10/15/2014. Objectives. APTA Vision Statement for the Physical Therapy Profession (beyond 2020)

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1 FUNCTIONAL APPROACH TO THE TREATMENT OF TFCC PROBLEMS: EXTENSION RADIAL DEVIATION SYNDROME OF THE WRIST Pieter Kroon, PT, DPT, OCS, FAAOMPT Brenda Boucher, PT, PhD, CHT, OCS, FAAOMPT Objectives 1. 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. 1

2 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. will emphasize manual techniques and specific exercises to address impairments and correct faulty movement patterns. Text & Reference Material pictures & illustrations Donald A. Neumann KINESIOLOGY of the MUSCULOSKELETAL SYSTEM Foundations for Rehabilitation Second Edition Mosbey Elsevier Shirley Sahrmann Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines 2010 Elsevier Health Services Manipulation Techniques of the Spine and Extremities The Manual Therapy Institute TFCC Injury: disruption of the ulnarsided capsuloligamentous structure of the wrist by way of trauma or degeneration. 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 microtrauma Description Pain/Weakn ess with grip and/or rotation 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) 2

3 Injury Classification Description 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 80% 20% Implications of Joint Position & Joint Mobility Scaphoid Lunate Triquetrum Anatomy 3

4 Joint Structure Distal Radio-carpal jt Triangular fibro-cartilage complex (TFCC) Anatomy 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 radiocarpal joint Helps transfer compression forces that cross the hand to the forearm Components 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 Anatomy Distal attachments at the triquetrum, hamate, and base of fifth metacarpal Anatomy Wrist Ligaments Maintain intercarpal alignment Transfer forces within and across the carpus Dorsal view Palmer view 4

5 Examination Patient Body Diagram & Subjective Report 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 play sports. Dull ache, Can be sharp When I use hand tools such as a hammer or screwdriver. When I pick up a gallon of milk. Impaired Movement Pattern Extension with Radial Deviation Dominant ECRB & ECRL Dominant thumb & digit extensors Muscle Imbalance Imbalance Patterns Forearm, Wrist & Hand Strong & Dominant ECRL & ECRB EPL, EPB, APL ED, EDM 5

6 Muscle Imbalance Imbalance Patterns Forearm, Wrist & Hand Weak ECU Lumbricales Interossei Muscle Length Muscle Length Restrictions Forearm, Wrist & Digits Short Radial wrist extensors Digit extensors (extrinsic) Thumb extensors? Pronators Joint Accessory Mobility Joint Mobility Forearm & Wrist Hypomobility/Hypermobility Radio-ulnar joints (radial head) Ulno-triquetral joint Scapholuno-radial joint 1 st CMC joint 6

7 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 ANALYSIS Weight-bearing Non-weight bearing Posture Analysis Weight-bearing Scapula, Elbow, Forearm, Wrist, Palm Scapula stability loss Elbow hyperextension Forearm hypersupination Wrist radial compression/ulnar distraction Palm arch collapse Courtesy Brandi Smith-Young, PT Board Certified Orthopaedic Specialist Fellow, American Academy Orthopaedic Manual Physical Therapists 7

8 Posture Analysis Weight-bearing Scapula, GH, Elbow, Forearm, Wrist, Palm Scapula winging Elbow hyperextension Forearm hypersupination Wrist radial compression/ulnar distraction Palm arch collapse Courtesy: Brandi Smith-Young, PT Board Certified Orthopaedic Specialist Fellow, American Academy Orthopaedic Manual Physical Therapists Posture Analysis Non-Weight-bearing Cervical 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-bearing Cervical Spine, Scapula, Humerus, Wrist, Thumb Cervical flexion Scapula depression, abduction, downward rotation Humeral anterior glide, medial rotation Wrist extension/radial deviation Thumb extension 8

9 EXAMINATION Forearm, Wrist, Hand Physical Examination 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): Suggested Clinical Tests Press test Weight-bearing tolerance test Functional load test Examination Special Tests 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. Press Test Reliability Sensitivity Specificity +LR -LR NT 100 NT NA NA Lester B, et al. Press test for office diagnosis of triangular fibrocartilage complex tears of the wrist. Am Plast Surg. 1995;35:

10 Examination Special Tests 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 tapesqueeze 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. Wrist Weight Bearing Test Reliability Sensitivity Specificity +LR -LR NT NT NT NA NA Examination Special Tests Functional Load Test Equipment: 3, 4, 5 lb barbell wt Patient holds the head of selected barbell weight at endrange positions of ulnar deviation 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. Functional Load Test Reliability Sensitivity Specificity +LR -LR NT NT NT NA NA Muscle Length Assessment Forearm, Wrist & Digits Short Radial wrist extensors Digit extensors Thumb extensors Physical Examination ECRB & ECRL EPL, EPB, APL ED, EI, EDM examples of tightness 10

11 Physical Examination Muscle Strength Assessment Forearm, Wrist & Hand Weak ECU Lumbricales Interossei ECU Lumbricales Dorsal & Palmar Interossei Joint Mobility Assessment Forearm & Wrist Hypomobility/Hypermobility Ulno-triquitral joint Scapholuno-radial joint Proximal Radio-ulnar joint (radial head) 1 st CMC joint Physical Examination Scapholunoradial jt (flex & ext) Ulnotriquitral jt (load & shift) DRUJ 1 st CMC jt (hypo) PRUJ (radial head mobility) Examination Palpation TFCC, Ulno-triquitral joint & DRUJ Assess for TTP: Distal radio-ulnar joint Ulno-triquitral joint Ulno-lunate joint 11

12 Address primary impairments, movement dysfunction and provide external support as indicated. Local & Proximal Manipulations - Local Radial head thrust Ulno-triquitral thrust Manipulations - Local Scapholuno-radial thrust 1 st CMC 12

13 Manipulations - Proximal Cervical-thoracic Upper thoracic Mobilizations PRUJ & DRUJ Radio-carpal joints Intercarpal joints Exercise Wrist extension strength training (ECU emphasis) Small finger placement Neutral fist position a. b. c. Avoid excessive activity of: a. radial extensors, b. thumb ext/abd, c. extensor digiti minimi 13

14 Exercise Lengthen Thumb extensors & abductor Wrist & extrinsic digit extensors Wrist radial extensors & thumb extensors/abductors Exercise Lumbricale hold Correct Incorrect Lumbricale hold with active wrist flexionextension Cuff Control Glenohumeral Joint Core Stabilization Supraspinatus Infraspinatus Teres minor Subscapularis Elevate Compress 14

15 Strap, Wrist Support, Tape Description: TFCC Injury Patient Management Model Anatomy & Biomechanics Pain Diagram Patient Self Report Measures Palpation Muscle Length History & Subjective Muscle Strength Physical Exam Joint Accessory Mobility Special Tests Muscle Imbalance & Impaired Movement Patterns Manipulation Mobilization Stretch Strengthen External Support References 1. Tracy MR, Wiesler ER, Poehling GG. Arthroscopic Management of Triangular Fibrocartilage Tears in the Athlete. Operative Techniques in Sports Medicine. 2006; (2) Tsai P, Paksima N. The distal radioulnar joint. Bull NYU Hosp Jt Dis. 2009;67: 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) Lester B, Halbrecht J, Levy IM. Press Test for Office Diagnosis of Triangular Fibrocartilage Complex Tears of the Wrist. Ann Plast Surg. 1995;35(1) 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) 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: Cober S, Trumble T. Arthroscopic repair of triangular fibrocartilage complex injuries. Orthop Clin North Am. 2001;32: , viii. 8. Estrella E, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocatilage complex tears. Arthroscopy. 2007;23: 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: 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: 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: Nagle DJ. Triangular fibrocartilage complex tears in the athlete. Clinical Sports Medicine. 2001;20(1): Carlsen B, Rizzo M, Moran S. Soft-tissue injuries associated with distal radius fractures. Operative Techniques In Orthopaedics. April 2009;19(2):

16 References continued 14. 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): 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): 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: 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): Park M, Jagadish A, Yao J. The rate of triangular fibrocartilage injuries requiring surgical intervention. Orthopedics. November 2010;33(11): Pho C, Godges J. Triangular fibrocartilage complex (TFCC) repair and rehabilitation. Loma Linda U DPT Program. TriangularFibrocartilageComplexRepair.pdf. Accessed September 15, 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): 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; Warwick D, Alam M. (i) Anatomy of the carpus and surgical approaches. Orthopaedics and Trauma. October 2011;25(5): Watanabe A, Souza F, Vezeridis P, Blazar P. Ulnar-sided wrist pain. II. Clinical imaging and treatment. Skeletal Radiol September; 39(9): Shin AY, Deithch MA, Sachar K, Boyer MI. Ulnar-sided wrist pain: Diagnosis and treatment. AAOS Instructional Course Lectures. 2005;54: Sachar K. Ulnar-sided wrist pain: Evaluation and Treatment of triangular fibrocartilage complex tears ulnocarpal impaction syndrome and lunotriquetral ligament tears 16