Ayala was a bright, articulate, and spunky first grader, but she had a terrible handwriting. Her classmates were learning to write full sentences, both in print and script, but Ayala could hardly write at all. When she started writing, her writing would start off strong and then gradually trail away into very lightly written, poorly formed letters. In addition, Ayala held her pencil in a strange and awkward way – instead of the typical three-finger “pinch” grip, Ayala wrapped all four fingers around the pencil and stabilized it by keeping her thumb covering the eraser. Ayala was always behind in her classwork and refused to do any homework that involved writing.


Ayala’s problem with handwriting did not stem from any problem with her hand but was actually due to a general weakness in her upper arms. In fact, Ayala presented with weakness in her entire shoulder saddle area, which includes the muscles of the lower neck, upper arm and upper back that support the shoulder. That weakness extended down the arm to her hands and fingers.

Ayala tried to compensate for that weakness by gripping the pencil in a way that concentrated the work of writing into her hand and not incorporating her arm muscles in the process. The problem was that it was difficult to maintain strong grip of the pencil without using those necessary muscle groups. With this ineffective method of writing, her handwriting was sloppy and weak. Even when Ayala managed to rally all her strength, she could maintain it only for a short time. Then she would tire and her handwriting would deteriorate after writing only a few words.


We worked with Ayala to strengthen the weak muscle groups. We started by strengthening the shoulder and worked our way down.

To strengthen the large muscles of the upper back, we used exercises like overhead press and throwing a weighted ball. We improved the strength and tone of her biceps by using weights and practicing bicep curls.

In some patients, after strengthening the shoulder and upper arm, the grip will naturally modify to the more comfortable and effective three-finger pinch grip, but that did not happen for Ayala. We began to work directly on the the fingers and grip itself. We helped Ayala practice holding a pen in the proper grip and we created repetitive exercises, like pulling a bungee cord with three fingers, to train her hand to naturally use the correct grip.

After several months of therapy Ayala was able to grasp a pen correctly, write clearly, and no longer complained of pain in her hand. This feisty little girl became another success story.