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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