT, DPT, OCS, CSCS

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Resources:
1-hp.org
2 hour Compilation of everything we have learned treating over 3000+ individuals with wrist & hand pain
Apply to work with us

Hey all, Matt here from 1HP.

If you are a software engineer, gamer, or office worker who has had wrist pain and visited several doctors without getting any real answers, you are not alone. And it is not entirely your doctor's fault. The system they operate within is not designed to adequately assess and nor fully understand why you may have developed or continue to struggle with repetitive strain injuries.

If you are here it is likely you have already had this suspicion over the past few months of going through the revolving door of physicians, specialists and MSK providers.

A diagnosis is typically given after only a 10-15 minute assessment. And treatment is provided based on 15 minutes of gathering information. This is NOT enough to fully understand your relevant medical history, current physical activity and conditioning profile, work and hobby habits leading to increased load on your wrist & hands, posture / ergonomics, understanding of pain and more.

And then after this assessment they should have at least another 10-15 minutes to help you understand what it means within the context of your life. This does not usually happen. Based on the past decade of clients we have seen, the depth of these initial evaluations varies significantly, often restricted by time constraints and a genuine lack of specialized musculoskeletal training.

I have written before about the idea that we have to be accountable for our own health, and we should expect a certain standard for what a healthcare visit should look like for your wrist and hand.

What the Typical Doctor Visit Actually Looks Like

Let us use the common example of palm-sided wrist pain. When you go to your primary care physician, they might ask a few basic questions about your pain, whether you have numbness, and inquire about what you do that makes the pain worse. In many of the patients we have worked with, the questions stay at that surface level of depth. They might support this with a few clinical tests like Phalen's Test or a validated questionnaire.

This might seem like a comprehensive workup. But all of these are focused on nerve-related pathology or inflammation-based pathology. If you have seen some of our content before around the misdiagnosis of carpal tunnel syndrome, then you know the current evidence best supports a non-inflammatory model of pain for tendon issues. If not, i’d encourage you read the article written by Elliot to further understand the first principles physiology of why carpal tunnel syndrome is so often misdiagnosed.

If the physician only understands how to evaluate for nerves and inflammation, that is all they will be able to diagnose and treat. Hence the recommendations for rest, braces, and medication that seem to have such low efficacy for this population.

Very few physicians will ask the appropriate questions that inquire more about muscle or tendon-based symptoms.

• They are not asking about your pain at rest versus with activity.
• They are not asking about your pain level after stopping the activity which is a critical indicator of tissue irritability.
• They are not asking whether the pain actually improves with a certain level of movement.
• They often do not actually evaluate the status of the muscle or tendon outside of passive resistance. (Putting your hand in certain positions). There is no endurance testing during your primary care visit and most physical therapists are only learning how to test for endurance through our research and publications.

These questions & objective tests matter enormously for understanding what is going on, and they are almost never asked or performed

Why Is the Assessment So Minimal?

Why does the healthcare system designed to help people fail so consistently when addressing repetitive strain injuries? It can get quite deep but here is an overview of three problems that actually connected

1. Poor Medical Education on musculoskeletal issues
2. Insurance incentives that restrict Time
3. Fragmented Referral system with poor communication between providers

The MSK Education Gap in Medical Schools

Despite the fact that musculoskeletal disorders account for approximately 30% of all primary care visits, medical education devotes remarkably little time to them. Research published in BMC Medical Education shows that many schools devote less than 3% of their total curricular time to musculoskeletal medicine and more than half of that time is spent on anatomy, not clinical assessment or rehabilitation. Only about 15% of allopathic medical schools require a practical rotation in musculoskeletal medicine.

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The consequences are clear. Studies show that greater than 50% of practicing physicians fail to obtain a passing score on a standardized basic competency musculoskeletal examination after graduation. This is not a failure of individual doctors, but is a result of a systemic failure of training. When you walk into a primary care office with chronic wrist pain, you are often being evaluated by someone who has extremely limited clinical instruction (estimated to be less than two hours) on the topic. So you show up to the office and are evaluated by a physician who may not have the competency to adequately assess and treat you. Then insurance influences the amount of time they take with you.

Insurance Incentives and Time Constraints

It is unfortunate but many physician visits are relatively short. And this is especially true for specialist visits (orthopedic surgeons). Shorter consult time is often driven by the reimbursement model of the specific insurance.

Because of this many clinics limit the overall amount of patients who hold certain insurance plans as their reimbursement may not be as lucrative (this is the reality of the business of healthcare). The more they see with these types of patients, the more they can potentially make.

Here is an example taking California & insurance reimbursement based on the type of code used by the physician. (Codes are used for a certain type of patient). When it comes to chronic wrist & hand pain they can be considered higher complexity patient visits.

The difference between medicare and BCBS/anthem can be $210.68 / 173.73, respectively. This is a 17.5% difference. Again this is not for all types of cases but for a specific code that is billed from the healthcare to illustrate the example (5-8). This type of reimbursement structure promotes VOLUME of patient care and also business-incentivized preferential care to individuals with certain types of insurance. This has NOTHING to do with what the doctor’s prefer to do when it comes to treatment. They all WANT To help to the best of their ability but with limited understanding of MSK and the insurance system…

I’m hoping you can understand why so many people come to reddit to ask questions about their issues OR have a poor understanding of why they are dealing with their issue.

Again..when a doctor only has 10 minutes to evaluate you, they simply do not have the time to understand your daily activity in depth.

They cannot assess your workstation, your posture, or the specific breakdown of your typing versus mouse usage. They cannot run through a thorough physical examination of your wrist, forearm, and shoulder girdle. The system rewards volume, not depth.

Lastly let’s talk briefly about the fragmented referral system.

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The Fragmented Referral Pipeline

Because general practitioners are pressed for time and lack specialized musculoskeletal training, they often refer patients out to specialists. This is what we want to happen because of what we mentioned above.

But when this happens many of our patients describe getting stuck in the referral cycle. You might be sent to an orthopedic surgeon who orders an MRI, or to a neurologist for nerve conduction studies. Each provider sees a slice of the problem. No single provider is looking at the complete biopsychosocial picture of your health (your sleep, your stress, your activity levels, your movement patterns, your ergonomics). They ALSO do not have the time for this due to the insurance reimbursement models.

This creates scenarios in which diagnoses are made when only certain systems are assessed (neurology, rheumatology, musculoskeletal) and some not even to the level that needs to occur (again 5 minutes) that can create a lot of harmful beliefs, fear and lowered self-efficacy in patients.

You just believe there is something wrong that no one can figure out. Or that you are your diagnosis of degenerative tendinopathy and will forever deal with it. This is factually NOT true. And not only the first principles understanding of physiology, current research on tendon rehab and our own clinical experience thousands of individuals get back to using their hands again supports this FACT.

You can see the fragmented healthcare system in action through the recent case study I posted with Amy.

What a Good Evaluation Should Actually Look Like

Proper screening means actually looking at all of the possible contributors to your pain. This includes posture, ergonomics, lifestyle, physiology, and psychosocial factors. The provider should be asking detailed questions about how the pain behaves across the full arc of your day

Pain and Disability Drivers Management Model for Rehabilitation

I’ve actually written a comprehensive thread on what a proper screening should look like here.

Tendons can actually improve with a certain level of activity, provided it does not exceed the capacity of what they can handle.

Performing resisted testing of the wrist and finger flexors can better help identify if there is muscle or tendon involvement. Layering this with a standardized endurance test on the specific muscle-tendon complex can help establish a clear baseline of physical capacity.

Understanding how much you are using your PC and phone, and the specific activities that influence your pain, guides the provider in telling you exactly how much you can modify in the early stages of recovery…rather than just telling you to stop entirely.

This is the difference between a provider who understands repetitive strain injuries and one who does not**. One gives you a path forward. The other gives you a brace and a follow-up in six weeks.** If you want to understand what a thorough evaluation should look like, again check out our article here

I really hope this provides some more clarity about why we share so many resources around recovering from chronic wrist & hand pain. We have done all of the researched, helped thousands and continue to publish content to help not only providers but anyone struggling with persistent wrist & hand pain understand more about what they can do. You can learn more about the exact system for how we work in this video here!

Otherwise check out all of the threads I’ve posted previously in my profile to learn more (or our youtube).

Best,
Matt, PT, DPT, OCS, CSCS

--

Resources:
1-hp.org
2 hour Compilation of everything we have learned treating over 3000+ individuals with wrist & hand pain
Apply to work with us

References

1. Peeler J. Addressing musculoskeletal curricular inadequacies within undergraduate medical education. BMC Med Educ. 2024 Aug 6;24(1):845. doi: 10.1186/s12909-024-05849-6. PMID: 39107718; PMCID: PMC11304564.

2. Wang T, Xiong G, Lu L, Bernstein J, Ladd A. Musculoskeletal Education in Medical Schools: a Survey in California and Review of Literature. Med Sci Educ. 2020 Oct 30;31(1):131-136. doi: 10.1007/s40670-020-01144-3. PMID: 34457873; PMCID: PMC8368391.

3. Benítez TM, Cichocki MN, Jin W, Seyferth AV, Wang L, Chung KC, Sears ED. Inappropriate wrist MRI: did guidelines have an impact? Am J Manag Care. 2024 Mar 1;30(3):e65-e72. doi: 10.37765/ajmc.2024.89517. PMID: 38457824.

4. Satterwhite S, Nguyen MT, Honcharov V, McDermott AM, Sarkar U. "Good Care Is Slow Enough to Be Able to Pay Attention": Primary Care Time Scarcity and Patient Safety. J Gen Intern Med. 2024 Jul;39(9):1575-1582. doi: 10.1007/s11606-024-08658-1. Epub 2024 Feb 15. PMID: 38360962; PMCID: PMC11255151.

5. CMS Evaluation and Management Services Guide

6. Public BCBS/Anthem CPT 99215 benchmark; commercial rates are contract-specific

7. Blavin and Holahan, Commercial Prices Relative to Medicare, JAMA Health Forum, 2025

8. MedPAC March 2026 Report to Congress, Chapter 4 (to determine rates, etc.)

This is a case study that highlights the frustrating experience that often occurs with the traditional healthcare system.

And why it can often lead to persistent pain. Here’s my case with Amy (and the full testimonial of her describing her experience with healthcare I'm sure many can relate to)

The work comp doctor told Amy she had carpal tunnel syndrome.

But the EMG came back normal.

The nerve conduction study came back normal. The hand surgeon told her, "I just do surgery and injections. There's nothing I can do."

After nearly a year of being passed from specialist to specialist with no answers, Amy ended up still in pain, confused, and started to lose hope. This is not an uncommon experience and more often than not it is the norm. If you are on this subreddit and you have been through several doctors, specialists, had normal imaging and have no idea why you might still be dealing with discomfort. It’s actually not your fault.

Our healthcare system is fragmented, inefficient and in its current state is unable to consistently provide the best care for individuals who are dealing with RSI. Now I’ve written about this full depth in several articles you can check out here

1. How the healthcare system can delay recovery
2. What does a proper screening look like and what is missing from traditional care
3. How do repetitive strain injuries actually occur?

Here’s the TL:DR. Due to the insurance and reimbursement system (and fee for service) it creates more of an incentive for physicians / specialists to maximize patient load leading to less overall time with their patients. While they may have the best intentions between 5-15 minutes is not enough to adequately assess an individuals complete history and establish a complete profile of their physical conditioning (see article 2). This leads to diagnoses and interventions that are made based on LIMITED information. And as many might have already experienced interventions often focus on the symptoms, rather than the actual cause.

So for this thread I wanted to share more about how we actually helped someone who had struggled through this frustrating ping pong experience of the healthcare system for an entire year with her condition WORSENING and was able to get back to full function in 12 weeks.

Here is exactly how we helped Amy get out of the frustrating loop of pain chasing interventions, eliminate her nerve pain, and get back to using her hands again with work, her daughter, and the activities she loves.

Clinical History & Relevant Information

Amy (late 30s) is a fiscal specialist in accounting. She spends her entire workday at a PC, with heavy mouse use accounting for about 70% of her activity. She reported that the pain started gradually, initially thinking it was from repeatedly picking up her 4-year-old daughter.

Over a year Amy went through the traditional healthcare process, starting from workers comp. She received an ergonomic assessment, went to physical therapy (focused on passive interventions like massage, ultrasound, paraffin). None of these helped with her pain.

A physician prescribed gabapentin and muscle relaxers. Four weeks later nothing had changed. An occupational therapist gave her ulnar nerve glides that brought the nerve pain down temporarily, but once it improved, she was discharged. Slightly less pain but no improvement at all in her ability to use her hands. She actually felt like she could do less.

By the time she found 1HP, she was checking in on her pain 100 times a day, catastrophizing about whether she would ever find the right help, and got to the point of heavy avoidance with hand use.

"I had been going to see all these specialists, and I was honestly getting depressed."

"Am I going to have to live with this my entire life?"

Watch her discuss this frustrating experience here

The Assessment: Establishing the Source of her Pain

Let’s start by describing what she was dealing with. After a comprehensive clinical exam and deep dive into her history here is what we found:

https://preview.redd.it/eb1b6z438nah1.png?width=403&format=png&auto=webp&s=4284d176519ab9058d6a4c6f48b295f3f5dd2581

https://preview.redd.it/r3ywgce48nah1.png?width=698&format=png&auto=webp&s=4f34d9c5b110706638a3577ef58af653f98825c9

When we started working with Amy she was stuck in a classic fear-avoidance loop. Because her pain was so easily triggered, this created fear from using it too much. Experiences in which the pain increased in response to more attempted activity also further supported this fear.

Her self-management strategy consisted of avoiding using her hands, wearing a counterforce brace, and doing the occasional nerve glide. She had no forearm support at her desk and was working through 8-hour days with almost no breaks.

This kind of approach provides temporary relief but never builds lasting capacity.

On our standardized endurance test, Amy could only complete 30 reps at 4 lbs for both wrist extension and wrist flexion. This was a significant deficit for someone spending 8+ hours per day at a computer. She had limited mobility in her wrist & hand and both the median and ulnar nerve showed mild tension signs with testing

On top of this we assessed her overall limitations in function & fear avoidance with validated questionnaires.

• Her QuickDASH score at intake was 61/100 for core function and 75/100 for work-related tasks. For context, a score of 0 means no disability. She was starting from a high baseline of dysfunction.
• Her Fear Avoidance Component Scale score at intake was 68/100 which indicated high fear avoidance. Scores ≥50 indicate significant psychological barriers to recovery and predict poor treatment outcomes.

This was the other component to Amy’s presentation: central sensitization.

For months Amy had been living with unexplained pain, failed treatments, and doctors passing her around without clear answers. Combining this history with a high-stress occupation and the physical demands of raising a young child, her nervous system had adapted to be on high alert.

Her pain and her anxiety had formed a feedback loop that was amplifying everything. Remember it is not just "in her head." Real neurophysiologic changes occur as a result of us dealing with pain for extended periods of time and fear-reinforced pain experiences.

"I worry about my painful medical condition. Will I find the right help? Will the nerve pain ever go away even if my tendon pain goes away? Are my nerves damaged?"

These thoughts and patterns of thinking might not seem harmful at the time. But over time it can lead to real changes and reduced self-efficacy during recovery.

To help Amy fully resolve her issue we didn't just need to improve her tissue's capacity. We needed to help her understand more about pain, retrain her nervous system, and learn how to reappraise her pain.

How I helped her build endurance and confidence

The two main areas of focus for Amy's recovery were: targeted endurance training for the forearms, and pain science education to interrupt her anxiety-pain cycle. We’ll start with the how we approached the lack of endurance.

Improving Her Forearm Endurance

Amy was provided with a progressive endurance routine focused primarily on her wrist and finger flexors and extensors. If you have tried exercises before and it didn’t work here is wehat you need to understand:

Exercise selection is important, but how they are performed (sets, reps, frequency, load) needs to be specific to help achieve specific adaptations. If you are only doing 2 sets of 8 repetitions 2-3x/week. That is NOT enough to build endurance to improve your ability to handle more stress. ANd at most it makes very minimal gains over time.

Over 11 years we have tested a multitude of protocols and have developed our own to ensure the fastest overall outcomes. This means not just the prescription but strategies to progress, regress and be considerate of loading cycles for the tendons at various stages of recovery (4, 6, 12, 16 weeks in)

Every exercise is performed to a standard cadence to ensure slow, controlled time under tension.

We worked closely with Amy to track her reps, fatigue, and response to exercise, monitoring her progress so we could adjust the prescription over time.

https://preview.redd.it/gsld7hz88nah1.png?width=565&format=png&auto=webp&s=5dad35a1fc91c9208a341e794dce68ec05be6bc6

These are the exercises she started with. Most of the exercises were started at 3x12-15 4# based on on her initial assessment.

Additionally, we made changes to her ergonomics. Specifically we addressed the lack of forearm support during her long hours of typing and mouse use. While this was a small change, it meaningfully reduced the cumulative load on her extensors throughout the workday.

With every single one of our patients, we communicate the expected recovery timeline based on their presentation: 40–50% improvement in 4–6 weeks, with greater than 80% improvement around 10–12 weeks. Tissue adaptation takes time, and setting realistic expectations is part of the treatment.

Pain Science Education & Reprocessing

Helping Amy understand more about pain led to the necessary reframing of her symptoms and a deeper understanding of how her occupational demands, past experiences, beliefs, and fears were all contributing to her pain experience.

Amy made significant early process during our work together and can be credited to how deeply she engaged with our pain science curriculum. She had let me know that she treated it almost as if she was back in school again….

Printing out the transcripts and taking notes during the course which allowed her to reflect on her own experiences that matched with what she was learning. In early conversations after learning more about pain Amy learned that her brain, heightened by stress and the lack of a clear understanding from traditional medicine, was creating an internal image of pain that was disproportionate to what was actually happening in her tissues.

One of the most powerful shifts was her rewriting of her own beliefs about pain. She came in believing: "If I'm in pain I should avoid all activity." She left understanding: *"There is a reason why I might have increased pain right now. Let me figure out what may have led to the increase in pain.

If it is due to my activity, I should modify activity but resume a lower level of activity and then gradually increase back to original level."*

She also came in believing that "pain means damage." She left understanding that "pain is a protective response" and is "influenced by multiple factors."

Through our meetings and research / metaphors presented in the course I was able to help Amy become more aware of her negative thought spirals and learn how to better respond to them.

She learned to step back, assess her actual load, and recognize that the nervous system was amplifying a signal that didn't require alarm. “My body is being overprotective, I can safely continue”. This allowed her to feel confident in safely continuing to use her hands without fear of making things worse.

And when she continued…DESPITE FEELING PAIN. She was able to show herself that the symptoms stayed the same… and over time, got better. This is the pattern associated with a reduction of sensitization.

Helping her better understand pain and appropriately load in response to her changes in symptoms was an essential part of recovery

What she was able to achieve over 16 Weeks

Amy had been dealing with her pain and limited function for nearly a year with no clear answers as to why it continued to persist despite multiple providers, specialists, and interventions. Here is an overview of the progress across each domain that we focused on (physiology, cognitive emotional, function)

Exercise Progression

Amy started at 30 reps with 4 lbs for wrist extension. By week 5, she had progressed to 58–60 reps at 4 lbs — hitting her rep target. At that point, we increased the load to 6 lbs and reset her reps, and she climbed back up to 58–60 reps at the heavier weight by week 10. She completed 113 sessions of wrist extension and 114 sessions of wrist flexion over the course of her program. That is the kind of consistent, progressive work that actually builds tissue capacity.

How she progressed with her exercises

QuickDASH Outcome Scores

The QuickDASH is a validated outcome measure for upper extremity disability. Lower scores mean less disability. Amy started with a core score of 61/100. By week 7, she was at 16/100 — a 74% improvement. Her work score dropped from 75/100 to 0/100. That means she went from significant work-related disability to reporting zero work-related limitations.

And on our last call everything was at 0.

Functional Capacity Changes

Fear Avoidance & Confidence in Using Hands

One of the ways that we assess progress in addressing the cognitive emotional aspects of pain is through a validated questionnaire that explores their beliefs, worries and overall anxiety around their condition.

A score > 50 typically indicates fear avoidance and kinesiophobia which has been shown in the research to be associated with those who are in chronic pain (essentially representing central sensitization).

https://preview.redd.it/hflt0fzl8nah1.png?width=631&format=png&auto=webp&s=83020486ca1c8ad6bd5c628e1a92e595ef050f48

This was where she started. 68/100 suggesting psychological barriers to recovery, higher catastrophizing and clear avoidance patterns leading to deconditioning. When we finished working together she was at 0.

We achieved this through what we mentioned above. We taught her more about pain. We gradually increased activity based on her capacity. We helped her understand how to attribute and reframe increase symptoms during the graded exposure. This helped her develop more confidence and gradually resolve her fears around using her hand with specific activities. Specific experiences like being able to pick up her daughter, push her daughter on a swing help and use her hands more around the house allowed this confidence to cumulatively develop.

Week-by-Week Clinical Highlights

Here are some of the week to week highlights over the course of recovery.

By Week 2, Amy had one difficult day where heavy Excel work pushed her to a 4/10 by end of day — but she recognized it was load-related, not structural damage. She started washing dishes every other day. Small wins.

Learning how to deal with “symptom increases” is one of the most important part of the recovery process. The better you are able to respond, the faster the progress.

By Week 3, she washed dishes for 15–24 minutes at 1/10 discomfort. She worked 4 hours, drove 20 minutes, played with her daughter, and did laundry all in one day. At the end of her day her pain level was only a 2/10 and took 2 hours to resolve.

She was beginning to attribute her flares to sensitization rather than damage.

By Week 4, things were going "really well." She made rice and banana pancakes, mixing with her hands. She used a knife. She picked up her daughter. She described her body as "a bit overprotective" on the first attempt… which is exactly the right way to think about it. No nerve pain.

By Week 8, she was using the traditional mouse every day with no issues. She rated her overall function at 90%. She had progressed to the 5 lb Varigrip and was tolerating it well. She recognized that some soreness from the new load was normal and expected.

By Week 10, she cooked a full Easter meal involving chopping, mixing, everything. She noted her arms hurt a little afterward, but it resolved overnight. She was doing everything unrestricted.

By Week 13, she was in the tapering phase. She was aiming to reduce session frequency while maintaining her gains. She could pick up heavy cases of water at the grocery store. She rated her overall function at 90%+.

One of the most important changes throughout the 16 weeks was Amy's understanding and relationship to pain.

For our patients, 100% is not "never feeling pain again" but rather understanding that pain is a normal part of the human experience and that it is normal to feel symptoms and discomfort when we push our bodies past what they can normally handle.

The positive consequence of this understanding, once you have improved your overall physical endurance and capacity, is having limited to no pain with your functional activity. But most importantly, recognizing that you are not broken, and that you can make a full recovery.

"I now know that nerves do regenerate. I now know that I do not have to stop working in order to recover. I now know that I do not have to change careers in order to recover. I now know that I can still take care of my family and I can make a full recovery."

Key Takeaways from Amy's Journey

Amy's story is incredibly common in the accounting, administrative, and knowledge-worker world. If you are dealing with chronic, unexplained wrist and forearm pain, here is what you need to take away from her experience.

It is not all in your head, but your head plays a role.

The physical strain is real. Amy's tendons were genuinely overloaded from months of high-volume computer use without proper support or conditioning. But chronic pain changes your nervous system. Anxiety and fear amplify danger signals, making the pain feel worse than the tissue damage warrants. You have to treat both the tissue and the nervous system simultaneously.

This occurs through better decision-making around:

1. What is actually too much when it comes to your symptoms?
2. How to determine the relative contribution of sensitization on your symptoms?
3. Can you still continue with exercises with certain levels of pain?
4. How much should you modify your activity and exercise based on how you're feeling?
5. What should be the graded exposure plan for this week depending on your conditioning and progression of pain understanding?

These are all questions we helped Amy understand throughout her recovery journey.

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Imaging and labels can mislead you.

Amy was told she had carpal tunnel syndrome but her EMG was normal. She was given a label that didn't match her actual presentation, which led to months of misdirected treatment.

Don't let a label convince you that you're permanently broken. Understanding the complete picture around your physiologic and cognitive-emotional factors helps you actually understand what you need to do on a regular basis.

Rest and passive treatments are not the answer.

Resting, taking muscle relaxers, or getting passive treatments like ultrasound might temporarily reduce your symptoms, but they shrink your overall capacity over time. Amy had stopped exercising and avoided daily tasks, leaving her tissues severely deconditioned. What helps to actually improve your ability to use your hands more over time is graded, progressive load: exposing your tissues to controlled stress so they adapt and build endurance.

Amy completed 113–114 exercise sessions over her program. That is not a passive treatment. That is deliberate, progressive work and the data shows exactly what it produced.

https://preview.redd.it/z8bcx8us8nah1.png?width=687&format=png&auto=webp&s=8510d33c1d2dc655fc5a744e100e92105ab45975

There Is No "One Size Fits All" Fix

Whether it is a specific ergonomic setup, a single stretch, or nerve glides, chronic pain rarely has a single solution. Amy's recovery required understanding her specific tissue deficits, her lifestyle factors (no forearm support, sedentary lifestyle, no regular exercise), and her cognitive relationship with pain (fear, catastrophization, checking in on her pain 100+ times per day).

Your "pie" of contributing factors is unique to you. A comprehensive assessment is the only way to understand what your pie actually looks like and to build a plan that addresses all of it.

If you are stuck in the healthcare loop frustrated by conflicting answers, told there's nothing they can do, or feeling like you have to choose between your career and your body…

Remember that complete recovery is possible. It just requires zooming out, assessing all contributing factors, and following a structured, comprehensive plan.

Hope this provides a better understanding of what it means to comprehensively assess and treat all of the contributing factors around an individuals issues based on their specific history, lifestyle, beliefs, physical conditioning, environment etc.

Let me know if you have any questions!

Best,
Matt

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Why can you have normal imaging and still have pain?

If you’ve gotten normal diagnostic imaging, ultrasound and nerve conduction studies and your doctor seemed confused about what to do next after a cycle of seeing several other specialists…This thread is for you.

A point in time image does not tell us the “entire picture” when it comes to the cause of your pain and dysfunction. And in many cases imaging results on their own have low overall utility.

In this thread I will help you understand the following

1. What is the purpose of the various types of imaging
2. What can we actually take away from imaging results
3. How your doctors visits and how they discuss imaging results can influence your pain
4. Why you can have normal imaging and still be in lots of pain and dysfunction

Heads up, this is a longer post and is based on the several threads I've done previously all put together to help everyone better understand the context around imaging and chronic RSI recovery.

I'm a Physical Therapist (PT, DPT, OCS, CSCS) and our team has spent the past decade specializing on treating, researching and publishing our work around treating RSI (we've helped more than 3000+ individuals resolve their issues without surgery, more injections, resting, bracing etc. Here is some of our work (we started with the olympians of desk work - esports athletes).

Journal of Orthopedic & Sports Physical Therapy

Tendinopathies in Gaming

Conditioning for Esports (Ch. 8,9,10)

Science of Esports Physical Therapy

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Let’s first talk about what diagnostic imaging & tests are typically ordered for RSI issues at the wrist & hand.

Most typically we hear X-rays, MRIs, & Ultrasounds. Each imaging technique has their benefits in visualizing certain types of tissues. And in many cases we see an overutilization of things like X-rays.

X-Rays: Good for seeing fractures, dislocations, misalignments, and narrowed joint spaces. X-rays can't show soft tissue problems. These are generally ordered since they are more affordable. But honestly many healthcare providers overutilize them.

X-Rays Visualize Bone & Joint Spaces

Magnetic Resonance Imaging (MRI): Good for seeing muscles, ligaments, tendons, organs, and other soft tissues. A majority of our patients seem to have had MRI’s ordered (60% of our patients this year who have been dealing with their problem for > 3 months). There are different techniques that can emphasize different tissues (T1 vs. T2 vs. Proton density imaging).

The contrast between the tissues and the presence of certain coloring (white for example) can indicate if there is water present (suggesting some swelling). Above shows a complete achilles tendon tear.

Ultrasound: Typically the most cost effective option for soft tissue issues, especially if you are trying to visualize more superficial tissues. There are less layers at the wrist & hand so this is often the best option for wrist & hand RSI issues. Ultrasound also providers greater detail compared to an MRI for the more superficial structures. Similarly with ultrasound presence of excess fluid can be indicative of tendon pathology. The image below shows a left and right comparison of a tendon with swelling present and thickening of the tendon.

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Nerve Conduction Velocity Tests: These tests are used to assess the function of the nerves in our arms. The Nerve conduction study (NCS) measures how quickly and how strong the signals are as they travel along the nerve. They compare the results with a “healthy nerve” either in the same arm or the other arm. Or they use “normative values” based on age, temperature, limb length, etc. Altered signaling have historically suggested nerve damage or potential compression.

https://preview.redd.it/ahcckkmta99h1.png?width=464&format=png&auto=webp&s=24cabf24e50cf1bca0b416f1746c0325eb3395f8

Now nerve signaling is a bit of a different discussion and there are really important lenses to consider when analyzing the research. Especially as we begin to layer on our understanding of pain science. I’ll share what some of the research says and try to explain why certain situations may occur. And most importantly I’ll help you understand how you can approach your own results. Look out for this in the sections below.

Imaging results on their own have limited clinical significance

All of the current evidence points to the idea that Imaging is best utilized to rule out more serious conditions than “rule in” a specific tissue (in this case a tendon)being the cause of the problem. Basically…they aren’t always necessary.

There are mountains of research over the past two decades that have shown that imaging for not only wrist & hand conditions but issues at the shoulder, neck, back, foot do not provide enough information for a diagnosis.

In this study done in 2016, 19 NONSYMPTOMATIC professional baseball pitchers went through a detailed clinical examination and three MRI’s of their dominant shoulders were taken before contract signing. (2)

• 68% (13/19) of the baseball draft picks showed tendinopathy
• 32% (6/19) had a partial thickness tendon tear of the supraspinatus
• 21% (4/19) had AC joint OA

And many other small lesions were found in the subjects. Yet none of them had any pain.

This was repeated in 634 runners, 3110 individuals for the lower back, and at least 20 other studies including several systematic reviews & meta analyses which have shown that altered tissue states in imaging does not always correlate to pain. (3-5)

I’ll leave some more references at the end of this article. But the research is clear.

What we know is that changes in the tendon tissue can be present with imaging. But BY itself it does not mean anything.

Instead only when you layer on the results of a comprehensive clinical exam taking into all of the details of the patient, patient’s history, activity & behaviors can you really make a decision with the results.

In some cases imaging can make things worse and it is often influenced by your experience with the healthcare provider

How your physician speaks about imaging matters.

With a better understanding about the purpose of each of these tests, let’s explore a key problem about imaging results: How each of these imaging & diagnostic tools are presented towards the patient.

If you’ve ever felt as though you needed imaging to “get an answer” as to what might be going on. There is a reason why and it is associated with the way doctors may be describing imaging in their discussion with their patients.

There is a big difference between

• “The Imaging will tell us what is going on”
• “Lets get some imaging to figure out what’s the problem”
• “I’ll order an MRI and we’ll get some answers” etc.

and

• “well see what we find in the imaging but know that we have to use that information on top of what we know about how your injury behaves to determine the right diagnosis”
• “Ultrasound is an easy way for us to see if there may be some fluid present around your tendon. While this can indicate some damage, it may not mean we have to do something about it. We often have more healthy tissue in damaged tendon tissue. So it be something you can work on to get back the function of your hands”
• “A nerve conduction study is going to be helpful identify how severe any nerve damage might be. It’s important to know the level of severity is NOT a direct measure of the function of the nerve. We’ll have to consider how your symptoms behave with the results of the test to determine the next steps”

It should always be approach #2 but unfortunately due to our healthcare system & how behind many primary care providers are in their recommendations (1), it is almost always #1. How do you think this type of presentation can impact your beliefs on the importance of imaging results?

There are real consequences with how these imaging tests are presented. And it is the responsibility of healthcare providers to provide the nuanced education. But as you have likely already experienced, many do not (it’s not always their fault, the insurance system has some influence on this)

This is WHY we believe imaging results are important. But what does the research say? There are many reasons why pain can worsen after we receive our imaging results with one of them being the altered behavior and beliefs about your pain and injury.

One study found that for work-related acute LBP, MRI within the first month was associated with more than an eightfold increase in risk for surgery and more than a fivefold increase in subsequent total medical costs compared with propensity matched control patients who did not have early MRI. (6)

What we believe about our pain and our experience around the injury can influence what we feel and how sensitive our bodies might feel.

If we believe we are unable to move because we have a “herniated disc” or “disc degeneration” then we tend to move less, perceive that our bodies are fragile and that leads to real physiologic changes that are detrimental to back pain.

If we believe we have to “rest” because our nerve is being compressed through “carpal tunnel syndrome” then we will avoid the activity that is actually beneficial to us.

Imaging is not as useful as we think for orthopedic conditions. For other medical conditions absolutely.

But for musculoskeletal injuries and more specifically those at the wrist & hand associated with tendons? They don’t offer much value as can be shown through all of the research referenced.

Abnormal imaging has been reported in various tendons in as many as 59% of asymptomatic individuals. (7)

Which means that even if they found your tendon to be pathological, it provides no predictive or diagnostic value.

https://preview.redd.it/irk167z2b99h1.png?width=538&format=png&auto=webp&s=66aea2453a76f2c330cc4db7b6c5da20c8f4bdb7

And many cases, when tendons are appropriately loaded through rehabilitation, there is often MORE healthy in the tissue than there is pathological in the tendon. (8)

More healthy tissue when you perform exercises appropriately for the tendon to allow it to positively adapt.

Which means the focus should not be on trying to change the pathology within the tendon, but instead focus on the tolerance to capacity.

All of the tendinopathy research has continued to support this and this has been exactly what we have seen in all of our cases. We only need to focus on

1. Performing endurance-based protocols to improve the tendon tissues capacity
2. Minimize overstressing the tendons
3. Make changes based on how you are responding to the exercises (increased pain & stiffness, etc.)

This again does not mean imaging is useless. It needs to always be placed in the context of the overall clinical picture to help guide decisions. What we have seen is that it is better as a tool for ruling out problems than ruling in.

It can better tell us if there IS NOT a problem than confirming if there is one. What about nerve conduction tests?

Nerve Conduction Tests:

As I mentioned this is a different conversation. Nerve conduction tests actually assess the ability of the nerve to send signaling which means it can accurately identify whether or not the nerve is capable of sending signals at a certain rate. Our experience over the past decade is consistent with what is found in the research in that nerve conduction tests can be helpful but what you do with the results matter.

What the evidence supports is that nerve conduction velocity tests (NCV) are a powerful ADJUNCT to the clinical assessment of nerve conditions. They can help to provide objective confirmation of the pathology of a nerve however they are LIMITED because they do not directly measure “function” and just like imaging always have to be interpreted in context (13).

Research in the past 10 years has found abnormal values within a NCV can be present without any functional deficits or symptoms (14). A study in 2016 performed a NCS on the median and ulnar nerves in 130 healthy individuals with 15% of these individuals demonstrating electrodiagnostic evidence of carpal tunnel syndrome (latency > 0.5ms, borderline mild). The authors cautioned providers AGAINST over-interpreting mild NCV abnormalities to avoid any aggressive interventions like surgery.

Other studies have also shown that the severity of NCV does not correlate with the symptom severity or function. Most importantly studies have supported that NCV cannot reliably predict clinical outcome. (13-17). Many patients with mild NCV changes can experience significant pain, numbness and disability while others with more severe NCV impairment can function better than expected.

Let’s use our clinical experience to provide some context as to why some of these situations have been found in the research (and with our patients).

Situation 1: Mild damage + ⬆️ symptoms & disability

In this situation it is possible that there is mild nerve damage but are contextual and cognitive emotional factors may be influencing pain and as a consequence leading to more symptoms and reduced function. An example we have seen is that the physician informs our patient that the NCV will tell us if we need surgery or not. With mild damage found the physician informs the patient they need to rest to avoid further damage and eventually getting to surgery. This leads to kinesiophobia and fear avoidance behaviors presenting as only being able to use hands for 5 minutes with typing or desk work and feeling 4-5/10 levels of pain. The belief and fear of movement leads to increased disability even though the damage is considered “mild.” Often these patients require some education and proof that they are able to handle more (through graded exposure and confidence in movement through physiologic testing).

Situation 2: More severe damage + less disability

In this situation while there is more severe damage of the nerve the healthcare provider has bene more thoughtful about the approach with the patient and was able to put the damage into the context of the individuals overall pain behavior and ability to still use his / her hands. Despite having more severe damage being shown on the NCV the patient has a better environment leading to less likelihood of sensitivity and consequential disability. There are still limitations due to the nerve damage but the provider works with the patient to understand what is leading to the nerve damage (entrapment somewhere) and is addressing the underlying endurance, postural and behavioral deficits leading to the problem. This is a situation we have seen and have helped individuals restore their function (over a longer timeline) with the right approach.

Situation 3: Mild damage = no symptoms or disability

There are many reasons why this might occur. What we believe to be the most common is the likelihood of a false positive (consistent with research) since the comparison to another nerve in the upper extremity could be unreliable. Or the normative data utilized by the NCS lab may not actually represent the individual creating the “difference” in signaling. This results in mild damage being found as as the studies suggest these results should not be over-interpreted.

Hopefully you can see some of the nuance around how to interpret NCV results. But the most important question is..What do we actually do with the information? To keep it simple it is up to the healthcare provider to identify HOW the nerve is getting irritated. And most of the time, this is barely explored within traditional healthcare environments. For desk workers, gamers, musicians, crafters these are some of the most common reasons why nerve symptoms or irritation may present

• Awkward work / hobby or sleeping postures leading to nerve damage
• Muscle tightness associated with endurance deficits leading to nerve irritation (FCU)
• Transient irritation of the tendons at the wrist & hand leading to some CTS-like symptoms. (underlying problem is still the tendons)
• Entrapment of nerves at the shoulder (TOS).

Why can you still have normal imaging results and no pain?

I'm hoping it is more clear now based on the previous sections why you can have normal imaging results and no pain. But let's make it completely clear.

If your imaging came back clean but you’re still in significant pain, it does not mean the pain is in your head. Your pain is 100% real. Imaging only captures a snapshot of the tissue and CANNOT measure:

• Capacity of your muscles & tendons you use for your specific tasks
• how sensitized your nervous system has become
• how your beliefs and behaviors are influencing your pain experience
• Your lifestyle, environmental and occupational stressors that may influence your pain

And because everyone's situation is different pain may still persist due to sensitization, poor tissue capacity or both. Remember sensitization is the process in which our nervous system becomes more efficient at generating pain signals even when there is no ongoing tissue threat.

https://preview.redd.it/worhhuk6c99h1.png?width=1057&format=png&auto=webp&s=9a2874ddc4e89e3ae12ee4e08578959efbf99ff5

Think of it like a car alarm that’s become too sensitive. The nerves in your wrist and hand become more excitable, your brain’s threat detection becomes amplified, and fear or anxiety around the pain can make the whole system even more reactive. This is a real underlying biological process which can be heavily influenced by your psychology

And again, NONE OF IT SHOWS UP ON AN MRI

Having normal imaging is actually a good sign. It means there is no structural failure requiring surgery. Your focus should be on building the capacity of the involved muscles and tendons through progressive loading, while also working on understanding your pain so your nervous system learns it is safe to move again.

Your body is not broken. It is overprotective. And is something you can work to change

What can you take away from this?

Take your imaging results with a grain of salt. If you have a doctors appointment, make sure there has been a thorough examination that has been performed:

• Physical tests to assess your muscle endurance & capacity of specific muscles you are using
• Clear identification of pain pattern and pain behavior with activity
• Assessment of your lifestyle, daily movement patterns & behaviors that could lead to increased stress on your hand

If your clinician wants imaging make sure the diagnosis provided includes the context of the examination details above.

If it is not taken into account, then you should find a better clinician.

And most importantly…

Understand that for a majority of wrist & hand issues the tendons are involved. The best approach with the evidence we have and the current research on tendon recovery is to manage how much stress is being applied. (load) And for the cases of nerve involvement, understanding how the nerve is getting irritated can ALWAYS be identified with a thorough assessment (posture, ergonomics, endurance deficits, mobility deficits etc.)

Hope this helps

Matt

--
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