New Research: Cartilage cell proliferation in degenerative TFCC wrist lesions. Read more: http://www.ncbi.nlm.nih.gov/pubmed/19415312?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
SEE! Central Tears do have the capacity to heal!
Press Test Article
I would recommend the scale as a more descriptive tool. The weight bearing test using a non digital scale allows one to view the number compared to the unaffected side. This then allows the patient to determine if there is progress over the course of time.
Heres the link:
http://www.ncbi.nlm.nih.gov/pubmed/7574285
Anatomy of the TFCC- great site for patients
http://www.eorthopod.com/public/patient_education/10171/triangular_fibrocartilage_complex_tfcc_injuries.html
Japan Study on splinting for TFCC tears- you can email me and I can send a file with photos
http://sciencelinks.jp/j-east/article/200510/000020051005A0243733.php
WRIST INJURIES IN GOLF MAY 2005 Larry Bowman, MD
Larry Bowman, M.D.
Team Orthopaedic Surgeon, Clemson
Danny Poole, MA, ATC
Director of Sports Medicine and Head Athletic Trainer, Clemson
Golf has become increasingly popular in the United States. There are an estimated 25 million participants of all ages and skill levels. Because of the lack of physical contact and low impact appearance, most people feel there is a low potential for injury. Unfortunately, this is not the case. The large majority of injuries are from overuse in professional golfers and poor swing mechanics in recreational golfers. Approximately one-third of golf injuries in the professional golfer are related to the wrist, compared to twenty percent in the amateur golfer. The most common injuries to the wrist are related to overuse. De Quervains syndrome, an inflammation of the tendons and the synovium in the tendon sheath of the first dorsal compartment of the wrist, is secondary to repetitive sliding of the tendons on the thumb side of the wrist. Forceful gripping with ulnar deviation which is the essential position in the golf swing, is responsible.
The treatment is rest, along with physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDS). Injecting corticosteroids in the first dorsal compartment sheath may be needed followed by surgical release if all else fails.
Dorsal impingement syndrome (pain on the top of the wrist) occurs especially in recreational athletes with poor swing mechanics. Correcting the swing along with NSAIDS, physical therapy, and occasional injection with corticosteroids will usually correct the problem. Wrist arthroscopic surgery is rarely necessary.
Triangular fibrocartilage complex injuries (TFCC) and extensor carpi ulnaris dislocation (ECU) occur from ulnar overload. The mechanism of injury can be acute (hitting the ball fat) or from repetitive, improper swing mechanics. Arthroscopic surgery for TFCC tears is the treatment of choice. There is still controversy among sports medicine professionals whether casting or open surgical repair is indicated for acute ECU sheath ruptures.
Fractures in the wrist are rare in golfers. Injury to the hook of the hamate (golfer's wrist) accounts for only two percent of all wrist fractures but thirty-three percent of all hamate fractures are found in golfers. It is the most common fracture in golf and can be undiagnosed for weeks or months. The hamate is situated at the base of the palm on the ulnar (little finger) side and is injured by hitting the ball "fat". When the club head strikes an immovable object; rock, root, or too much ground, the butt of the club is forced into the ulnar side of the palm of the hand. The fracture is not seen on standard x-ray views and requires a special carpal tunnel view or even a CT scan or MRI to make the diagnosis. Cast treatment for acute injuries or surgical excision of the fracture fragment in the late diagnosed cases is the treatment of choice. To prevent this injury, proper club length (butt should extend beyond the palm of the leading hand) and proper size and padded grips are necessary.
In conclusion, golf is a popular sport enjoyed by millions of athletes in the USA with a high concentration of participants in the geographical region of the ACC. With proper equipment, warm-up, and swing mechanics, injuries can be minimized. If overuse and poor swing mechanics can be avoided, chronic and more serious wrist problems will be the source of discussion and not surgery.
REFERENCES
1. McCarrol JR, Rettig AC, Shelbourne KD: Injuries in the amateur golfer. Phys Sportsmed 1990;18(3):122-126
2. Rettig AC: Athletic Injuries of the Wrist and Hand. The American Journal of Sports Medicine 2004; 32(1):262-271.
3. Murray PM, Cooney WP: Golf-induced injuries of the wrist. Clin Sports Med 1996;15(1):85-108.
4. Skolnick AA: 'Golfer's wrist' can be a tough break to diagnose. JAMA 1998;279(8):571-5
ECU subluxation in the professional Golfer Allison Taylor OTR, CHT
ere is a Case Study on someone with ECU subluxation: This was presented at the ASHT conference.
Slide One:
Background
female age 21
Collegiate Level Player- Auburn University
History of Chronic Pain on ulna side of wrist - left during practice and play with impact phase
Reported that she "couldnt play golf- ECU tendon rolls over the bone"
Complicated by extreme compression by taping over the ulna head (to reduce pain) which resulted in Wartenburgs syndrome (ulnar nerve injury)
Splint is the only option
Golf Statistics- see posting.
26.2 million golfers in the us
50% of older comprise 33% of this group Weisler, MD and Lumsden, MD
Literature review- most common wrist injuries occur to the left wrist
12-36% in females, 18-28% in males
20-32.7% in professionals
Most commonly occurring in Impact phase
GOLF SWING
6 phases Theriault and Lachance 98
-1-2 Ball address and backswing
2-3 Forward swing and ball impact
5-6 Early and late follow through
4 phases described by Cahalan et al and Chao et al
Description of the biomechanics of each phase- murray and cooney 96 (right handed golfer)
A back swing- left and right wrist in radial deviation
B. Downswing- release of wrist from radial deviation to ulnar deviation
C. Ball Strike- Both wrist are straight completing the release of radial deviation to ulnar deviation
D. Follow through wrist fully released from an ulnar deviation to a radial deviation
IMPACT Phase
Left wrist comes from "cocked" position with radial deviation and full dorsiflexion to a more neutral to slight ulnar deviation just prior to impact
Force is applies at wrist on impact with the motion progressing to a left forearm supinating end the right arm pronating creating a roll over action in the hands
Left wrist acts as catapult while right wrist extends, flexes and deviates
The ROM at the wrist in the golf swing exceeds the what is normal functional ROM
Golf Injuries
Epidemiology
Etiology
Profiles and characteristics
Specific injuries
Anatomy of the ECU
Origin and insertion- base of 5th metacarpal
6th compartment
Subsheath
Structures at the ulna side of the wrist
TFCC and ECU correlation
Why Pain? forced flexion and Ulnar deviation
ECU as a wrist stabilizer- dorsal stability
Injury usually occurs with sudden ulna load ie- club striking the groung
Treatment or Surgery
ECU subluaion- LAC and 4 weeks wrist extended as well as Radial deviation forearm supinated
4 weeks splinted
no golf for 2 months
Chronic ECU subluxation: Burkhart et all described reconnection of subsheath long with restraining structure for ECU tendon - retai of ulna septum of 6th dorsal comparment plus sling
4-6 weeks casted with forearm in supination? other literature indicates pronation
Splinted for 4-6 weeks with ROM
Golf- gentle short range after 3 months.
HISTORY
Originally injured hitting a Tee Shot Sept 27th 03
Pt desctibed as "extreme pain and a popping sensation" over the dorsoulnar aspect of the wrist
Was having pain at Dorsoulnar aspect of wrist since the spring of that year which was aggravated by this injury.
First MD appointment at Auburn University 10-02-2003 Ulnar blocking splint for 2-3 weeks
MRI reveled ECU sheath rupture
Also diagnosed with ECU tendon partial tear
Pt is diabetic
TESTING
FUSS
TFCC
Pisform Triquetral compression
Lincsheil balltoment
Reagan Shuck
Kleinman Shear
Watson Maneuver
HTCC Diagnosis
DR Lourie- dx Partial ECU subsheath rupture with partial subluxation
A portion of the subsheath appeared intact
May be consistent in wormen with this injury that the TFCC is toen however appears to be intact in this case
1st treatment at this location
MD injected pat with 1/2 + 1/2 X C injection into the ECU subsheath and placed in LAC- elbow at 90 degrees, forearm pronative to 35 degrees to stabilize ECU, wrist slightly dorsiflexed to take pressure off the subsheath. fingers free
Plan- return in 3 weeks and change to a LAC with forearm only slightly pronated for 3 more weeks then start ROM
No golf for 3 months.
March 424
Plaster cast changed to less pronation, March 26 cast removed FUSS performed and no exidence of subluxation of the ECU
Place in SAS and sent back to AUburn to begin ROM avoiding ulnar deviation with flexion
Ok to start strengthening in 3 weeks
April 22 05-
Returns was ok until recently- pt taped her wrist heavily to prevent subjective subluation resulted in numbness and tingling over distribution of dorsal radial sensory nerve.
MD at Auburn described the pat as non compliant and has been taping with a twisted braided rope which whe added a link so that it circumferentially constircted her wrist both proximal and distal to ulna styloid
***NOTE- this is what everyone does intuitively and how the WW was designed but without the risk******
April 22
ECU still stable with FUSS
Slight bogginess at ECU insertion with pain on resisted wrist dorsiflexiion
Positive tinels and slight carpal tunnel
EPL tenosynovitis probably due to taping.
Treatment- injection at ECU insertion as well as distribution of the DRSN at area of perineural fibrosis.
MD concerned about her resting, tenosynovitis and the sensation that the tendon rolls over
Was placed on another medication at Auburn and returned to therapy as well as instructed to wear a splint at all times except golf. Plan to return at end of season
May 26
Doing well at regionals ok to take 3-4 weeks off Wartenburgs improving
No ECU instability
Tender over ECU
Wose when she is in her back swing at the time of her radial deviation. As she comes down just prior to impact when she is supinating she aggrivates this
June 21 05
Numbness and Tingling improving, One more injection. CHT to fabricate a splint which will be on the ulna side of the wrist and not aggrivate the DRSN
Plan- wait and see.
Anatomy TFCC and Ulnar Wrist Extensor (ECU)
Paragraph. Click here to This article written in 1998 is a great one which describes the connection between the ECU and TFCC.
Published in the Journal of Hand Surgery. Anyone know how to get ahold of JB Tang?
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJK-4MK13W4-4&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=6cfb7d71c604b508fa42c681b839b2a5.
Research on the Press Test
Finally found something that supports what I have seen for the past 5 years. Direct correlation between weight bearing and TFCC tears!!
http://www.iaom-us.com/docs/NWSLET15.pdf
NOW- study the effectiveness of changing the press test with the WristWidget!
UT tear?
Here is a terrific website which describes a fovea test and new treatment for Ulnar sided wrist pain. http://www.mayoclinic.org/ulnar-wrist-pain/
This journal is a step in the right direction. I would add that they are still describing a surgical solution for the problem. Dr. Berger is noting the lack of a reliable objective evaluation for ulnar sided wrist pain.
I have learned that the weight bearing test is more reliable. This area is quite painful in ECU tendonitis....
How about a study on the correlation of fovea sign and weight bearing tolerance?
http://www.jhandsurg.org/article/PIIS0363502307001748/abstract