Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20

Manual therapy for work-related wrist pain in a

manual physical therapist

Alexandra R. Anderson & Craig P. Hensley

To cite this article: Alexandra R. Anderson & Craig P. Hensley (2019): Manual therapy for
work-related wrist pain in a manual physical therapist, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2019.1686671

To link to this article: https://doi.org/10.1080/09593985.2019.1686671

Published online: 31 Oct 2019.

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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2019.1686671

Manual therapy for work-related wrist pain in a manual physical therapist

Alexandra R. Anderson, PT, DPT, OCS, FAAOMPT, CMTPTa and Craig P. Hensley, PT, DPT, OCS, FAAOMPTb
a
Physical Therapy Department, University of Illinois Health, Chicago, IL, United States; bFeinberg School of Medicine, Department of Physical
Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, United States

ABSTRACT ARTICLE HISTORY

Introduction: The wrist is a common site for work-related musculoskeletal disorders (WMSD) Received 3 March 2019
among physical therapists (PTs), often due to manual therapy. There are limited data on manage- Revised 27 June 2019
ment of wrist injury in PTs. The purpose of this case is to describe the management of a PT with Accepted 24 September 2019
wrist pain. KEYWORDS
Case Description: The patient was a 28-year-old female with a 6-month history of right ulnar- Wrist; work-related
sided wrist pain, aggravated by performing thoracic/lumbar posterior to anterior (PA) glides. The musculoskeletal disorders;
patient reported 7/10 on the Numeric Pain Rating Scale and 6.5/10 on the Patient-Specific physical therapist
Functional Scale (PSFS). Symptoms were reproduced at the lunotriquetral joint.
Outcomes: The patient was seen for two visits. Following anterior to posterior non-thrust
mobilization at the triquetrum on lunate, the patient improved inability to perform thoracic/
lumbar PA glides. The patient was educated on manual therapy modifications, isometrics, and
self-mobilization. At 2-month follow-up, the patient reported 0/10 pain, scored 10/10 on the PSFS,
and +7 on the Global Rating of Change.
Discussion: This case demonstrates the successful use of education, manual therapy, and exercise
in the management of a PT with a wrist-related WMSD. Future research should focus on the
prevention/treatment of wrist-related WMSDs in PTs who perform manual therapy.

Introduction therapy. Most PTs report using different parts of their body
to administer manual therapy, and 50% warmed up and
Musculoskeletal conditions in health-care providers, parti-
stretched before performing manual therapy as a self-
cularly in the physical therapy profession, are frequently
treatment option (Rozenfeld et al., 2010).
attributed to occupational tasks (Truszczynska, Scherer,
WMSDs in physical therapy have many notable con-
and Drzal-Grabiec, 2016). Estimates suggest that the pre-
sequences, including modifying treatment techniques,
valence of work-related musculoskeletal disorders
taking time off work, decreasing work hours, and most
(WMSDs) in physical therapists (PTs) range from 53-91%
commonly changing practice setting (Vieira et al., 2016).
(Vieira et al., 2016). There are common occupational activ-
Although less common, some PTs actually leave the pro-
ities that put PTs at risk for WMSDs, including patient
fession due to WMSDs (Campo, Weiser, Koenig, and
handling and manual therapy (Campo, Weiser, Koenig,
Nordin, 2008). Occupational demands of PTs make the
and Nordin, 2008; Hignett, 2001). Injury to the wrist is
management of these injuries difficult (Baldwin, Johnson,
reported by 14% of PTs, particularly in those who perform
and Butler, 1996; Jette and Jette, 1996).
manual therapy (Darragh, Huddleston, and King, 2009).
The lunotriquetral (LT) joint sits along the proximal
Manual therapy is responsible for 69.1% of wrist/hand
ulnar side of the wrist. Joint kinematics are dependent on
injuries in all PTs and occupational therapists (Darragh,
joint surface geometry and ligaments given that there are no
Campo, and King, 2012). Repetitive manual therapy, being
dynamic constraints. Stability is provided by both intrinsic
female, and having less than 5 years of experience as a PT
and extrinsic ligaments. The intrinsic LT ligament is
are risk factors for developing wrist/hand pain (Vieira et al.,
C-shaped and composed of three regions; the dorsal and
2016). It has been hypothesized that the repetitive motion,
palmar true ligaments, of which the palmar is the strongest,
force, and/or sustained positions with soft tissue and joint
and a wedge-shaped proximal membrane (Ritt et al., 1998).
mobilization contribute to these WMSDs (Darragh,
Extrinsic ligaments connect the proximal carpus to the
Campo, and King, 2012). There are limited data on treat-
radius, ulna and mid-carpus, and prevent the proximal
ment options for PTs with wrist/hand pain due to manual
row from supinating/pronating beyond the normal range

CONTACT Alexandra R. Anderson aanders523@gmail.com Physical Therapy Department, University of Illinois Health, Chicago, IL, United States
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
© 2019 Taylor & Francis Group, LLC
2 A. R. ANDERSON AND C. P. HENSLEY

(van de Grift and Ritt, 2016). The LT joint articulation is

planar, with the medial surface of the lunate articulating
with the triquetrum through a small triangular surface
(Mastella and Zelouf, 2004).
Injury to the LT joint and its associated structures can
be related to acute trauma or degenerative processes with
or without acute trauma. The mechanism of injury is
thought generally to be multi-factorial, although isolated
LT trauma is often the result of a fall on an extended wrist.
Isolated injury to the LT joint is usually asymptomatic
initially (Ranzenberger and Carter, 2019). If the LT joint
continues to be stressed, symptoms may present on the
ulnar side of the wrist. Degeneration of the LT joint may
be the result of repetitive overuse, arthritis, ulnar impac-
tion syndrome, or inappropriately treated ligament
trauma (van de Grift and Ritt, 2016). Regardless of acuity,
a non-operative approach can initially be attempted
(Ranzenberger and Carter, 2019; van de Grift and Ritt,
2016). There is no evidence to our knowledge regarding
non-surgical intervention performed by a PT in those
with LT injury. In this report, the examination, evalua-
tion, and management of an orthopedic manual PT with
ulnar-sided wrist pain secondary to an increase in work-
load is described.

Case description
Patient history
A 28-year-old, right-hand dominant, orthopedic manual
PT presented to physical therapy with right ulnar-sided
wrist pain (Figure 1). The differential diagnosis for ulnar-
sided wrist pain, along with exam findings supporting/
refuting each diagnosis, is outlined in Table 1. The patient
had been practicing for 3 years. Her wrist pain began 6
months prior to the initial evaluation. She attributed her
pain to an increase in manual therapy usage. Using the
Numeric Pain Rating Scale (NPRS) (Ferraz et al., 1990), the
patient described pain ranging from 0-7/10. Her main
complaint was performing posterior to anterior (PA) glides
on patients’ lumbar and thoracic spines (Figure 2) on more
than two patients per day. The pain typically resolved
immediately when moving the wrist out of the aggravating
position but could linger into the evening if significantly
provoked. Other aggravating factors included falling asleep
with the wrist flexed, using a hammer, and pulling open
a heavy door.
Pertinent past medical history included a right sca-
pholunate injury in high school and undiagnosed
wrist pain with tumbling and handstands in college
gymnastics. She received an occupational therapy
intervention for her scapholunate injury in high
school but did not seek treatment in college. Her
Figure 1. Body chart. Checkmarks indicate symptom-free areas.
Red marked area indicates the region of pain. The patient
described her pain as sharp, dull, and stiff.
current episode of pain was different than episodes
in the past. She had attempted to manage her current
problem with occasional use of NSAIDs and night
splints without success. She denied previous trauma
or current pain in the cervical spine, shoulder girdle,
or elbow. No red flags, numbness or tingling, or weak-
ness were reported. Patient-informed consent was
provided. Regarding patient-reported outcomes, she
scored a 6.5/10 on the Patient-Specific Functional
Scale (PSFS) (6/10 with PA techniques, 7/10 opening
a door) (Stratford, 1995).
Physical examination
The cervical spine, shoulder, elbow, and forearm were
screened and cleared. Observation of the wrist/hand was
unremarkable for edema, ecchymosis, ulnar prominence,
 PHYSIOTHERAPY THEORY AND PRACTICE 3

Table 1. Differential diagnosis, with exam findings in this case, for ulnar-sided wrist pain.
Diagnosis Exam findings
Lunotriquetral pain Likely given pain was provoked with joint mobility testing along with passive range of motion into
flexion, extension, and ulnar deviation.
Osteoarthritis: distal radioulnar joint, intercarpal, Unknown without imaging
or ulnocarpal joints Unlikely given patient’s age and no signs of crepitus with physical examination
Triangular fibrocartilage complex injury Negative on all special tests
Extensor carpi ulnaris tendinopathy/tenosynovitis Unlikely given pain-free manual muscle testing and palpation to tendons
Flexor carpi ulnaris tendinopathy Unlikely given pain-free manual muscle testing and palpation to tendons
Ulnar impaction syndrome Unknown without imaging
Unlikely given no ulnar variance observed and negative ulnocarpal stress test (Nakamura et al., 1997)
Carpal instability (pisotriquetral and Passive accessory joint assessment did not reveal hypermobility
lunotriquetral)
Distal radioulnar joint (DRUJ) instability Negative on special tests and joint mobility testing
Keinbock’s disease Unknown without imaging
Unlikely given no severe range of motion limitations, tenderness directly over the lunate, and edema
Pisotriquetral pain Unlikely given negative joint mobility testing
Ulnolunate/ulnotriquetral pain Unlikely given negative joint mobility testing
Lunotriquetral coalition Mobility was noted between lunate and triquetrum
Stress fracture Unknown without imaging
Only known risk factor would be repetitive manual therapy
Ulnar neuritis Unlikely given no paresthesias and neurological findings
Hypothenar myalgia Unlikely given pain-free manual muscle testing and palpation to hypothenar muscles
C8 radiculopathy Unlikely given cervical spine range of motion was deemed normal with active range of motion and
overpressure
No paresthesias and neurological findings
Ulnar artery thrombosis Unlikely given no paresthesias, color/temperature changes

patient described as painful. A calibrated scale was used to

Figure 2. Non-thrust lumbar mobilization technique that the
patient described to be painful and limiting.
or other gross abnormalities. The patient was not found
to be grossly hypermobile and was deemed negative on
the Beighton score (Remvig, Jensen, and Ward, 2007).
The symptom-provoking functional movement was
the performance of the PA non-thrust mobilization the
assess the amount of weight (in pounds) prior to the onset
of pain (Figure 3) and the weight was converted into
kilograms. The patient was instructed to setup as if she
was going to perform a PA non-thrust technique with her
involved extremity on the scale. Weight was applied
directly into the scale with the instructions to relay the
point at which she felt initial onset and maximum pain.
The first onset of pain was noted to be a 2/10 at 17.5 kg
and a maximum pain rating of 6/10 at 31.5 kg.
Wrist and forearm active range of motion (AROM)
were measured using a goniometer (Table 2) (Norkin
and White, 2009). All measurements were equal to the
left forearm/wrist except ulnar deviation (UD). The
patient’s symptoms were reproduced most significantly
with active and passive wrist flexion at the end range.
Wrist flexion was less painful with the addition of radial
deviation (RD) and more painful with adding UD pas-
sively. Familiar pain was also reported during end range
active and passive UD ROM. Wrist extension passive
ROM with overpressure also reproduced patient symp-
toms. Wrist and hand ROM were deemed normal other-
wise. Manual muscle testing of the forearm and wrist was
performed, according to Kendall, McCreary, and
Provance (1993), and was 5/5, pain-free.
The passive accessory motion was tested in a neutral
wrist position. Hypermobility and crepitus were found at
the radiocarpal joint in all directions on the involved side
without pain. Anterior to posterior mobility of the trique-
trum on the lunate reproduced the patient’s pain and was
hypomobile. Intercarpal mobility throughout the
4 A. R. ANDERSON AND C. P. HENSLEY

Special tests including: triangular fibrocartilage complex

(TFCC) grind test (Young, Papp, and Giachino, 2010);
press-up test (Lester, Halbrecht, Levy, and Gaudinez,
1995); lunotriquetral Ballottement test (Porretto-Loehrke,
Schuh, and Szekeres, 2016); fovea sign (Porretto-Loehrke,
Schuh, and Szekeres, 2016); and piano key sign (Rhee,
Sauvé, Lindau, and Shin, 2014) were negative.
Weightbearing through the radiocarpal joint was
noted to be painful in a pronated position when using
the treatment table to stand up (Figure 4). This movement
was pain-free when adjusting the force through the inter-
carpal joint by moving the hands forward on the table
with the table crease lining with the intercarpal joint.

Physical therapy diagnosis and prognosis

The patient presented with ulnar-sided wrist pain and
a history of wrist instability and pain. Current complaints
were postulated to be a result of repetitive non-thrust
techniques to patients’ lumbar and thoracic spine, which

Figure 3. Simulated non-thrust mobilization technique on

a weighted scale, used as the functional assessment/reassess-
ment sign.

Table 2. Range of motion.

Motion Right Left
Wrist flexion 85° p* (up to 5/10 with OP added) 85°
Wrist extension 80° p* with OP only, 3/10 80°
Wrist ulnar deviation 42° p* (up to 2/10 with OP added) 38°
Wrist radial deviation 20° 20°
Forearm supination 85° 85°
Forearm pronation 85° 85°
Abbreviations: p*, patient’s familiar pain; OP, overpressure

remainder of the involved wrist was hypomobile and

pain-free in both anterior to posterior and posterior to
anterior directions, except at the scapholunate joint where
hypermobility was found in both directions. Passive phy-
siological movement revealed hypermobility of the radio-
carpal joint into flexion and extension and hypomobility
of distal on proximal carpal row into flexion and exten-
sion. The patient denied joint line tenderness, ligamen-
tous tenderness, or muscular/tendon tenderness of the
wrist flexors and extensors. It should be recognized that
while reliability and validity of joint mobility testing at the Figure 4. Weightbearing through the radiocarpal joint was noted
to be painful in a pronated position when using the treatment table
wrist has not been tested, both reliability in the lower
to stand up. This movement was pain-free when adjusting the force
extremities (van Trijffel, van de Pol, Oostendorp, and through the intercarpal joint by moving the hands posteriorly on the
Lucas, 2010) and validity in the spine (Landel et al., table with the table crease lining with the intercarpal joint. This was
2008) have been questioned. Palpation was pain-free also used as a self-mobilization technique, mobilizing the distal on
throughout bilateral wrists. proximal carpal row.

had become problematic 6 months prior to evaluation.
The clinical impression was LT joint pain secondary to
repetitive microtrauma from her gymnastics history and
current repetitive performance of manual therapy. Some
pathologies could not be ruled out completely after the
exam. For instance, Kienböck’s disease, or avascular
necrosis of the lunate, requires imaging to make
a diagnosis, but the patient had no systemic diseases that
would increase her risk (Porteous, Harish, and Parasu,
2012). If conservative management failed, radiographs
and/or further medical workup could be ordered to assist
in the diagnosis process. Mobility at other intercarpal
joints was deemed a contributing factor. The mechanism
of injury from performing manual therapy was described
in a position of repetitive wrist extension with compres-
sive forces through the ulnar-side of the wrist.
Positions involving approximation of the ulnar-sided
wrist joints (i.e. flexion, extension, and UD) were most
provocative. Many PTs elect to use the ulnar side of the
wrist to mobilize spinal segments to eliminate stress
through the thumbs, as the use of mobilization is related
to increased prevalence of thumb pain (Vieira et al., 2016).
This patient’s work-related impairment involved specific
mobilization techniques through the ulnar side of the
wrist, which likely caused further stress on the hypomobile
LT joint.
Given the findings, it seemed that mobilizing the LT
joint would be a suitable first-line intervention. Prognosis
was excellent considering the patient’s knowledge regard-
ing her injury and awareness of body mechanics contri-
buting to further LT pain and dysfunction.
Intervention
Treatment was aimed at improving LT joint mobility and
pain utilizing an anterior to posterior (AP) non-thrust
mobilization of the triquetrum on lunate. This was per-
formed by blocking the lunate with one hand and provid-
ing pressure in a posterior direction on the triquetrum.
Large amplitude oscillations into 75% of resistance (grade
III+) (Hengeveld, Banks, and Maitland, 2005) were per-
formed in a position of wrist flexion and UD because this
combination was most provocative during the physical
exam (Figure 5). Mobilization into 75% of resistance was
utilized as resistance was felt before the first onset of pain.
Further, it has been demonstrated that higher forces
applied to painful segments have an enhanced effect on
symptoms between sessions (Snodgrass, Rivett, Sterling,
and Vicenzino, 2014). Following 2 min of oscillatory
mobilization, the patient was re-tested on the scale. Her
first onset of pain was 1-2/10 measured at 29.8 kg and her
maximum pain was 6/10 measured at 35.4 kg, improving
12.2 and 3.6 kg, respectively. Following re-assessment, the
PHYSIOTHERAPY THEORY AND PRACTICE 5
Figure 5. Non-thrust mobilization technique. An anterior to
posterior glide of the triquetrum on lunate was applied in
wrist flexion and ulnar deviation. The physical therapist’s left
hand was used to block the lunate while gliding the triquetrum
posteriorly with the right hand.
patient was given the following instructions for self-
management: 1) AP non-thrust oscillatory mobilizations
(grade III+) to the triquetrum with the wrist in a flexed
and ulnar deviated position (Figure 6), 1-3x/day for 2
min; 2) Isometrics into wrist UD and flexion starting in
a neutral wrist position (5x45 second holds with 2 min
rests, 3x/day) (Rio et al., 2015); and 3) Oscillatory self-
mobilization (grade III+) of distal carpal row on proximal
carpal row x 1 min, 1-3x/day as needed (Figure 4).
We discussed the use of mobilization wedges as an
alternative means to administer manual therapy through-
out the day. Further, we discussed the use of administering
PA non-thrust mobilizations to the spine with the left wrist
in contact with the spinous processes. The patient verba-
lized understanding and acknowledged that she would add
these techniques in the future. She was completely adherent
with her home program throughout the plan of care.
Outcomes
Outcomes are reported in Table 3. The patient returned
for her follow-up visit 1 month following her initial
evaluation. Her pain at worst was 3/10 in the past week,
reporting only one occurrence during lumbar non-
thrust mobilizations at the end of a long work shift.
She reported that she used the mobilization wedge and
left hand to mobilize the spine as needed.
The PSFS improved to a 10/10. The Global Rating of
Change (GROC), scaled from −7 (a very great deal worse)
to a + 7 (a very great deal better) (Kamper, Maher, and
Mackay, 2009) was used to measure the patient’s percep-
tion on the efficacy of intervention, as this has been shown
6 A. R. ANDERSON AND C. P. HENSLEY

patient was also able to place 39.5 kg through the wrist

on the scale with 0/10 pain.
One month after visit 2, a phone call follow-up was
made. The patient reported 0/10 pain at worst, 10/10
on the PSFS, and she reported to be a very great deal
better (+7) on the GROC. It was recommended to
continue with strategies to reduce overloading the
involved wrist secondary to her history and repetitive
nature of manual therapy required for her job. It should
also be noted that the patient’s pain and function
improved despite her workload remaining unchanged
after her initial physical therapy evaluation.

Discussion
Physical therapy is a profession requiring increased
demands on the musculoskeletal system in the amount
of force, movement, and/or postures required for effective
examination and treatment. These requirements can lead
to WMSDs. It is likely that the repetitive stress with
increasing patient loads played a significant role in this
patient’s development of wrist pain (Vieira et al., 2016).
Campo, Weiser, Koenig, and Nordin (2008) found that
Figure 6. Self-mobilization in wrist flexion and ulnar deviation. those PTs who performed joint mobilization on more
The patient performed an anterior to posterior glide of the than 10 patients per day had a 7.95 times higher risk of
triquetrum in wrist flexion and ulnar deviation as a part of developing wrist and/or hand pain compared to those
her home exercise program. who did not perform joint mobilization. As mentioned
earlier, PTs who are of female gender and younger age are
at a higher risk for developing wrist/hand pain.
Interestingly, the average age of PTs who experience
Table 3. Outcome measures. their first major WMSD is 28 years old (West and
1 month follow
up after visit 2
Gardner, 2001), the age of the patient in this case. The
Assessment Evaluation Visit 2 (phone call) patient’s former sport, gymnastics, has been shown to
PSFS (performing non-thrust 6/10 10/10 10/10 increase the prevalence and incidence of wrist pain (Kox
spinal mobilization)
PSFS (pushing heavy door) 7/10 10/10 10/10
et al., 2015). It is likely that the patient’s history of sca-
NPRS 7/10 3/10 0/10 maximum pholunate injury may have increased susceptibility to
maximum maximum
GROC +6 +7
injury at the adjacent LT joint due to changes in joint
Simulated non-thrust 17.5 kg 39.5 kg and ligamentous stability and/or compensatory patterns
mobilization (weight on (2/10 (0/10
scale converted to kgs) pain); pain)
to decrease the load on the scapholunate joint.
Initial pain onset; 31.5 kg Ulnar-sided wrist pain is a common reason for medical
maximum tolerable (6/10 visits. It is often referred to as the low back pain of the
pain)
Abbreviations: PSFS, Patient-Specific Functional Scale; NPRS, Numeric Pain
wrist due to difficulty in identifying the nociceptive driver
Rating Scale; GROC, Global Rating of Change. of pain (Porretto-Loehrke, Schuh, and Szekeres, 2016). In
this case, the LT joint was seemingly the nociceptive
source, as joint mobility testing here provoked the
to have high face validity. The patient scored a + 6 (a great patient’s symptoms. Non-thrust joint mobilizations were
deal better), indicating significant change (Jaeschke, chosen to improve mobility at hypomobile segments,
Singer, and Guyatt, 1989). including the LT joint. Following non-thrust joint mobi-
AP mobility was pain-free at the triquetrum on lizations at the LT joint, the patient was able to tolerate
lunate. Wrist AROM with overpressure was pain-free a considerable increase in weight through the wrist with
in all directions except flexion at a 1/10 pain. No pain her manual therapy techniques. Immediate response to
was present during combined wrist flexion and UD. All manual treatment may be explained by the application of
goniometric measures of AROM were unchanged. The mechanical input to the central nervous system, enabling

augmented analgesic effects or heightening conditioned
pain modulation, confirmed by reduced deep tissue sen-
sitivity to pressure (Courtney et al., 2016). The home
exercise program included self-mobilizing techniques to
normalize joint mobility at the LT and intercarpal joints,
as well as isometric exercise to induce hypoalgesia.
Isometric exercise has been shown to produce significant
analgesic effects across varying pathologies and treatment
protocols (Naugle, Fillingim, and Riley, 2012; Rio et al.,
2015, 2017). Modifications to the patient’s use of manual
therapy likely assisted in maintaining improvement in
pain and function. The use of consistent assessment/reas-
sessment during examination/intervention was critical in
determining the appropriate intervention. In this case, the
use of a scale for objective measurement was used before
and after non-thrust joint mobilizations.
It should be noted that the patient in this case report
had excellent outcomes following only 1 formal treat-
ment. As a PT, the patient’s knowledge was an advan-
tage in improving her ability to apply self-mobilizations
and modify techniques at work, therefore likely contri-
buting to improving outcomes.
Most PTs do not seek formal evaluation and treatment
for their own injuries, especially for WMSDs (Campo,
Weiser, Koenig, and Nordin, 2008; Vieira et al., 2016).
PTs should consider formal evaluation/treatment to
improve pain in the workplace, work-related function,
and occupational longevity.
Limitations
There were several limitations in this case report. The
diagnosis, in this case, was inconclusive. No imaging was
performed, but it seemed unreasonable to recommend
imaging given the patient’s positive response to interven-
tion. In addition, the reliance on subjective report was used
during assessment/reassessment. No handheld dynam-
ometer was available. However, a scale was used to simulate
patient-specific occupational restrictions. Finally, it is
impossible to attribute which intervention (manual ther-
apy, home exercise, and/or activity modification) was most
responsible for the patient’s successful outcome. It is
believed that the combination of manual therapy, activity
modification, and adherence with the home program all
assisted in improving function in this case.
Conclusion
This case report details the examination, clinical reason-
ing, and successful treatment (including manual therapy,
exercise, and patient education) used for an orthopedic
manual PT with ulnar-sided wrist pain stemming from
the LT joint. Although WMSDs are common among PTs,
PHYSIOTHERAPY THEORY AND PRACTICE 7
particularly at the hand/wrist, there is little evidence on
prevention and treatment allowing for the maintenance of
job performance and long-term participation. Future
research should focus on the incidence/prevalence of
ulnar-sided wrist and/or LT pain in those with previous
scapholunate injury and in PTs who perform manual
therapy. Finally, research should look to improve ways
to both prevent and treat WMSDs amongst PTs.
Declaration of Interest
We have no financial conflicts of interest.
References
Baldwin ML, Johnson WG, Butler RJ 1996 The error of using
returns-to-work to measure the outcomes of health care.
American Journal of Industrial Medicine 29: 632–641
Campo M, Weiser S, Koenig KL, Nordin M 2008 Work-
related musculoskeletal disorders in physical therapists:
A prospective cohort study with 1-year follow-up.
Physical Therapy 88: 608–619
Courtney CA, Steffen AD, Fernandez-de-Las-Penas C, Kim J,
Chmell SJ 2016 Joint mobilization enhances mechanisms
of conditioned pain modulation in individuals with
osteoarthritis of the knee. Journal of Orthopaedic and
Sports Physical Therapy 46: 168–176
Darragh AR, Campo M, King P 2012 Work-related activities
associated with injury in occupational and physical
therapists. Work 42: 373–384
Darragh AR, Huddleston W, King P 2009 Work-related
musculoskeletal injuries and disorders among occupational
and physical therapists. American Journal of Occupational
Therapy 63: 351–362
Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P,
Goldsmith CH 1990 Reliability of pain scales in the assess-
ment of literate and illiterate patients with rheumatoid
arthritis. Journal of Rheumatology 17: 1022–1024
Hengeveld E, Banks K, Maitland GD 2005 Maitland’s
Peripheral Manipulation 4th, Edinburgh, Scotland:
Elsevier/Butterworth Heinemann
Hignett S 2001 Manual handling risk assessments in occupa-
tional therapy. British Journal of Occupational Therapy 64:
81–86
Jaeschke R, Singer J, Guyatt GH 1989 Measurement of health
status: Ascertaining the minimal clinically important
difference. Controlled Clinical Trials 10: 407–415
Jette DU, Jette AM 1996 Health status assessment in the
occupational health setting. Orthopaedic Clinics of North
America 27: 891–902
Kamper SJ, Maher CG, Mackay G 2009 Global rating of
change scales: A review of strengths and weaknesses and
considerations for design. Journal of Manual &
Manipulative Therapy 17: 163–170
Kendall FP, McCreary EK, Provance PG 1993 Muscles:
Testing and Function. Baltimore, MD: Williams & Wilkins
Kox LS, Kuijer PP, Kerkhoffs GM, Maas M, Frings-Dresen
MH 2015 Prevalence, incidence and risk factors for
8 A. R. ANDERSON AND C. P. HENSLEY
overuse injuries of the wrist in young athletes:
A systematic review. British Journal of Sports Medicine
49: 1189–1196
Landel R, Kulig K, Fredericson M, Li B, Powers CM 2008
Intertester reliability and validity of motion assessments
during lumbar spine accessory motion testing. Physical
Therapy 88: 43–49
Lester B, Halbrecht J, Levy IM, Gaudinez R 1995 “Press test”
for office diagnosis of triangular fibrocartilage complex
tears of the wrist. Annals of Plastic Surgery 35: 41–45
Mastella DJ, Zelouf DF 2004 Anatomy of the lunotriquetral
joint. Atlas of the Hand Clinics 9: 7–15
Nakamura R, Horii E, Imaeda T, Nakao E, Kato H, Watanabe K
1997 The ulnocarpal stress test in the diagnosis of ulnar-sided
wrist pain. Journal of Hand Surgery (Br) 22: 719–723
Naugle KM, Fillingim RB, Riley JL 2012 A meta-analytic
review of the hypoalgesic effects of exercise. Journal of
Pain 13: 1139–1150
Norkin CC, White JD 2009 Measurement of Joint Motion:
A Guide to Goniometry 4th, Philadelphia, PA: F.A. Davis
Company
Porretto-Loehrke A, Schuh C, Szekeres M 2016 Clinical
manual assessment of the wrist. Journal of Hand Therapy
29: 123–135
Porteous R, Harish S, Parasu N 2012 Imaging of ulnar-sided
wrist pain. Canadian Association of Radiologists Journal
63: 18–29
Ranzenberger LR, Carter KR 2019 Lunotriquetral Instability.
StatPearls Treasure Island, FL: StatPearls Publishing.
Remvig L, Jensen DV, Ward RC 2007 Are diagnostic criteria for
general joint hypermobility and benign joint hypermobility
syndrome based on reproducible and valid tests? A review of
the literature. Journal of Rheumatology 34: 798–803
Rhee PC, Sauvé PS, Lindau T, Shin AY 2014 Examination of
the wrist: Ulnar-sided wrist pain due to ligamentous
injury. The Journal of Hand Surgery 39: 1859–1862
Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ,
Cook J 2015 Isometric exercise induces analgesia and
reduces inhibition in patellar tendinopathy. British
Journal of Sports Medicine 49: 1277–1283
Rio E, van Ark M, Docking S, Moseley GL, Kidgell D,
Gaida JE, van den Akker-scheek I, Zwerver J, Cook J
2017 Isometric contractions are more analgesic than iso-
tonic contractions for patellar tendon pain: An in-season
randomized clinical trial. Clinical Journal of Sports
Medicine 27: 253–259
Ritt MJ, Linscheid RL, Cooney III WP, Berger RA, An KN
1998 The lunotriquetral joint: Kinematic effects of sequen-
tial ligament sectioning, ligament repair, and arthrodesis.
Journal of Hand Surgery (Am) 23: 432–445
Rozenfeld V, Ribak J, Danziger J, Tsamir J, Carmeli E 2010
Prevalence, risk factors and preventive strategies in
work-related musculoskeletal disorders among Israeli phy-
sical therapists. Physiotherapy Research International 15:
176–184
Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B 2014 Dose
optimization for spinal treatment effectiveness:
A randomized controlled trial investigating the effects of
high and low mobilization forces in patients with neck
pain. Journal of Orthopaedic and Sports Physical
Therapy 44: 141–152
Stratford P 1995 Assessing disability and change on indivi-
dual patients: A report of a patient specific measure.
Physiotherapy Canada 47: 258–263.
Truszczynska A, Scherer A, Drzal-Grabiec J 2016 The occur-
rence of overload at work and musculoskeletal pain in
young physiotherapists. Work 54: 609–616
van de Grift TC, Ritt MJ 2016 Management of lunotriquetral
instability: A review of the literature. Journal of Hand
Surgery (Eu) 41: 72–85
van Trijffel E, van de Pol RJ, Oostendorp RA, Lucas C 2010
Inter-rater reliability for measurement of passive physio-
logical movements in lower extremity joints is generally
low: A systematic review. Journal of Physiotherapy 56:
223–235
Vieira ER, Schneider P, Guidera C, Gadotti IC, Brunt D 2016
Work-related musculoskeletal disorders among physical
therapists: A systematic review. Journal of Back and
Musculoskeletal Rehabilitation 29: 417–428
West DJ, Gardner D 2001 Occupational injuries of phy-
siotherapists in north and central Queensland. Australian
Journal of Physiotherapy 47: 179–186
Young D, Papp S, Giachino A 2010 Physical examination of
the wrist. Hand Clinics 26: 21–36