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Pieter Kroon, PT, DPT, OCS, FAAOMPT

Brenda Boucher, PT, PhD, CHT, OCS, FAAOMPT

FUNCTIONAL APPROACH TO THE TREATMENT OFTFCC PROBLEMS: EXTENSION RADIAL DEVIATION SYNDROME OF THE WRIST

Objectives1. Discuss the structure and function of the TFCC

1. Describe TFCC dysfunction in relation to a movement syndrome

2. Define an examination process to identify relevant impairments

3. Demonstrate intervention strategies to address identified impairments

1. Describe home exercises to match designated treatment objectives

APTA Vision Statement for the Physical Therapy Profession (beyond 2020)

Transforming society by optimizing movement to improve the human experience.

The physical therapist will be responsible for evaluating and managing an individual’s movement system across the lifespan to promote optimal development; diagnose impairments, activity limitations, and participation restrictions; and provide interventions targeted at preventing or ameliorating activity limitations and participation restrictions.

The movement system is the core of physical therapist practice, education, and research.

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Guiding Principles• Painful conditions of the upper extremity are often a

response to faulty mechanics and overuse.

• Faulty alignment, inadequate muscle length/strength/motor recruitment, and impaired movement can result in cumulative stresses that lead to pain and dysfunction.

• This presentation will focus on examination of the upper extremity with emphasis on alignment, tissue status, and movement patterns to identify factors that contribute to TFCC dysfunction.

• Intervention will emphasize manual techniques and specific exercises to address impairments and correct faulty movement patterns.

Donald A. NeumannKINESIOLOGY of the

MUSCULOSKELETAL SYSTEM Foundations for Rehabilitation

Second EditionMosbey Elsevier

Text & Reference Material – pictures & illustrations

Shirley SahrmannMovement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines

2010Elsevier Health Services

Manipulation Techniques of the Spine and Extremities

The Manual Therapy Institute

Pain with loaded, end-range:

- wrist extension

- wrist ulnar deviation

- forearm rotation

MOI- FOOSH with pronated

hyperextended wrist

- Distraction injury that pulls ulnar side of wrist

-Repeated microtraumaPain/Weakness with grip and/or rotation

TFCC Injury: disruption of the ulnar-sided capsulo-ligamentous structure of the wrist by way of trauma or degeneration.

Facts of interest: 1. Incidence: up to 80% of individuals post

distal radius fracture (Bombaci et al. 2008)2. Vascular supply: inner portion avascular;

periphery vascular (Steinberg et al. 1995)

Description

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DescriptionInjury Classification• Traumatic (Type 1) lesions include axial loading with or

without rotation, pure rotational type injuries, or wrist distraction. May occur with fractures.

• Degenerative (Type 2) lesions include overuse syndromes. Factors include excessive ulnocarpal impaction, ulnar variance (length of the ulna relative to the radius) and age.Palmar Classification of Acute TFCC Injuries

Palmar Classification of Degenerative TFCC injuries

Anatomy

Radiocarpal joint

Midcarpal joint

20%

80%

AnatomyImplications of Joint

Position & Joint Mobility• Scaphoid

• Lunate

• Triquetrum

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AnatomyJoint StructureDistal Radio-carpal jt

• Triangular fibro-cartilage

complex (TFCC)

Functions of the TFCC

•Primary stabilizer of the distal radio-ulnar and ulnar wrist joints•Reinforces the ulnar side of the wrist•Forms part of the concavity of the radiocarpaljoint•Helps transfer compression forces that cross the hand to the forearm

AnatomyComponents of TFCC:

• fibrocartilage (articular disc)• dorsal and palmar radioulnar ligaments• meniscus homologue• sheath of the extensor carpi ulnaris• Ulnar collateral ligament• Origins of the ulno-lunate and

ulno-triquital ligaments

Distal attachments at thetriquetrum, hamate, and base of fifth metacarpal

Anatomy

Wrist Ligaments– Maintain intercarpal alignment

– Transfer forces within and across the carpus

Dorsal view Palmer view

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“When I pick up a gallon of milk.”

Patient Body Diagram & Subjective Report

Dull ache, Can be sharp

“When I use my hand to push such as pushing up from sitting or performing a push-up.”

“When I swing a bat or racquet.”

“When I use hand tools such as a hammer or screwdriver.”

“When I play sports.”

Examination

Extension with Radial Deviation•Dominant ECRB & ECRL

•Dominant thumb & digit extensors

Impaired Movement Pattern

Muscle Imbalance

Imbalance PatternsForearm, Wrist & Hand

Strong & Dominant•ECRL & ECRB•EPL, EPB, APL•ED, EDM

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Muscle Imbalance

Imbalance PatternsForearm, Wrist & Hand

Weak•ECU•Lumbricales•Interossei

Muscle Length

Muscle Length RestrictionsForearm, Wrist & Digits

Short•Radial wrist extensors•Digit extensors (extrinsic)•Thumb extensors

? Pronators

Joint Accessory Mobility

Joint MobilityForearm & Wrist

Hypomobility/Hypermobility•Radio-ulnar joints (radial head)•Ulno-triquetral joint•Scapholuno-radial joint•1st CMC joint

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The imbalance pattern leads to sustained and/or repeated anterior glide of the medial column of the

hand, which can result is excessive stress on the TFCC and eventual tissue breakdown

POSTURE ANALYSISWeight-bearing

Non-weight bearing

Posture Analysis

Weight-bearingScapula, Elbow, Forearm, Wrist, Palm

•Scapula stability loss•Elbow hyperextension•Forearm hypersupination•Wrist radial compression/ulnardistraction•Palm arch collapse

Courtesy Brandi Smith-Young, PTBoard Certified Orthopaedic SpecialistFellow, American Academy Orthopaedic Manual Physical Therapists

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Posture Analysis

Weight-bearingScapula, GH, Elbow, Forearm, Wrist, Palm

•Scapula winging•Elbow hyperextension•Forearm hypersupination•Wrist radial compression/ulnardistraction•Palm arch collapse

Courtesy: Brandi Smith-Young, PTBoard Certified Orthopaedic SpecialistFellow, American Academy Orthopaedic Manual Physical Therapists

Posture Analysis

Non-Weight-bearingCervical Spine, Scapula, Humerus, Wrist, Thumb

•Cervical flexion•Scapula depression, abduction, downward rotation•Humeral anterior glide, medial rotation•Wrist extension/radial deviation•Thumb extension

Posture Analysis

Non-Weight-bearingCervical Spine, Scapula, Humerus, Wrist, Thumb

•Cervical flexion•Scapula depression, abduction, downward rotation•Humeral anterior glide, medial rotation•Wrist extension/radial deviation•Thumb extension

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EXAMINATIONForearm, Wrist, Hand

Physical Examination

Suggested Clinical Tests

• Press test

• Weight-bearing tolerance test

• Functional load test

Common Clinical Tests TFCC stress test

TFCC stress test

w/compression (TFCC comp test)

Gripping rotary impaction test (GRIT)

Piano key sign

Supination lift test

Prosser R et al. Provocative wrist tests and MRI are of limited diagnostic value for suspected wrist ligament injuries: a cross-sectional study. J of Physiotherapy. Dec 2011, 57(4): 247-253.

ExaminationSpecial Tests Press Test• Press Test• Patient places both hands

on arms of a stable chair or chair arm and pushes off to suspend the body using only hands.

• Positive test is the reproduction of wrist pain while pressing up the body’s weight.

Lester B, et al. “Press test” for office diagnosis of triangular fibrocartilagecomplex tears of the wrist. Am Plast Surg. 1995;35:41-45.

Reliability Sensitivity Specificity +LR -LR

NT 100 NT NA NA

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ExaminationSpecial Tests

Wrist Weight Bearing

Test• Wrist Weight Bearing Test• Equipment: NON digital scale• Test on the unaffected wrist first• Test the affected wrist slowly• Stop at the point of pain• Take 2 pieces of non elastic tape-

squeeze wrist together without compression on the ulna head (or fit with Wrist Widget).

• RETEST with the tape or Widget on.There should be an immediate change in weight bearing tolerance.

Reliability Sensitivity Specificity +LR -LR

NT NT NT NA NA

ExaminationSpecial Tests

Functional Load Test

• Functional Load Test• Equipment: 3, 4, 5 lb barbell wt• Patient holds the head of

selected barbell weight at end-range positions of ulnardeviation or supination (or pronation)

• Positive test is the reproduction of wrist pain while maintaining end-range position.

• Selection of testing position based upon patient’s report of aggravating movements/positions.

Reliability Sensitivity Specificity +LR -LR

NT NT NT NA NA

Physical Examination

Forearm, Wrist & Digits

Short•Radial wrist extensors•Digit extensors•Thumb extensors

Muscle Length Assessment

ECRB & ECRL

EPL, EPB, APL

ED, EI, EDM examples of tightness

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Physical ExaminationMuscle Strength AssessmentForearm, Wrist & Hand

Weak•ECU•Lumbricales•Interossei

ECU

Lumbricales Dorsal & Palmar Interossei

Physical Examination

Forearm & Wrist

Hypomobility/Hypermobility•Ulno-triquitral joint•Scapholuno-radial joint•Proximal Radio-ulnar joint (radial head)•1st CMC joint

Joint Mobility AssessmentUlno-triquitral jt(load & shift)

Scapholuno-radial jt(flex & ext)

PRUJ (radial head mobility)

DRUJ

1st CMC jt (hypo)

ExaminationPalpation

TFCC, Ulno-triquitral joint & DRUJ

Assess for TTP:• Distal radio-ulnar joint • Ulno-triquitral joint • Ulno-lunate joint

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Intervention

Address primary impairments, movement dysfunction and provide external support as indicated.

Local & Proximal

Intervention

Manipulations -Local• Radial head thrust

• Ulno-triquitral thrust

InterventionManipulations -Local• Scapholuno-radial thrust

• 1st CMC

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Intervention

Manipulations -Proximal• Cervical-thoracic

• Upper thoracic

Intervention

• Mobilizations • PRUJ & DRUJ

• Radio-carpal joints

• Intercarpal joints

InterventionExercise•Wrist extension strength training (ECU emphasis)

Small finger placement

Neutral fist position

Avoid excessive activity of: a. radial extensors, b. thumb ext/abd, c. extensor digitiminimi

a. b. c.

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InterventionExercise•Lengthen

Wrist & extrinsic digit extensors

Thumb extensors & abductor

Wrist radial extensors & thumb extensors/abductors

InterventionExercise•Lumbricale hold

Correct Incorrect

Lumbricale hold with active wrist flexion-extension

Intervention – Cuff ControlGlenohumeral Joint Core Stabilization•Supraspinatus•Infraspinatus•Teres minor•Subscapularis

CompressElevate

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Intervention

• Strap, Wrist Support, Tape

Patient Management

Model

Pain Diagram

History &

SubjectivePhysical

Exam

Palpation Muscle Length

Muscle Strength

Manipulation Mobilization Stretch Strengthen External Support

Joint Accessory

Mobility

Special Tests

Patient Self Report

Measures

Muscle Imbalance &

Impaired Movement Patterns

Description: TFCC Injury

Anatomy & Biomechanics

Intervention

References1. Tracy MR, Wiesler ER, Poehling GG. Arthroscopic Management of Triangular Fibrocartilage

Tears in the Athlete. Operative Techniques in Sports Medicine. 2006; (2) 95-100.2. Tsai P, Paksima N. The distal radioulnar joint. Bull NYU Hosp Jt Dis. 2009;67:90-96.3. Albastaki V, Sophocleous D, Gothlin J. MRI of the TFCC lesions: A Comprehensive

Clinicoradiologic Approach and Review of the Literature. Journal of Manipulative and Physiological Therapeutics. 2007;30(7)522-526.

4. Lester B, Halbrecht J, Levy IM. “Press Test” for Office Diagnosis of Triangular FibrocartilageComplex Tears of the Wrist. Ann Plast Surg. 1995;35(1)41-45.

5. Bombaci H, Polat A, Deniz G, et al.The value of plain X-rays in predicting TFCC injury after distal radial fractures. The Journal Of Hand Surgery, European Volume. 2008; 33 (3) 322-6.

6. Nakamura T, Nakao Y, Ikegami H, Sato K. Open repair of the ulnar disruption of the triangular fibrocartilage complex with double three-dimensional mattress suturing technique. Tech Hand Up Extrem Surg. 2004;8:116-123.

7. Cober S, Trumble T. Arthroscopic repair of triangular fibrocartilage complex injuries. Orthop ClinNorth Am. 2001;32:279-294, viii.

8. Estrella E, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocatilage complex tears. Arthroscopy. 2007;23:729-737.

9. Shih JT, Lee HM. Functional results post-triangular fibrocartilage complex reconstruction with extensor carpi ulnaris with or without ulnar shortening in chronic distal radioulnar joint instability. Hand Surg. 2005;10:169-176.

10.Husby T, Haugstvedt JR. Long term results after arthroscopic resection of lesions of the triangular fibrocartilage complex. Scand J Plast Reconstr Hand Surg. 2001;35:79-83.

11.Infanger M, Grimm D. Meniscus and discus lesions of triangular fibrocartilage complex (TFCC): treatment by laser-assisted wrist arthroscopy. J Plast Reconstr Aesthet Surg. 2009:62:466-471.

12.Nagle DJ. Triangular fibrocartilage complex tears in the athlete. Clinical Sports Medicine. 2001;20(1):155-66.

13.Carlsen B, Rizzo M, Moran S. Soft-tissue injuries associated with distal radius fractures. Operative Techniques In Orthopaedics. April 2009;19(2):107-118.

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References continued14. Cheng HS, Hung LK, Ho PC, Wong J. An analysis of causes and treatment outcome of

chronic wrist pain after distal radius fractures. Hand Surgery. 2008;13(1):1-10.15. Gerlach D, Chun K, Trumble T. Triangular fibrocartilage complex repair through bone tunnels

(palmer type 1D). Operative Techniques In Sports Medicine. September 2010;18(3):173-180.16. Husby T, Haugstvedt JR. Long term results after arthroscopic resection of lesions of the

triangular fibrocartilage complex. Journal of Plastic Reconstructive Hand Surgery. 2001; 35:79-83.

17. Joshy S, Lee K, Deshmukh S. Accuracy of direct magnetic resonance arthrography in the diagnosis of triangular fibrocartilage complex tears of the wrist. International Orthopaedics. April 19, 2008;32(2):251-253.

18. Park M, Jagadish A, Yao J. The rate of triangular fibrocartilage injuries requiring surgical intervention. Orthopedics. November 2010;33(11):806.

19. Pho C, Godges J. Triangular fibrocartilage complex (TFCC) repair and rehabilitation. Loma Linda U DPT Program. http://xnet.kp.org/socal_rehabspecialists/ptr_library/04WristandHand%20Region/21Wrist-TriangularFibrocartilageComplexRepair.pdf. Accessed September 15, 2012.

20. Scheer JH, Adolfsson LE. Patterns of triangular fibrocartilage complex (TFCC) injury associated with severely dorsally dislocated extra-articular distal radius fractures. Int. J Care Injured. February 2012;43(6):926-932.

21. Shih JT, Lee HM. Functional results post-triangular fibrocartilage complex reconstruction with extensor carpi ulnaris with or without ulnar shortening in chronic distal radioulnar joint instability. International Orthopedics. 2008, 32;251-253.

22. Warwick D, Alam M. (i) Anatomy of the carpus and surgical approaches. Orthopaedics and Trauma. October 2011;25(5):317-323.

23. Watanabe A, Souza F, Vezeridis P, Blazar P. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skeletal Radiol. 2010 September; 39(9): 837–857.

24. Shin AY, Deithch MA, Sachar K, Boyer MI. Ulnar-sided wrist pain: Diagnosis and treatment. AAOS Instructional Course Lectures. 2005;54:115-128.

25. Sachar K. Ulnar-sided wrist pain: Evaluation and Treatment of triangular fibrocartilagecomplex tears ulnocarpal impaction syndrome and lunotriquetral ligament tears