Return-to-Work Decision for a Hairdresser with De Quervain Tendinopathy
A 41-year-old hairdresser has a 4-month history of radial wrist pain, positive Finkelstein and Eichhoff tests, and pain with thumb abduction. She has had one corticosteroid injection 6 weeks ago with partial, temporary relief. She works 40 hours weekly with repetitive scissor use and wrist deviation. She is keen to avoid surgery and asks you to certify her fit for full duties now. Her pain is 6/10 with work tasks and she has reduced grip endurance.
1. Evaluate the evidence and clinical findings relevant to her request for immediate full-duty clearance.
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Immediate full-duty clearance is not supported.
Reasoning:
- Positive Finkelstein/Eichhoff and pain with thumb abduction support first dorsal compartment (APL/EPB) tendinopathy.
- Partial, temporary relief after injection at 6 weeks suggests ongoing load intolerance; the underlying mechanical demand has not been addressed.
- Her job involves repetitive thumb/wrist loading and deviation-the exact provocative loads-so returning to full duties at 6/10 pain with reduced endurance risks flare and chronification.
- Evidence supports activity modification and graded loading over simply resuming provocative tasks; certification should reflect capacity, not the patient's preference.
Decision: decline immediate full-duty certification, document the rationale, and offer a graded return plan with modified duties.
2. Propose a graded return-to-work and load-management plan, and specify objective criteria for stepping up duties.
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Plan:
- Modified duties first: reduce sustained thumb/wrist deviation and scissor time (e.g., alternate tasks, scheduled micro-breaks, ergonomic scissors), starting at reduced hours if needed.
- Rehab: isometric then graded eccentric loading of wrist extensors/abductors, thumb stabiliser strengthening, and tendon-loading education; splint for provocative periods only, not continuously.
- Step-up criteria (objective): pain ≤3/10 during and after work tasks, improving grip endurance on repeated testing, negative or reduced Finkelstein provocation, and tolerance of simulated scissor/cutting tasks without next-day flare.
- Review: reassess at 2 weeks; escalate to the referring clinician if no improvement or worsening, given the partial injection response.
Certify modified duties with clear review dates rather than open-ended full clearance.