If you have pain on the pinky side of your wrist and someone has said the letters TFCC to you, this video is for you.

Most people with TFCC injuries are told to rest, brace, get an injection, or consider surgery. Some of them get better. Most don't. And almost none of them are ever given an explanation for why the pain keeps coming back even when they're following every instruction. In this video I break down the actual mechanism behind TFCC tear wrist pain, what the TFCC really does, why a structural tear doesn't have to mean permanent pain, and how the loss of passive stability forces your muscles into a second job they were never meant to do alone.

I also cover the three exercises we use to rebuild ulnar wrist endurance, why rest and bracing make this specific problem worse over time, and the one structural scenario, positive ulnar variance and ulnar impaction syndrome, where a surgical consultation is genuinely warranted.
If you are new here, my name is Elliot Smithson. I'm a Physical Therapist, Athletic Trainer, and co-founder of 1HP. I started my career working with musicians and moved into esports medicine, which gave me a front-row seat to what repetitive hand and wrist use actually does to tissue over time, and how badly the traditional medical system mismanages it.

Over the past decade our team has worked with over 3,000 patients, software engineers, surgeons, competitive gamers, musicians, people who can't afford to stop using their hands and who got exactly nowhere with rest, bracing, and the standard referral chain.

The problem in almost every case wasn't structural damage. It was a tissue capacity problem. And that is a problem you can actually solve.

To anyone watching this who has been told their only options are to wait it out or get cut open, there is another path. I've seen it work for people who had been suffering for years.

Hope this helps.
Elliot
1-hp.org

Hey guys, Elliot from 1HP here. I know this is a topic that comes up all the time in this sub and new programs for this are popping up every week. (I'm sure there will be no less than 3 people in the comments chiming in about why their voice-to-text solution is the best) and that's all well and fine, but I want to talk to you here today about how voice-to-text can be a tool in the recovery toolkit but shouldn't be the ultimate solution. Same reason that if you were using crutches for a broken leg your ultimate plan shouldn't be to walk with crutches forever.

The honest answer is that voice-to-text can be either. Used one way, is one of the most useful tools in a recovery plan. Used another way, it actively sets your recovery back. The difference comes down to a concept called the envelope of function, and once you understand it, you will think about every activity modification you make differently.

In this thread, I will help you understand the following:

• What voice-to-text is actually good for, and the trap most people fall into
• What specific endurance is, and why you cannot just stop doing the activity you want to get back to
• What the envelope of function (the Goldilocks zone) is
• Why doing too much AND too little both set your recovery back, at the tissue level and the nervous system level
• How to use voice-to-text as a precision tool to keep your typing inside that envelope while you recover

This framework applies to far more than just dictation. It applies to how you manage every activity that aggravates your hands.

I am a Physical Therapist (PT, DPT, MS, ATC) and our team has spent the past decade specializing in treating, researching, and publishing our work on RSI. We have helped more than 3000 individuals resolve their issues without surgery, more injections, endless rest, or bracing. We started with the olympians of desk work, pro esports players.

First, the trap most people fall into

The instinctive way to use voice-to-text is as an off-switch. The typing hurts, so you stop typing entirely and dictate everything instead. Problem solved, or so it seems.

Voice-to-text is a precision dial, not an off-switch. Stopping entirely makes your tissues weaker.

This is the same mistake as complete rest, just dressed up in better technology. If you stop doing the activity you need to recover for, your tissues do not get stronger. They get weaker. And then when you eventually try to type again, you are in a worse position than when you started.

To understand why, you need to understand how tolerance to a specific activity actually gets built.

What specific endurance actually is

There are two kinds of endurance we care about in recovery, and they work together.

You cannot fully build tolerance to typing without typing. Both general and specific endurance must be trained in parallel.

General endurance is what you build with dedicated rehabilitation exercises, the high-repetition, low-load wrist and forearm work. This builds the raw endurance capacity of the tissue in a controlled, measurable way.

Specific endurance is different. Specific endurance is a function of time spent doing the actual activity you need to return to. The typing itself. The mousing. The drawing. The gaming. It is the tolerance of your tissues to the precise demands of the real-world task, and it is built by doing that task in a progressive, carefully managed way.

Here is the key principle. You cannot fully build tolerance to typing without typing. General exercises build the foundation, but the specific neuromuscular tolerance to the exact activity has to be trained by doing the exact activity. This is why we never want you to completely stop the thing you are trying to get back to. You have to keep doing some of it, in the right amount, to build specific endurance.

Think of a soccer player coming back from a hamstring injury. You would not have them do nothing but gym rehab for twelve weeks and then drop them into a full ninety-minute match. You would build their general capacity with rehab exercises, and at the same time you would have them progressively return to the sport itself. Light drills, then partial scrimmages, then longer sessions, gradually increasing the specific demand until they can handle a full match. Both kinds of work, running in parallel.

The same is true for your hands. You build general capacity with exercises, and you build specific capacity by doing managed, progressive amounts of the actual activity. So the goal is never to stop typing. The goal is to type the right amount.

The envelope of function (your Goldilocks zone)

This is the concept that ties everything together, and it comes out of the loading research that underpins all modern tendon and overuse rehabilitation (1).

The envelope of function is the safe zone where you build capacity without tipping into overload or atrophy.

For any given activity, there is a window of how much you can do that is just right. Enough to build and maintain capacity, but not so much that you cause harm. This window is called the envelope of function, and you can think of it as a Goldilocks zone.

There is an upper limit. If you exceed it, if you do too much, you overload the tissue beyond what it can currently tolerate. This triggers a flare-up, with inflammation and irritation. And critically, repeated overload and repeated flares also drive neurological sensitization. The nervous system, responding to the repeated threat, becomes more reactive and lowers its threshold for producing pain. So overshooting does not just irritate the tissue. It makes the whole system more sensitive over time, which is part of why people who keep blowing past their limit get progressively worse and more pain-sensitive.

There is also a lower limit. If you stay below it, if you do too little, you run into the opposite problem:

• The endurance fibers of the muscle, the slow-twitch Type I fibers responsible for sustained activity, begin to atrophy from understimulation (2).
• The motor drive, the strength and efficiency of the signal your brain sends to recruit those muscles, degrades with disuse (3). Your brain literally gets worse at activating the muscle when the muscle is not being used.

So doing too little does not keep you safe. It shrinks your capacity from both the tissue side and the nervous system side at the same time.

Between those two limits is the envelope. The right amount of the activity to build capacity and maintain motor drive, without tipping into overload. The entire art of recovering from a repetitive strain injury is finding that window and staying inside it, day after day, while your capacity gradually expands and the window itself moves upward.

Where voice-to-text actually fits

Now you can see exactly what voice-to-text is for. It is a precision tool for keeping your total typing load inside the envelope of function.

Type the amount that keeps you inside the envelope, and offload the excess to dictation.

Here is the right way to use it. On a given day, you have a certain amount of typing your tissues can tolerate before you hit the upper limit. But your actual work might demand far more typing than that. Without a tool, you would either type the full amount and blow past your limit into a flare, or stop entirely and fall below your limit into understimulation. Neither is good.

Voice-to-text gives you a third option. You do the amount of typing that keeps you inside the envelope, enough to keep building specific endurance, and you offload the excess to dictation. The typing you do builds your tolerance. The dictation handles the work that would have pushed you over the edge. You stay productive, you keep building specific endurance, and you protect the irritated, overloaded tendons from the volume that would flare them, all at the same time.

It is not an off-switch. It is a dial. It lets you precisely manage how much load your tendons take, so you can stay in the Goldilocks zone even when your work demands more than your tissues can currently handle.

• On a high-irritability day, you lean on dictation more heavily to keep your typing volume low.
• On a good day, with more capacity available, you type more and dictate less, pushing your specific endurance a little further.

The tool flexes with where your tissues actually are. Used this way, voice-to-text becomes one of several levers for staying inside your envelope while you recover, alongside the general rehab exercises building your foundation and the careful progression of your specific activity over time.

Why this requires an actual strategy

Here is the catch. The envelope of function is not fixed. It moves.

As your capacity grows, the window shifts upward, so the right amount of typing this week is more than it was last week. And on any given day, your tolerance fluctuates based on how irritable your tissues currently are, how you slept, and how much cumulative load you have carried recently.

This means using voice-to-text well is not as simple as deciding to dictate half the time. You need to actually know where your upper and lower limits are on any given day, so you know how much to type and how much to offload. Too much offloading and you slip below your limit into atrophy and declining motor drive. Too little and you flare. The tool is only as good as your ability to know where the window is.

The way we handle this with the people we work with is to calculate tissue irritability on a daily basis and translate it into specific guidance on how much of each activity is safe that day. That tells you precisely how much typing fits inside your envelope, and therefore how much to offload to a tool like voice-to-text. As capacity grows, the targets move upward in a controlled, progressive way, so you are always working at the productive edge of your envelope without falling off either side. The tool becomes a precise instrument rather than a guess.

TLDR: What you can take away from this

• Do not use voice-to-text as a way to stop typing entirely. That feels safe, but it quietly drops you below the bottom of your envelope, where your tissues atrophy and your brain gets worse at firing the muscle.
• Keep doing a managed amount of the real activity. Specific endurance is built by doing the specific task, progressively. General exercises build the foundation, but they do not replace the activity itself.
• Aim for the envelope of function. Too much causes flares and nervous system sensitization. Too little causes atrophy and loss of motor drive. The win is in the window between them.
• Use voice-to-text as a dial, not an off-switch. Offload the excess that would push you over your limit, while still typing enough to build tolerance. Lean on it more on bad days, less on good days.
• You need a way to know where your limits actually are. The envelope moves daily and over time, so a real activity modification strategy is what separates a tool that helps from a tool that stalls you.

The goal is never to dictate forever. The goal is to use the tools intelligently in the meantime, while you rebuild your capacity to the point where you can type as much as you want, freely, without thinking about it.

Hope this helps.

-Elliot

1-hp.org

Apply to work with us

References

1.  Dye SF. The knee as a biologic transmission with an envelope of function: a theory. Clinical Orthopaedics and Related Research. 1996;(325):10-18.
2.  Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. British Journal of Sports Medicine. 2016;50(4):209-215.
3. Kannus P, Jozsa L, Renstrom P, et al. The effects of training, immobilization and remobilization on musculoskeletal tissue. Scandinavian Journal of Medicine & Science in Sports. 1992;2(3):100-118.
4. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. 2009;43(6):409-416.

This is how I helped a CNC machinist resolve bilateral wrist extensor tendinopathy and restore full function in 12 weeks, even after he'd "lost hope" from reading posts in this very subreddit.

https://reddit.com/link/1tec3h9/video/ytbkq6cdnd1h1/player

https://youtu.be/wI801ViIIEY

The Presentation

Alex was 26, working as a CNC machinist and CAD designer. He'd been dealing with bilateral wrist and forearm pain for over two years. By the time he found us, he was limited to 1-2 hours of computer use before hitting 6-7/10 pain.

His goal was to transition into a full-time CAD designer role, a position requiring significantly more computer work. But he couldn't sustain the hours. His career was effectively blocked by his symptoms.

Before our consultation, Alex had been researching his condition online. What he found wasn't encouraging.

>"I was starting to lose hope looking into it. I remember watching a video where the guy said he completely stopped playing video games and had to get a job where he wasn't using his hands as much."

This is the kind of content that creates fear-avoidance cycles. Alex was beginning to believe he might have to abandon both his hobbies and his career aspirations.

The Paradox That Told the Real Story

During his initial evaluation, Alex mentioned something that immediately caught my attention: He could rock climb without significant pain. High-load, grip-intensive activity, no problem.

But moving a mouse for an hour? That triggered significant symptoms.

This paradox is clinically meaningful. If there was severe tissue pathology, we would expect high-load activities like climbing to be equally or more provocative than low-load computer work. The fact that they weren't suggested that context and threat appraisal were playing a significant role in his pain experience.

His baseline assessment confirmed this:

• QuickDASH Disability Score: 20/100
• QuickDASH Disability Score Work Module: 56/100
• QuickDASH Disability Score Hobby Module: 69/100
• Fear-Avoidance Score: 27/100 (with elevated catastrophizing)
• Irritability Index: 30.0 (Severe)
• Endurance Testing: 20-30 reps at 5 lbs (approximately 25-50% of benchmark)

Alex had fair physical capacity but moderate central sensitization. His nervous system had learned to treat computer work as a threat and was amplifying signals accordingly.

What He'd Tried Before

Alex's self-directed interventions included:

• Grip strengthening with squeeze balls (targeting flexors, not the affected extensors)
• Wrist bracing (creating stress shielding and contributing to deconditioning)
• Activity avoidance (perpetuating the fear-avoidance cycle)

His only guidance came from online research, which had led him to believe the condition might be permanent.

None of these approaches addressed either the endurance deficit or the sensitization component.

The Intervention

We enrolled Alex in our Power Leveling program, which addresses both capacity deficits and central sensitization simultaneously.

Physical Conditioning

Alex was provided with a twice-daily endurance routine targeting his wrist extensors, wrist flexors, radial deviators, and thumb muscles. All exercises were performed with controlled tempo to ensure appropriate time under tension.

He started at 4-5 lb dumbbells and progressively increased load as his tissues adapted. We tracked reps, pain response, and recovery to adjust prescriptions over time.

Activity pacing was implemented with structured work-to-rest ratios (3:1 or 4:1) and daily load tracking to monitor irritability trends.

Pain Science Education

This was equally critical. Alex completed our curriculum covering pain neurophysiology, central sensitization mechanisms, and the role of beliefs and expectations in pain perception. He also read Explain Pain and completed the companion handbook exercises.

The core framework we taught was DIMs and SIMs, Danger In Me signals versus Safety In Me signals. The goal was to help Alex identify what was amplifying his threat response and begin collecting evidence that his hands were actually safe.

One of the DIMs Alex identified was particularly relevant:

>"One DIM is definitely when I'm doing work and I don't really know what I'm doing. There's a lot more stress just because of that, and then it's like 'oh no' and then my hands are hurting and it's making the quality of my work worse. Everything's just spiraling downhill."

This connection between work stress and pain amplification is extremely common in knowledge workers. Once Alex could recognize the pattern, he could begin to interrupt it.

The Recovery Timeline

Week 2: QuickDASH dropped from 20 to 14 (30% improvement). Alex articulated his first major insight:

>"I think a big part of it was just understanding that a lot of it is mental and not that the tendons are screwed or anything and that I can actually make it out of this. That definitely reduced the anxiety that I had."

Week 3: Completed Explain Pain materials. Reported that DIMs felt "suppressed" and that he now understood what was happening when pain occurred:

>"Whenever my hands hurt, I kind of understand what's going on."

This shift, from catastrophic interpretation to accurate attribution, is the core mechanism of pain science education.

Week 4: First flare-up occurred when Alex pushed wrist extension to 6-7/10 pain without rest breaks. Critically, he did not catastrophize. He accepted the modification, continued at reduced load, and resumed progression within a week.

This response pattern, treating setbacks as data rather than danger, indicated successful integration of the educational component.

Week 5: Completed 8-hour stress test (computer work with natural breaks). Reported 3/10 pain at conclusion.

>"A couple months ago, it would have been almost unbearable doing something like that."

Week 8: Temporary regression due to over-progression on exercises (exceeded prescribed rep ranges after weight increases). Corrected within one week by implementing rest breaks and returning to system prescriptions.

Week 9: Completed 12-hour stress test, a Civ 5 session until 3am. Zero pain during or after.

>"Maybe like a little bit of uncomfortable here and there, but I think anybody's hands would normally be sore after that. Normal response."

This statement demonstrates complete integration of the framework. He wasn't ignoring pain; he was accurately attributing normal physiological sensations rather than catastrophizing.

Week 12: Final assessment. Alex reported attending a job fair and feeling confident applying for computer-intensive positions.

>"It's nice that I feel confident applying for more desk-heavy jobs. I have a lot more confidence going into other things now because my hands work so much better."

The Results

Measure	Baseline	Final	Change
QuickDASH	20	2	-90%
QuickDASH Work	56	0	Resolved
QuickDASH Hobby	69	0	Resolved
Fear-Avoidance	27	1	-96%
Irritability Index	30.0	0.0	-100%
Computer Tolerance	1-2 hrs	12+ hrs	6-10x increase

Exercise Progression:

• Radial Deviation: 4 lbs → 12 lbs (+200%)
• Wrist Flexion: 4 lbs → 12 lbs (+200%)
• Wrist Extension: 4 lbs → 9 lbs (+125%)
• Thumb Flexion: 1 band → 4 bands (+300%)

Key Takeaways from Alex's Case

1. The paradox matters.

If you can do high-load activities (climbing, lifting, etc.) without significant symptoms but low-load repetitive work triggers pain, that's meaningful clinical information. It suggests context and threat appraisal are contributing to your pain experience, and that's addressable.

2. Fear-avoidance makes it worse.

Alex's pre-program strategy of avoidance and bracing was contributing to his deconditioning. Activity modification is appropriate; complete avoidance typically is not. The key is progressive loading within tolerance, not rest until it goes away.

3. Education isn't optional.

The 96% reduction in fear-avoidance scores paralleled the 90% reduction in disability scores. For Alex, the psychological component was rate-limiting. Building tissue capacity was necessary but not sufficient; changing his relationship to pain was equally critical.

4. Reddit doom-scrolling creates real harm.

Alex came to us believing he might have to quit gaming and change careers, beliefs he absorbed from online content. Those beliefs were contributing to his pain through fear-avoidance mechanisms. If you're stuck in that cycle, recognize it for what it is.

5. Setbacks are data, not disasters.

Alex had two regressions during his recovery, one flare-up from pushing too hard, one from over-progressing exercises. In both cases, he didn't catastrophize. He accepted the modification and continued. That response pattern predicts successful outcomes.

The Lesson Notes That Tell the Story

From Alex's written homework early in the program:

>"I am afraid that if I keep gaming or working my hand will get worse. I am afraid that if my hand gets worse it will severely impede me career wise. I am afraid it could impair my ability to enjoy other hobbies like rock climbing."

From his final check-in:

>"All the issues are mostly gone at this point. I have a lot more confidence going into other things now because my hands work so much better."

That transformation, from fear to confidence, from avoidance to engagement, is what this work is actually about.

Final Thoughts

Alex's case is representative of what we see frequently in this community: someone with a real physical capacity deficit who has also developed sensitization and fear-avoidance from years of unexplained pain and discouraging online content.

Neither component can be addressed in isolation. Building endurance without addressing fear leaves the nervous system amplifying signals. Addressing psychology without building capacity leaves tissue tolerance insufficient for functional demands.

The combination, progressive loading plus pain science education, is what produces these outcomes.

If you're in a similar situation, you don't have to accept that this is permanent. Alex was convinced he might have to change careers three months before completing a 12-hour gaming session without pain.

Hope this is helpful.

- Dr. Elliot

1-hp.org

Work with Us

I'm a doctor of physical therapy who specializes in repetitive strain injuries, and I'm currently working with 2 gastroenterologists. It's opened my eyes to just how physically demanding endoscopy and colonoscopy work actually is on the wrist and hand, something that almost never gets talked about in the broader RSI conversation, which tends to focus on desk workers and surgeons.

A few things I'm genuinely curious about from people in this field:

Where does it hurt? Palm side of the wrist? Thumb base (a lot of scoping mechanics load the thenar muscles)? Forearm? Elbow?

When does it show up? During a long case? End of day? Next morning?

Has anyone had to modify their practice or take time off because of it?

What, if anything, has actually helped? I've heard everything from bracing between cases, to grip-strengthening routines, to switching scope brands.

I ask because in most professions dealing with repetitive hand strain, the solution people reach for first (rest, bracing, injections) often isn't what gets them back long-term, but I'm curious whether GI has developed any informal culture or institutional wisdom around this that I haven't seen elsewhere.

just trying to understand the problem better from the people who actually live it.