Clinical case review
Review the complete Rehabilitation case, its five progressive clues, the diagnosis, and the clinical reasoning behind the answer.
Want to test yourself first? Play the original case before reading the clues and explanation below.
These are the case findings in their original reveal order, moving from the broader presentation to the most discriminating evidence.
Clue 1
A 34-year-old woman arrives at the outpatient PT clinic five weeks after delivering her first baby, frustrated by a nagging right wrist pain. A left-handed graphic designer, she says the ache flares every time she scoops her newborn out of the crib, and she has started dreading the 3 a.m. feedings because of it.
Clue 2
The pain began gradually about three weeks ago along the thumb side of the wrist, described as a deep ache that turns sharp with movement and occasionally shoots up the forearm and into the thumb. It worsens when she lifts the baby under the arms with her thumbs spread wide, wrings out washcloths, or opens jars, and eases with rest. There was no fall or blow, and she reports no numbness or pins-and-needles in the hand.
Clue 3
On exam there is focal tenderness and mild fusiform swelling directly over the radial styloid, with pain reproduced on resisted thumb extension and abduction. Axial compression with rotation of the thumb basal joint (the grind test) is painless and produces no crepitus, and the thumb carpometacarpal joint is non-tender.
Clue 4
Plain radiographs of the wrist and thumb are unremarkable — no fracture, and normal carpometacarpal joint spaces without osteophytes. Diagnostic ultrasound of the radial wrist shows thickening of the extensor retinaculum over the first dorsal compartment with a small rim of fluid within the tendon sheath.
Clue 5
When she tucks the thumb into her palm, closes the fist over it, and the examiner passively deviates the wrist toward the little-finger side, a sharp, familiar pain fires precisely at the radial styloid. The point of maximal tenderness sits about 1–2 cm distal to the styloid — not 4–6 cm proximal where two forearm tendons cross — and sensation over the dorsoradial hand is fully intact.
Diagnosis
Radial-sided wrist pain in a postpartum woman aggravated by repetitive thumb abduction and lifting, with point tenderness and swelling directly over the radial styloid, localizes the problem to the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis). Reproduction of sharp radial-styloid pain when the wrist is passively ulnar-deviated with the thumb tucked inside a closed fist, together with ultrasound retinacular thickening and tendon-sheath fluid, confirms stenosing tenosynovitis of that compartment. The key discriminator from thumb carpometacarpal osteoarthritis is the site of maximal tenderness and a negative grind test — basal-joint arthritis produces pain and crepitus at the thumb CMC joint, not at the radial styloid — while pain fixed at the styloid (rather than 4–6 cm proximal with crepitus) rules out intersection syndrome, and the absence of any dorsoradial sensory loss excludes superficial radial nerve entrapment.
The explanation and decisive case findings were checked against the source below.
Open the clinical referenceFor education and entertainment only. This fictional case is not medical advice and does not replace supervised clinical training, diagnosis, or treatment.
