Carpal Instability

[Crystal R. Westergard]

Okay, I'll weigh in with a suggestion. Since she gets clunking painfree on some mobilizations and good power, try finding the nearby carpals that don't move as well.
My theory is that while the lunate and it's one neighbor might be highly mobile (which is normal for her) there may be other nearby carpals not moving as much and this creates an imbalance. Try mobilizing the other joints to her physiological norms.
Crystal
(almost a hand therapist)

I have just seen a lady who works as a masseuse with a 3 month history of carpal pain following an increase in her workload (as well as the size of the clients she is seeing). She reports a gradual onset of pain around the capitate/lunate area, initially this was only provoked with weightbearing ++ through a hyeperextended wrist (she is reasonably hypermobile). Over the past few months this pain has increased to the point where she is now finding it difficult to work effectively.

Objectively she has FAROM that is painfree, pain on OP of extension more than flexion (the pain on flexion has only occurred over the past 3 weeks) full power - no pain on resistance, neurology is all normal. She has a clunking feeling with stabilisation of the ulnar and accessory movements of pisiform and lunate but no pain.

Her GP prescribed a course of anti inflammatories that had no effect followed by a 2week immobilisation in a wrist splint (this actually bought on a new pain betweent he ulna and pisiform that has since disappeared now the wrist splint is no longer worn.

All X-rays and MRI have come back with normal (with the exception of a small amount of fluid noted around the pisiform).

I'm thinking that her hypermobility has been aggravated by the continued extended position of her wirst during work which has caused a carpal instability. Unfortunately there are no hand specialists in the clinic and she is unable to travel to see one due to work and family commitments. Any advice on management would be greatly appreciated or would referral to a hand/ortho specialist ultimately be where this lady is heading?

Thanks for your help.