What is the next step in management for a 35-year-old male patient with a left hand injury and anterior palm pain, who has shown improvement with physical therapy and has a normal ultrasound of the left hand?

Management of Left Hand Injury with Normal Ultrasound and Improving Symptoms

Continue physical therapy as the primary treatment approach since the patient is showing improvement and has a normal ultrasound of the left hand.

Current Clinical Situation

• 35-year-old male with left hand injury from 3 months ago
• Anterior palm pain
• Normal ultrasound findings (no tendon tear, effusion, tenosynovitis, or abnormal fluid collection)
• Currently undergoing physical therapy with reported improvement

Recommended Management Approach

Continue and Optimize Physical Therapy

• Physical therapy has demonstrated effectiveness for hand injuries and should be continued as the primary treatment 1, 2
• The exercise program should include:
  • Range of motion exercises
  • Strengthening exercises targeting hand and forearm muscles
  • Proprioceptive exercises for neuromuscular re-education 3
  • Gradual progression of intensity as symptoms improve 2

Education and Self-Management

• Provide education on:
  • Ergonomic principles to avoid adverse mechanical factors
  • Activity pacing to prevent overuse
  • Joint protection techniques 1, 2
• These educational interventions have been shown to significantly improve hand function with a number needed to treat of 2 (95% CI 1 to 6) 1

Supplementary Interventions

• Consider topical NSAIDs (e.g., diclofenac gel) as first-line pharmacological treatment if pain persists 2
• Oral acetaminophen (up to 4g/day) can be used as second-line treatment for breakthrough pain 2
• Oral NSAIDs at lowest effective dose and for shortest duration can be considered as third-line treatment 2

Assistive Devices and Modalities

• If pain persists, consider:
  • Appropriate assistive devices to reduce stress on the hand during daily activities 2
  • Local application of heat before exercise sessions to improve tissue extensibility 1

Expected Outcomes and Follow-up

• Continue physical therapy for at least 4-6 weeks, as multiple studies have shown this duration is necessary for optimal outcomes 4
• Higher therapy intensity has been associated with better outcomes in hand rehabilitation 5
• Reassess in 4-6 weeks to evaluate:
  • Pain levels
  • Grip strength (power grip, key pinch, precision pinch)
  • Range of motion
  • Functional ability in daily activities

When to Consider Referral

• If symptoms persist despite 4-6 weeks of optimal treatment
• If new symptoms develop suggesting inflammatory arthritis
• If significant functional impairment persists
• If systemic symptoms develop 2

Common Pitfalls to Avoid

• Discontinuing physical therapy prematurely - evidence shows continued therapy leads to better outcomes 6
• Relying solely on passive treatments - active exercises have shown greater effect sizes for pain relief (ES=0.32) and functional improvement (ES=0.32) compared to education alone (ES=0.06 for pain, ES=0.02 for function) 1
• Failing to address ergonomic factors that may contribute to ongoing symptoms 1
• Overuse of NSAIDs without appropriate gastrointestinal protection in high-risk patients 2

Physical therapy has demonstrated effectiveness for hand conditions with improvements in pain, function, and strength without adverse effects 7, 4. Since the patient is already showing improvement with physical therapy and has a normal ultrasound, continuing this approach is the most appropriate next step in management.