PSA: If ultrasound, procedures or long shifts are starting to irritate your hand/wrist, here’s how I’d approach it
Hey everyone! My name is Matt and I'm a Physical Therapist (PT, DPT, OCS, CSCS) with 1 Health Point who specializes in repetitive strain injury (primarily those in the wrist & hand). Over the past decade we’ve worked with a number of residents and physicians whose wrist and hand symptoms start interfering with their ability to tolerate their normal clinical workload.
The exact problem varies by specialty. For radiology it may be hours of mouse, keyboard and dictation use. For anesthesia it may be ultrasound/probe positioning and procedures. For surgical specialties it may be instruments, suturing and prolonged operating. Even outside procedural specialties, long hours of charting and computer work can create a surprisingly large cumulative hand workload. What frustrates me is that most of it is very treatable, and the standard advice residents and other healthcare providers often get (rest it, brace it, inject it, cut back your schedule) often conflict with what current tendon research supports.
Because of this I wanted to see if I could provide some practical, evidence-based guidance that we commonly use within the residents, physicians and procedural specialists.” (surgeons, anesthesiologists, etc.). This isn't just "rest and ice" advice that I’m sure you have all learned about in your own education. I want to give you actionable steps to actually prevent and address these issues.
Why residency and long clinical shifts can create a wrist/hand workload problem
Most of the residents we’ve treated specifically for this have been in diagnostic radiology, so I’ll use radiology as the main example throughout the post. The exact demands change by specialty, but the broader principles around workload, capacity and recovery are the same. I’d also be interested to hear how this shows up differently in surgery, anesthesia, EM, etc.
Radiology
- PowerScribe/dictaphone
- mouse/keyboard
- PACS manipulation
- long reading blocks
- high call volume
Surgery
- prolonged instrument
- grip suturing
- laparoscopy
- sustained wrist positions
- long cases
Anesthesia
- ultrasound probe manipulation
- IVs/lines
- regional procedures
- prolonged gripping/positioning
Hospital Medicine & Nonprocedural specialties
- typing/charting
- mouse use
- EHR navigation
- laptop/desktop volume
- long/high-volume shifts
To bring in a bit more specifics since radiology is where we’ve treated this most frequently. I’ll provide some more in-depth task assessment
- Repeated thumb activation to hold dictaphone button down to start & stop dictation. This is often interspersed with
- Frequent mouse and keyboard use: to select current and prior studies for comparison. Correction of dictation may also occur. Constant selection of cases from the work list based on priority. Clicking through EPIC or EHR system
- Mouse use to manipulate studies, zoom, pan, measure, draw, swap between studies, etc.
- Logitech G502 seems to be a commonly used mouse due to its programmable buttons although some of our clients who are MMO players have used the multiple thumb button mice as well. (G600 or razer naga)
- Natural breaks throughout the day for residents for presenting cases / EOD things
- On call often is more intense (many of the initial bouts of pain start during ED rotations for the DR residents that we’ve worked with).
Please feel free to help me understand if I missed anything! Now the reason why it is important for us to understand the specific tasks and movements that occur during ANY job-related activity is because… when you control any input device (dictaphone, vertical mouse, G502, etc.) you are using specific muscles and tendons in the forearm wrist & hand. Here are some examples of what we have seen
- Floating Forearm When Typing - Increased use of the extensor digitorum and the forearm & finger flexors as you bend your wrist and fingers down to press keys. The extensors (top side) are used since you are holding up the weight of your forearm and wrist against gravity over time.
- Holding the Dictaphone - The key pinch grip with the thumb controlling the buttons leads to increased use of not only the thumb flexors (thenar mm group) but also the thumb abductors and extensors. Depending on the angle you are holding the dictaphone or if your elbow is supported can either increase load or offload, respectively. Many end up using dictaphone stands or microphone stands as things tend to get worse / more chronic
- Vertical Mouse use - Increased use of the pinky side of the wrist, thumb extensors and thenar muscles. The pinky side of the wrist (ECU, FCU) tends to increase its usage due to the pressure into the table. The neutral wrist position and if there are use of thumb binds also tends to increase the use of the thumb muscles / tendons
Now you might have already noticed throughout the introduction I have frequently mentioned the tendons as an involved tissue source. The MAJORITY of the MSK issues we treat as a result of repetitive activities resulting from resident work involve the tendons. We’ll touch on this later on but first…
One thing I’ve also learned is that many radiology residents are also gamers… which is why I wanted to share a concept of the health bar to help you understand more about RSI.
How Your "Healthbar" Works
I’ve spent many years working in the gaming & esports industry so we built this model of thinking around repetitive strain injuries like a health bar in a video game.
Starting Capacity: Your initial healthbar size depends on your baseline tissue endurance and conditioning. The size is typically dependent on your overall levels of physical activity and specifically targeted endurance-based exercises for the wrist & hand. More physical activity & exercise would lead to a larger “HP bar” and less physical activity is a smaller healthbar.
Daily Depletion: Every action or task you are performing while at work will gradually deplete your healthbar. This depletion rate depends on:
- Intensity: How hard are applying pressure to click, grip the dictaphone, type etc.
- Duration: How long you have to perform these tasks without breaks
- Posture & Ergonomics: The way we use our input devices can influence stress per unit time. When you death grip your dictaphone or mouse you will lose 4 HP per unit time vs. 1HP with a relaxed grip. The input device itself often influences where the stress is applied. Pure dictation? Vocal cords become stressed Foot pedals? Ankle and foot activity. Mouse with thumb binds? Lots of thumb use Dictaphone for 90% of the day? lots of thumb use
Recovery Threshold: When your healthbar drops below a critical point, discomfort and pain begin. If you continue using your hands without allowing recovery, severe pain and tissue damage can develop.
There is some more nuance to this for those interested which consider some of the cognitive emotional, environmental and occupational stressors relating to pain. You can check that out in this longer and more in-depth thread of mine
RSI can occur when your external demands exceed your healthbar. Said differently Load > Capacity (load equation). With this being said here is a quick review on tendon pathology and why this load equation has to be considered
Continuum Model of Tendon Pathology
A quick tendinopathy primer
Chronic overuse tendon pathology is not an "-itis" in the classic sense. The current model (Cook & Purdam's continuum) describes a spectrum: reactive tendinopathy, tendon dysrepair, and degenerative tendinopathy. When a tendon is loaded beyond its capacity, tenocytes respond by upregulating proteoglycans, which bind water and cause the tendon to swell and thicken. Early on this is completely reversible. It's an adaptive, load-driven cell response, not primarily an inflammatory cascade. This is why reducing inflammation or pain alone doesn't necessarily restore the tendon’s ability to tolerate its previous workload
Tendons are mechanoresponsive tissue: load them appropriately and they remodel stronger, unload them (rest, bracing) and they weaken.
Remember the word "swell," because it is important in this next section. I want to discuss one of the most common diagnoses we see when treating DR residents
Why dequervain’s may not be the appropriate diagnosis
By the time many of the residents and other healthcare professionals we work with get to us, they have gone through the workup of their colleagues and specialists. Because of the high frequency of thumb-related tasks (dictaphone / power scribe) pain on the thumb-side of the wrist is common.
Now I don’t think I need to go into depth about what dequervain’s tenosynovitis is for this subreddit since many might understand the pathology. But what we have seen clinically over the past decade instead supports the idea that the tenosynovitis (if present) is often a sequelae of an underlying tendon problem rather than a pure tenosynovitis.
When you repeatedly utilize your thumbs to perform your daily tasks you are using the APL / EPB to move the thumb. When the tendons are exposed to a high volume of load which exceed the capacity (exceed your health bar) then they reactively swell (water and proteoglycans enter the tendon structure). This swelling can then create the pressure on the sheath and resulting friction between sheaths.
Interventions are often focused on just addressing the “inflammation” through bracing, resting, medication. It works yes to reduce the pain but does not IMPROVE your ability to handle the repeated thumb and hand activity especially when you are on call and often have limited to no breaks.
Taking the healthcare framework model - the external demand of you job requires a 100 HP. You only have 80 HP. This causes irritation of your tendon. When you rest for extended periods of time and avoid use your capacity will reduce so you then have 70HP and then try again to perform a 100 HP day. This is why tissues can continue to get irritated when you “get back” to work with “less pain”
You didn’t improve your capacity! So the instead of dequervain’s we tend to see the diagnosis as APL / EPB tendinopathy with associated tenosynovitis (and in many cases there isn’t even sheath-based inflammation or irritation!)
Now i”m hoping it’s clear why the traditional approaches often fail but I want to make it clear
Why Traditional Treatments Often Fail
Most individuals who develop radial sided wrist pain (APL / EPB tendinopathy) through a predictable cycle of treatments that provide temporary relief but never actually solve the problem. Here is why the “passive” approaches tend to fall short:
Rest and Anti-Inflammatories: While inflammation can be a contributor to pain, it is often just the source rather than the cause of the pain and limitation. Pain will reduce temporarily with this approach but will not address the underlying tendon weakness & occupational demands (cumulative load) that caused the problem. Worse, extended rest actually makes tendons weaker and less capable of handling load when you return to work.
Braces and Straps Braces can provide some symptom relief by distributing forces differently, but they're essentially a band-aid. Again, they will not improve your healthbar or your tendon's capacity to handle stress, so you become dependent on them. We have seen many individuals resort to just working with dual thumb spica braces (which can allow them to get through the day) but the moment they take them off and try to return to prior level of activity… the pain comes back. This is because the tendons were never trained (for endurance not strength)
Steroid Injections Recent research has shown that cortisone injections for tendinopathy can actually be harmful long-term. It will definitely help to address inflammation associated with the tenosynovitis and provide weeks and sometimes months of relief.
Research has continued to point towards the possibility of cortisone (and repeated injections) weakening tendon structure and increasing the risk of future problems. The unfortunate part of this is that being at the hospital and surrounded by specialists it is often the path of least resistance to try the “quick relief” solution. If there is an injection it should ALWAYS be paired with an appropriate load-based program or protocol.
Traditional Physical Therapy Many physical therapy approaches focus on stretching and light strengthening with resistance bands. While these aren't harmful, they often don't provide enough stimulus to actually improve tendon capacity significantly. It's like trying to prepare for a marathon by walking around the block.
Another common presentation across specialties: carpal tunnel-type symptoms
It is not carpal tunnel syndrome (in the classic sense). It is more of a symptom / sequelae like the dq. This is an important part I want every resident to understand, both for your own hands and potentially for your fellow colleagues to understand.
Carpal tunnel symptoms (numbness/tingling in thumb, index, middle finger) mean the median nerve is being compressed. But there are two very different ways that compression happens, and they have opposite treatments:
Think of the carpal tunnel like a sandwich. The transverse carpal ligament is the top of the bread. The nine flexor tendons are the meat. The median nerve is squeezed in between. You can compress that nerve either because the roof got thicker, or because the meat swelled up.
True carpal tunnel syndrome is the roof problem, and the research on the timeline of “roof” thickening is important to know. Serial imaging studies show the transverse carpal ligament thickens at roughly 0.02mm per year. Clinically significant CTS is associated with a ligament that's 20-30% thicker than normal, which works out to roughly 0.3-0.6mm of actual growth. At 0.02mm/year, that is decades of cumulative loading, which is why ligament-driven CTS is a condition of midlife and older, and why it's so strongly associated with systemic accelerants: diabetes, hypothyroidism, RA, pregnancy. Interesting side note: studies of young professional pianists, about the highest hand-use population imaginable, found their ligaments were about 22% stiffer than controls but not meaningfully thicker. Overuse changes the ligament's mechanical properties early, but true tunnel-narrowing thickening takes many years.
Tendon-mediated median nerve compression is the meat problem, and it's far more common in working-age hands. Overloaded flexor tendons swell (that proteoglycan/water mechanism above), take up space in a fixed tunnel, and secondarily compress the nerve. The symptoms are identical. The treatment is completely different: release surgery cuts the roof, but the roof was never the problem, which is a big part of why we see people get a carpal tunnel release and still have symptoms when they return to work.
This is why a comprehensive clinical exam & imaging matters before any more aggressive treatment is recommended like surgery. A release is a reasonable operation when the ligament is actually the compressing structure. But you can't establish that from symptoms and a Phalen's test.
Before accepting a structural CTS diagnosis, the workup should include diagnostic ultrasound (first-line at the wrist, it's superficial anatomy and ultrasound visualizes ligament thickness, tendon swelling, and median nerve changes well) and/or MRI, plus NCS/EMG to characterize the nerve involvement, and ideally endurance testing of the wrist musculature to identify the capacity deficit. Other important details to explore are the mechanism of injury (Usually associated with peak volumes of activity more suggestive of the load-based pathology), understanding of pain, physical activity history, ergonomics and much more.
Swollen, hypoechoic tendons with a normal-thickness ligament is a rehab problem, not a surgical one.
If someone is recommending release surgery to a 32-year-old whose symptoms developed over four months of heavy clinical volume, without imaging that actually shows a thickened ligament, that's worth a second opinion.
The Real Solution: Building up your HP bar
Here's the fundamental principle behind effective treatment of any repetitive strain injury for the wrist & hand: RSI develops when the load on your tendons consistently exceeds their capacity to handle that load.
Load = How much stress you put on your tendons (work demands, amount of clicking and use of hands throughout the day, etc)
Capacity = How much stress your tendons can handle (their strength and endurance)
This gives us two ways to address the problem:
- Reduce Load (work less [Haha…. nope], modify environment & input devices)
- Increase Capacity (strengthen and condition the tendons)
Again, most traditional treatments focus only on reducing load, which is why symptoms return as soon as you normal use of your hands with work. The key to long-term resolution is increasing your tendon capacity so they can handle the demands of your job without breaking down.
Load Based Rehab Program
Based on the research and our clinical experience, here is a basic starting program for tendon-dominant wrist/thumb presentations. I'll continue using the common radiology thumb-sided presentation as the example, but the exact exercise selection should obviously depend on the tissues involved and the demands of your specialty.
I want to add some nuance here - this plan will only address the physical contributors to your pain and limited function. Addressing the other variables
- Lifestyle: Sleep, Activity management (work schedule, breaks, etc.), Posture & Ergonomics, Occupational Stressors, etc.
- Psychosocial Factors: Pain Avoidance Behaviors, Expectations, Pain-Related Beliefs, Self-Efficacy.
is necessary to ensure long-term relief while being considerate of the many variables which can affect our body.
Pain Drivers and Disability Model of Care
Additionally it’s important to recognize that exercise prescription is typically specific to the individual based on their initial assessment of endurance, current irritability etc. This program will be more conservative in nature since it is unlikely to address all possible distributions of severity and chronicity of cases.
Basic Exercise Program
Start with isometric exercises that allow you to load the tendon without moving through range of motion. Ideally I'd start with just the isometrics & stretches during the first two weeks (conservative approach). These help reduce pain while beginning the endurance and strength building process. I’ll include exercises targeting some of the other regions to cover multi-region pathologies that many often have.
Isometrics (daily, 3 x 45-second holds each)
Can provide short-term pain relief, build baseline tendon tolerance and can be helpful during any downtime you might have during your shifts.
Wrist flexion isometric: forearm supported, palm up, resist with the other hand
Wrist extension isometric: same setup, palm down
Thumb Extension isometric: sustained sub-maximal thumb extension
Stretches (2-3x/daily), 3x20-30 seconds each
Wrist flexor stretch (arm extended, palm up, gently pull fingers back)
Wrist extensor stretch (palm down, gently pull hand down and in)
Thumb extensor stretch (thumb in fist, gentle ulnar deviation)
Endurance training (daily, the actual fix)
Once you can perform isometric exercises without pain, progress to the key endurance-building movements that will help to actually restore your function. But remember to be patient since it does take time for tendons to adapt. The exercises included target both the flexors, extensors and radial deviators
Forearm on a table, wrist off the edge, light dumbbell (start ~4-5 lbs for wrist work, 1-2 lbs for thumb/radial work), paced to a metronome at 50 BPM, one beat up, one beat down. Additionally if you do not have arm rests you can perform them leaning against your thigh. The main goal is to ISOLATE the wrist & hand movement.
Wrist flexion curls: 2x15 building to 3x30 over 4-6 weeks
Wrist extension curls: same dosing
You want to ideally hold it at the base of the dumbbell for this one and you can use things like frying pans, golf clubs, long dowels, to find offloaded weight. There are other variants which can also significantly increase the tendon load (but we can maybe go over that in a different post)
The metronome might seem strange but it is something we adapted from research done on lower extremity tendons and have seen great outcomes for the distal upper extremity (hoping we can publish more of this work of ours soon!). Externally paced loading comes from the tendon neuroplastic training research (Rio et al.) and improves motor cortex drive and muscle fiber recruitment efficiency, which distributes stress across more of the tendon.
Bonus: Nerve Symptoms
For the cubital tunnel presentations (we often see issues arising from the ulnar nerve irritated as the nerve travels between FDS / FDP or with FCU tightness) you can add ulnar nerve glides.
Additionally we suggest: avoid sustained end-range elbow flexion (watch how you hold your dictophone or phone in general, how you sleep, a towel loosely wrapped at the elbow at night keeps you out of full flexion), and build the wrist flexor endurance above, since decompressing an irritated ulnar nerve long-term means raising the capacity of the flexor mass it runs through.
These ulnar nerve glides are also incredibly useful for making sure the ulnar nerve is sliding through the cubital tunnel space smoothly.
Load Management: Return to Work Strategies
The exercise program addresses the capacity side of the equation, but you also need to manage your work-based load intelligently as you recover. There is some nuance to this but I’ll try to provide some general recommendations based on the cases that we have seen.
In many if not all cases residents find modifications (some of what we have mentioned above) to avoid the use of the hands for daily tasks. Additionally use of other passive interventions and modalities can help to temporarily reduce pain (restore HP) during the day. You guys are smart, so you guys always find a way to make it work throughout the day.
The exact load-management strategy will depends heavily on specialty. A radiology resident may redistribute mouse/dictation demands. A surgical resident may need to adjust nonessential hand loading outside the OR while maintaining required procedural exposure. An anesthesia resident may change probe grip, alternate hands where appropriate, or modify positioning while symptoms settle.
Here is one real radiology example to show what this looks like in practice:
Resident Schedule & Modifications
This is how a resident found modifications to reduce load on his wrist & hand throughout the various work blocks. This individual’s issues started during ICU rotation (go figure..haha)
Start work at 8:00 AM
8-12:00 PM** First Work Block, Every 60 minutes this resident would take a 5 minute break
- During this time you can either take more breaks to “restore HP” throuhgout your day (30/5 distribution) or you can
- Leverage modifications in ergonomics so you can still get your tasks done (For example)L. handed use of Razer Naga Mouse, R. hand for Power Scribe).
- You can also map alot of binds to the keyboard to minimize use of dictaphone
12:00 PM-1:30 Lunch / Conference (Lectures, etc.)
- This is lower overall load of the wrist & hand,
1:30 -5:00 PM - Second Work Block
- Work to reduce overall load through increased breaks & ergonomic modifications. See above
After Work:
Now the amount of modifications at work will allow you to perform the exercises to actually build up your endurance and capacity. Everyone has a different lifestyle but if you are a gamer it could be a good idea to temporary reduce your gaming volume by 25-50% as you are working on regularly exercising. Then as you build up your capacity (considering tissue adaptation timelines) you can work it back up!
There is of course nuance to the progressive increases in activity and exercise but again, this is just an overview of how you can think about improving your activity.
Now that we’ve gone over the physical aspects (training & load management) I wanted to briefly touch on the psychosocial aspects of pain that I highlighted above
Understanding the Cognitive Emotional Aspects of Pain
I’ve written a long post on the physiology of persistent and chronic pain and what tends to influence these underlying changes you can check out here
But as a general piece of guidance I’d really advise anyone interested in understanding this to look into the biopsychosocial model of pain, central sensitization and begin to learn more about how these variables can influence your pain experience. Many times the initial acute & subacute period are dominated by physical & lifestyle contributors to pain. But as things tend to persist past the 3 month mark with less clarity or understanding of why things may have developed in the first place that is when fear avoidance, catastrophization, kinesiophobia, anxiety, occupational stressors and other factors can start to lead to more pain despite no real damage being done to your peripheral tissues
The Bottom Line
Wrist & hand problems during residency or clinical practice are often manageable even when simply resting or reducing your work schedule isn't realistic. The key insights are:
- It's a tendon capacity problem, not an inflammatory condition
- Rest alone doesn't solve the underlying weakness
- Progressive, consistent loading is the most effective treatment
- Recovery takes time - usually 6-12 weeks with proper management
- Prevention through ongoing conditioning is much easier than treatment
- Understanding pain helps to navigate more chronic cases
Hoping this helps! Always happy to answer any questions in the comments, etc. I’ve also included some references around the psychosocial aspect for those who are interested
-Matt
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Resources:
-1-hp.org
-Case Studies & Free Guides
-2 hour Compilation of everything we have learned treating over 3000+ individuals with wrist & hand pain
-Apply to work with us
References
- Rio E, Kidgell D, Moseley GL, et al. Tendon neuroplastic training: changing the way we think about tendon rehabilitation. Br J Sports Med. 2016;50(4):209-15.
- Cook JL, Purdam CR. Is tendon pathology a continuum? Br J Sports Med. 2009;43:409-416.
- Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology. Br J Sports Med. 2016;50:1187-1191.
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- Hinckley NB, et al. Time-dependent change in carpal tunnel cross-sectional area and transverse carpal ligament thickness using serial MRI. J Hand Surg Am. 2025;50(4):507.e1-507.e8.
- Marquardt TL, Gabra JN, Evans PJ, Seitz WH Jr, Li ZM. Thickness and stiffness adaptations of the transverse carpal ligament associated with carpal tunnel syndrome. J Musculoskelet Res. 2016;19(4):1650019.
- Mhanna C, Marquardt TL, Li ZM. Adaptation of the transverse carpal ligament associated with repetitive hand use in pianists. PLoS One. 2016;11(3):e0150174.
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- Crombez G, Eccleston C, Van Damme S, Vlaeyen JWS, Karoly P. Fear-avoidance model of chronic pain: the next generation. Clin J Pain. 2022 Apr;38(4):277–286. doi: 10.1097/AJP.0000000000001005. PMID: 35394847.
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Posted Sep 25, 2026, 5:15 PM UTC