Tendinopathies in the hand and wrist are common in athletes. This article reviews some of the common hand and wrist conditions, such as trigger digits, first dorsal compartment tendonitis, and extensor carpi ulnaris tendonitis. In addition, it reviews less commonly seen tendon conditions of the flexor carpi radialis and ulnaris, intersection syndrome, and extensor pollicis entrapment conditions. Diagnosis, nonoperative and operative treatment, and postoperative recommendations and return to play are also discussed.
Key points
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Sports-related tendinopathies of the hand and wrist are common and are predominantly related to overuse.
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Most cases can be diagnosed with history and physical examination alone, with the need for advanced imaging in recalcitrant cases.
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Nonoperative management, consisting of rest, activity modification, antiinflammatory medications, temporary splinting or bracing, hand therapy, and possibly steroid injections, plays a pivotal role. Surgical intervention may be offered in those patients who fail nonoperative treatment.
Introduction
Hand and wrist tendinopathies are commonly seen in athletes, ranging from contact to noncontact racquet/stick sports. Many of these typically do not cause the athletes to lose time from their sports because treatment is symptomatic and rarely time specific. Diagnosis for tendinopathies in the hand and wrist is predominantly made on clinical examination. If the diagnosis is uncertain or the patient fails nonoperative treatment, advanced imaging may help. Most of these conditions respond to nonoperative treatment with activity modification, antiinflammatory medications, hand therapy, and corticosteroid injections. Although the level of steroid used for injection is typically very low, athletes in competitive leagues, in which testing is performed for performance-enhancing medications, should be aware of possible testing parameters for banned substances before having an injection. Although the authors do not believe these injections will improve overall performance, sports vary regarding their specific testing parameters and banned substances, and thus the medical personnel and the athletes should be aware of the specifics for their sports. When symptoms persist in spite of nonoperative treatment, clinicians offer surgical treatment. This surgery can typically be done under local anesthesia (WALANT [wide awake local anesthesia no tourniquet]) or local anesthesia with sedation. Following operative treatment, a structured rehabilitation program to resume motion and tendon gliding is imperative under the guidance of a hand therapist and then athletic trainer/coach.
Extensor tendinopathies
De Quervain Tenosynovitis
Tendinopathy involving the first dorsal extensor compartment, or de Quervain tenosynovitis, is a notable source of radial-sided wrist pain in athletes participating in racquet sports, rowing, golf, volleyball, and bowling. In tennis, golf, and rowing, the condition has been attributed to varied grips, altered swing mechanics, and tight grips with poor technique, respectively. In contrast, in volleyball, repetitive microtrauma from impact of the ball on the dorsal radial wrist and increased training time has been implicated with the risk of developing de Quervain tenosynovitis. Regardless of the proposed sport-specific mechanisms, the end result is restricted, painful motion of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) within the fibro-osseous sheath in which they travel immediately proximal to the radial styloid. The tendon sheaths of those affected may be up to 5 times thicker as a result of accumulation of mucopolysaccharides and increased vascularity, consistent with myxoid degeneration rather than acute inflammation. ,
A higher rate of de Quervain tenosynovitis has been shown in women, with a slight predilection for individuals more than 40 years of age or of African American decent. Affected individuals invariably have some degree of swelling in the vicinity of the radial styloid and tenderness with palpation to the first extensor compartment tendons. The Eichhoff and Finkelstein maneuvers ( Fig. 1 ) have been described to clinically confirm the diagnosis of de Quervain tenosynovitis. They are commonly thought of as the same maneuver; however, there are differences. The Eichhoff maneuver is performed by asking the patient to gently grasp the thumb in the palm while the wrist is ulnarly deviated by the examiner. Pain over the region of the first extensor compartment is considered a positive maneuver and considered consistent with de Quervain tenosynovitis. The Finkelstein maneuver, as originally described, has the examiner passively flex the thumb and ulnarly deviate the wrist, with a positive maneuver producing pain over the first extensor compartment. Wu and colleagues compared these maneuvers on 72 wrists (36 patients) and found the Finkelstein maneuver was more accurate, with fewer positive results and less discomfort for the patients. More recently, the wrist hyperflexion and abduction of the thumb (WHAT) maneuver ( Fig. 2 ) has been described as an additional diagnostic tool with better sensitivity (0.99 vs 0.89) and specificity (0.28 vs 0.14). A positive maneuver is reproduction of symptoms with resisted thumb abduction with the wrist maximally flexed.
As with most tendinopathies, conservative treatment begins with avoiding the inciting event. A short course of immobilization, hand therapy, and nonsteroidal antiinflammatory medications can be an effective adjunct to limit pain and symptoms. Injection of corticosteroid and local anesthetic into the tendon sheath of the first dorsal compartment is often combined with these conservative modalities. Earp and colleagues reported on the effectiveness of a single injection and determined that 82% of patients are symptom free for the first 6 weeks and more than half were without symptoms at 1 year. A more recent study by Oh and colleagues found that more than 70% of patients who responded to 1 or 2 injections had resolution of symptoms. Surgical release may be warranted in cases of recalcitrant symptoms; however, patients are counseled about the possibility of an extended recovery, incomplete relief, and transient numbness in the superficial radial nerve distribution. In our practice, new patients with de Quervain tenosynovitis are offered a corticosteroid injection in combination with a forearm-based thumb spica orthosis. If possible, athletes are encouraged to await return to play until symptoms have resolved, but no formal restrictions are placed. When symptoms persist, we offer first extensor compartment release, which is done through a transverse incision, taking care to protect the sensory branches of the radial nerve and lateral antebrachial cutaneous nerves, under local anesthesia. The incision in the extensor retinaculum is along the dorsal/ulnar aspect of first extensor compartment in order to minimize the chance of tendons subluxing in a volar direction with wrist flexion and thumb motion. The EPB often has a separate subcompartment that must be recognized and released. A soft dressing is applied, and early movement of the thumb is encouraged to promote tendon gliding. Return to activities depends on wound healing and comfort, but is generally at 2 to 3 weeks after surgery.
Intersection Syndrome
Intersection syndrome is characterized by radial-sided wrist pain, swelling, tenderness, and occasional crepitus in an area approximately 4 cm proximal to the Lister tubercle ( Fig. 3 ). Controversy remains with regard to the precise location of the syndrome: the intersection of the muscle bellies of the APL and EPB and the extensor tendons of the second compartment, or stenosing tenosynovitis within the second compartment itself. One of the few reports on this condition, provided by Grundberg and Reagan in 1985, concluded that the disorder was stenosing tenosynovitis of the sheath of the common radial wrist extensors, suggesting that space limitations within this compartment lead to accumulation of reactive tissue beneath the APL and EPB. In their limited cohort, all patients improved with surgical release of the second compartment, indicating its role with this condition.
As with other tendinopathies of the hand and wrist, this has been associated with repetitive use and may be seen in athletes participating in rowing, weightlifting, and cycling. Pain is often elicited with resisted wrist extension and radial deviation, and careful attention should be paid to the location of tenderness because this can be misdiagnosed as de Quervain tenosynovitis. Treatment involves a combination of activity modification, temporary immobilization with a wrist splint in neutral extension, stretching exercises, and antiinflammatory medications. Steroid injections into the tendon sheath of the second compartment in the area of maximal tenderness may be provided in refractory cases. It has been our experience that most cases resolve with conservative modalities, hence the paucity of reported cases in the literature. In the event that symptoms persist in spite of nonoperative treatment, we release the second extensor compartment and debride any inflamed tenosynovium. This operation is typically performed out of season, with a short period of immobilization and therapy to regain motion and strength. Four to 6 weeks is expected to return to full activities.
Extensor Carpi Ulnaris Conditions
Disorder involving the extensor carpi ulnaris (ECU) tendon is a common source of ulnar-sided wrist pain, particularly in athletes using a club or racquet. A broad spectrum of modalities have been described, including stenosing tenosynovitis; tendinosis; bony erosion of the sixth compartment floor; subluxation; and, rarely, rupture. Given the anatomy of the ulnar side of the wrist, thorough physical examination is imperative. Tenderness about the ECU tendon sheath and pain or weakness with resisted wrist extension and ulnar deviation is invariably present. The ECU synergy maneuver ( Fig. 4 ), described by Ruland and Hogan, provides another tool to help better differentiate tendon versus intra-articular disorder. To perform this maneuver, the patient’s elbow is flexed to 90° with the forearm fully supinated. The patient is then asked to radially abduct the thumb against resistance as the examiner places a counterforce on the middle digit. In doing so, the second extensor compartment tendons activate and to keep the wrist in neutral position, and the ECU fires. The maneuver is deemed positive if the patient’s ulnar-sided wrist pain is recreated. The investigators noted symptomatic relief in all patients with a positive test following an ECU tendon sheath lidocaine injection, whereas those with a negative test were found to have intra-articular disorder on either MRI or wrist arthroscopy. ECU subluxation, or snapping ECU, can be evaluated by having the patient flex and ulnarly deviate the wrist with the forearm in supination because that creates the greatest angulation of the ECU tendon with respect to the ulna.
