Tendinopathies are extremely common in athletes. Any sport that requires a repetitive motion, such as a tennis serve or volley, a basketball free throw, or “turning the wrists over,” as in the completion of a golf or baseball swing, puts an athlete at risk for tendon inflammation, instability, degeneration, or even rupture. Even recreational rock climbing, which is well known for its association with flexor pulley rupture, has been implicated in tendinopathy of the wrist. Swimming, bowling, gymnastics, weightlifting, cycling, and skiing are among the many other sports associated with repetitive use tendinopathy.
Montalvan et al. categorized extensor carpi ulnaris (ECU) tendinopathy using 28 cases recorded in elite tennis players. The authors divided ECU tendon injuries into three categories: tendinopathy, instability, or rupture. Allende and Le Viet reported on 28 patients who underwent surgical treatment for ECU tendinopathy between 1990 and 2002. Seventeen of the 28 patients reported onset of symptoms after sports activity. Of the 28 patients, 15 had tenosynovitis or tendinosis, 5 had dislocation of the tendon, 4 had subluxation, and 4 had a tendon rupture. Twenty-two of the 28 patients were able to return to their previous level of activity at a mean of 23 months after surgery.
The first dorsal compartment, which contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, is also subject to wrist tendinopathy, specifically De Quervain tenosynovitis, especially in persons who participate in sports involving a racquet.
Soejima et al. reported a case of flexor carpi radialis (FCR) tendinopathy in a professional baseball player that was associated with a malunited trapezial ridge fracture. The patient was successfully treated with excision of the trapezial ridge. Buterbaugh and colleagues, in evaluating ulnar-sided wrist pain in seven professional athletes, reported acute calcific flexor carpi ulnaris (FCU) tendinitis as one of the contributing sources. Some sports that require repetitive wrist extension and radial deviation, such as rowing and powder skiing, have been found to be associated with intersection syndrome.
Even the extensor retinaculum, the soft tissue layer that provides a sheathlike investing roof for the extensor tendons over the dorsal aspect of the distal radius and carpus, has been implicated in athletes as a source of pain. Thickening and diffuse proliferation of this tissue may result from hyperextension activities required in certain athletic pursuits. This particular scenario has been termed extensor retinaculum impingement .
For all of the tendinopathies described in sports, early diagnosis and nonoperative treatment with activity modification, use of a splint or brace, and use of nonsteroidal antiinflammatory drugs has been the cornerstone of management. This chapter presents a discussion of the history and physical examination and the common tendinopathies associated with sports, as well as treatment options, with return to sports as the ultimate goal.
As in all areas of medicine, the history is a critical component in making a correct diagnosis. When one asks the appropriate questions and listens carefully to the responses, the diagnosis of wrist tendinopathies can be quite straightforward. Tendons, which are the structures that connect muscle bellies to bones, allow for confluent joint and extremity motion. Therefore any repetitive wrist or hand motions that elicit pain are an important focus in a person with a suspected tendinopathy. If active wrist flexion causes pain, then the flexor tendons may be inflamed. Similarly, if active extension is painful, then extensor tendons may be implicated in the pathology. Conversely, passive stretching of an irritated tendon also causes pain and can be a clue as to which tendon, or tendons, are involved.
The location of the pain is very important as well. Often when tendinopathy is present, an athlete runs his or her hand longitudinally along the tendon(s) involved, offering a key diagnostic clue. A fracture is often painful at a specific place, whereas tendons tend to “hurt” along the longitudinal course of the tendon. At this point, it is important to note that “pain” is a historic, or subjective, complaint, whereas “tenderness” is a component of the physical examination in which the examiner elicits pain through palpation or pressure.
Next, the timing of the injury is important. Is the pathology the result of repetitive activity, or did it occur after one specific incident? For example, a tendon rupture typically occurs suddenly, after a single event, whereas tendinosis tends to be the result of repetitive movements of the hand or wrist, such as is seen in ping pong, tennis, or sports that involve throwing. Often with tendinosis, the pain recurs with the specific exacerbating motion, such as flexion, extension, radial or ulnar deviation, and, in some cases, pronation and supination of the wrist. All of these questions should be included in the history to help elucidate the correct diagnosis. Any exacerbating or alleviating events should also be ascertained. It is important to know if placing the wrist in a certain position or if performing certain motions or maneuvers worsen (or lessen) the pain; these facts also may provide a clue to the diagnosis. Any prior treatments, no matter how menial, are important historic data. If therapy has been initiated, which is often the case in high-level athletics, it is important to distinguish between exercises or modalities that have proven beneficial or detrimental to recovery. For example, stretching programs may exacerbate the symptoms of tendinopathy when they are implemented before tendon healing, which helps lead the interviewer to the correct diagnosis.
Direct evaluation of the wrist should always begin with inspection. Any visible swelling or asymmetry when compared with the other wrist is a very important clue in diagnosing wrist tendon pathology. In the case of De Quervain tenosynovitis, which involves the tendons of the first dorsal compartment, it is quite common for swelling to occur over the radial aspect of the wrist at the level of the radial styloid. When the wrists are placed side by side, the asymmetric swelling often becomes evident.
The hallmark of physical examination in persons with acute calcific tendinitis is severe tenderness to palpation along the course of the tendon. Whereas tenderness in a fracture occurs at the point of fracture, tenderness associated with tendinosis is often more diffusely felt along the course of the involved tendon. The exception may be insertional tendinopathy, in which case the maximal tenderness is elicited at the insertion point of the involved tendon onto bone. The pain is exacerbated by passive stretch of the involved tendon, further aiding diagnosis. Arthritis pain, conversely, tends to increase with compression across a joint, whereas passive stretching may actually alleviate the pain associated with arthritis or joint pathology.
Certain tests have been determined to be associated with specific tendon pathology. The Finkelstein test ( Fig. 75-1 ) passively stretches the APL and EPB tendons—that is, the tendons of the first dorsal compartment—and aids in diagnosing De Quervain tenosynovitis. The patient is asked to clasp his or her thumb inside the flexed fingers of the hand and then ulnarly deviate the wrist. This maneuver will reproduce pain in most patients with this condition.
Other palpation techniques include the detection of tendon snapping or popping during wrist motion. For example, the ECU tendon may snap over the ulnar styloid when the extended wrist is brought actively from a pronated to a fully supinated position. The patient often feels the tendon snap with the supination maneuver, and the examiner’s index finger, when lightly placed over the ulnar styloid, may confirm the abnormal tendon subluxation or frank dislocation.
To comprehensively assess motion, the patient should be asked to flex and extend, radially and ulnarly deviate, and pronate and supinate the wrist in sequence. Repeating these motions against resistance may reveal subtle tendon pathology. Because variations of normal exist, comparing the range of motion with the contralateral wrist is necessary to detect loss of motion in any direction.
A respect for the differential diagnosis of wrist pain should always guide the remainder of the examination. Deciding whether bone, joint, ligament, nerve, or even a vascular structure is concurrently injured depends on the examiner’s ability to synthesize appropriate history clues with key physical examination findings. This approach will help the practitioner avoid compartmentalizing every athletic wrist complaint as a tendon-related pathology and steer him or her toward appropriate adjunctive imaging studies.
Tendinopathy of the wrist is not a bony pathology, but plain radiographs and advanced imaging, when indicated, can help determine and finely hone diagnostic evaluations of the wrist. Imaging can either eliminate or support the diagnosis of fracture, carpal instability, and Kienbock disease, for example, which are in the differential diagnosis of the athlete with wrist pain.
At a minimum, radiographs of the wrist that include two orthogonal views, a posteroanterior (PA) view, and a lateral view should be obtained. A 45-degree semipronated oblique view and a PA view in ulnar deviation to maximally delineate the scaphoid are also valuable when standard views are unrevealing. A clenched-fist anteroposterior view is a form of stress view that may suggest ligament injury and potential carpal instability. Whenever doubt exists, a radiograph of the contralateral wrist is warranted, because widening of the scapholunate interval, for example, may be a bilateral finding and not indicative of a specific injury.
Additional studies should be directed by history and physical examination findings and should be used to confirm or deny the presence of a suspected injury rather than as a “shotgun” element of the workup. A magnetic resonance imaging (MRI) study, with or without intraarticular administration of gadolinium, is occasionally performed to assess the presence of intrinsic ligamentous or triangular fibrocartilage complex (TFCC) injury. Gadolinium injected into the radiocarpal joint may be seen to leak into either the midcarpal joint or into the distal radioulnar joint if a significant ligament injury is present. This magnetic resonance arthrogram is an extremely useful tool when correlated with history, physical examination, and plain radiographic findings that suggest a specific injury.
Nuclear medicine studies such as bone scintigraphy (a bone scan) can be helpful as a sensitive indicator of acute injury, such as occult scaphoid fracture, but may lack the specificity to define an exact injury. Bone scans should be ordered no less than 24 to 48 hours after injury to eliminate the possibility of false-negative results. Practically speaking, given the widespread availability of MRI, bone scans have fallen out of favor as a preferred imaging modality for wrist pathology.
Common Wrist Tendinopathies
Extensor Carpi Ulnaris Tendinopathy
Situated in the sixth dorsal compartment at the ulnar aspect of the wrist, the ECU tendon is commonly compromised by sporting activities. Golfers, tennis players, and other participants in racquet sports are at particular risk for injuries to the ECU. ECU tendon problems may manifest as inflammatory tendinitis, degenerative tendinosis, instability (subluxation or dislocation), or rupture. One specific form of tendinopathy, acute calcific tendinitis, presents with intense pain in the area of the involved tendon, and the etiology that differentiates it from degenerative tendinosis is poorly understood.
Anatomically the ECU is adjacent to the ulnar styloid, and dorsal-to-palmar dislocation or subluxation of the tendon can lead to a painful snapping sensation when the wrist undergoes simultaneous extension and rotation. Because the floor of the ECU sheath is inherently considered a part of the TFCC, tendinopathy can and does coexist with TFCC injury in some cases.
Differentiating between three types of tendon pathology for the ECU is useful in directing treatment. As previously stated, Montalvan et al. classified ECU tendon pathology into three categories: acute instability, intrinsic tendinopathy, and rupture. The authors indicate that treatment differs for each of the tendon pathology subtypes, making the classification relevant and important. For any athlete who presents with acute onset of ulnar-sided wrist pain, ECU tendinopathy is high on the list of differential diagnoses. Because it may exist in the presence of other pathology, such as TFCC injury, the exact etiology may not be easily ascertained.
Occasionally, swelling over the ECU tendon sheath is present, and active extension with ulnar deviation of the wrist elicits pain. The practitioner should inquire about a history of snapping, especially when it is associated with twisting movements of the wrist. Any sudden loss of motion, especially extension combined with ulnar deviation, may provide evidence that rupture is possible.
Pain with active wrist extension and ulnar deviation against resistance suggests a component of ECU tendinopathy. Tenderness along the ECU tendon should be expected. Any instability of the tendon, as mentioned in the physical examination section, should also be tested. To detect instability, the examiner places an index finger lightly on the patient’s supinated wrist, with the wrist in full extension. The patient then ulnarly deviates the wrist and brings the wrist into flexion. A painful snap indicates ECU instability. Lastly, an inability to extend and ulnarly deviate the wrist may be an indication of rupture.
For cases of acute tendonitis or degenerative tendinosis without instability, immobilization in a short-arm cast, splint, or brace is warranted, along with the administration of oral nonsteroidal antiinflammatory drugs. Selective use of corticosteroid injection for symptoms unresponsive to splinting and oral medications can be attempted, but patients need to be warned about the theoretical risk of tendon rupture.
Early immobilization for instability involves the use of a long-arm splint or cast with the wrist in pronation, because the supinated wrist, when brought from extension into ulnar deviation and flexion, may elicit the painful snap. If splinting fails to alleviate subjective and objective instability, surgical reconstruction of the ECU tendon sheath to reroute and stabilize the tendon dorsally is justified. For tendon rupture, primary repair or tendon transfer may be needed to rebalance wrist extension and maximize function in the competitive athlete.
Criteria for Return to Sports
After nonoperative management, the timing for return to sport is based on symptom resolution, which may vary from 1 or 2 weeks to 3 months in some cases. After simple surgical release of the ECU tendon from its investing compartment, postoperative splinting is discontinued after only 2 weeks, with therapy directed at restoring motion and strength. When the patient demonstrates full painless motion and adequate strength similar to that of the contralateral side, return to sport is allowed, typically 6 weeks after surgery.
In the case of ECU tendon sheath reconstruction, a long-arm splint is used for 6 weeks after surgery, followed by an additional 6 weeks of therapy before the athlete is allowed to return to his or her sport. Resolution of pain and instability, coupled with near-normal strength and motion, are the benchmarks for permitting a safe return to sports. Although 3 months is a guideline, individual recovery times may vary. If it is practical for the given sport, intermittent use of a protective short-arm wrist brace is encouraged until confidence in the strength of the wrist is restored.
In all cases of ECU tendinopathy without instability, I prefer to immobilize the tendon in a short-arm brace or cast for a period of 4 weeks, along with prescription of an oral nonsteroidal antiinflammatory drug. This approach is typically effective for cases of early degenerative tendinosis or acute calcific tendonitis. If splinting and medication are ineffective, I offer a corticosteroid injection, followed by an additional period of protective splinting. I prefer to use 1 mL of 10 mg/mL dexamethasone mixed with 1 mL of 1% lidocaine without epinephrine. Patients are counseled about the possibility of tendon rupture after a steroid injection and are free to decline this treatment. Surgery is warranted only in recalcitrant cases unless persistent instability is present. Surgical release of stenosing tenosynovitis typically brings a good degree of relief. I use an incision that overlies the course of the dorsal sensory branch of the ulnar nerve so it can be identified and protected. The extensor retinaculum is incised over the ECU tendon from proximal to distal. No cases of late instability have been reported after surgical release of the ECU tendon from its sheath.
In cases of acute instability, on the other hand, a period of immobilization in a pronated long-arm splint is tried first. In cases refractory to initial splinting or for recurrent episodes of symptomatic dislocation, surgical reconstruction of the ECU tendon sheath with the extensor retinaculum is preferred ( Fig. 75-2 ). The tendon is immobilized in a long-arm splint in pronation for 6 weeks after surgery, followed by a period of motion recovery and progressive strengthening exercises.