Looking Further When Symptoms Are Disproportionate to Physical Findings

A 36-yr-old man presents with left ulnar-side wrist pain during an ice hockey game that prevented him from playing hockey or golf. There was no acute mechanism of injury. The usual clinical examination revealed only minimal tenderness and minimal pain with resisted wrist extension. Careful attention to precipitating factors led to testing resisted wrist extension with the forearm fully supinated, which reliably reproduced the intensity of the patient's symptoms, and a diagnosis of extensor carpi ulnaris tendinopathy. A literature review suggested three additional special tests (two were positive) and management. However, a standard of care has yet been established because neither the tests nor the management has been properly validated through research, thus leaving the management of this condition as an art.