Wrist Tendinopathies

History

The history is a critical component in making a correct diagnosis. Tendons are the structures that connect muscle bellies to bones and 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. 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.

Physical Examination

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, in which the examiner grasps the patient's thumb and ulnarly deviates the wrist to passively stretch the APL and EPB tendons—that is, the tendons of the first dorsal compartment—aids in diagnosing de Quervain tenosynovitis. 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.

Range of motion (ROM) may be diminished in tendinopathies such as wrist extension in the case of flexor tendon irritation. 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 ROM with the contralateral wrist is necessary to detect loss of motion in any direction.

In addition to the tendinitis, 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.

Imaging

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 Kienböck disease, for example, which are in the differential diagnosis of the athlete with wrist pain ( Fig. 71.1 ).

At the minimum, imaging should include two orthogonal views; a posteroanterior (PA) view and a lateral view of the wrist should be obtained. A 45-degree semipronated oblique view and a PA view in ulnar deviation to maximally delineate the scaphoid are also valuable in examining for scaphoid pathology. A clenched-fist anteroposterior view is a form of stress view that may suggest a scapholunate 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. In addition, in-office imaging with ultrasound may be of benefit. Ultrasound has the advantage over radiographs in its ability to dynamically assess for tendon pathology including ECU instability, but is highly operator dependent.

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 MRI study, with or without intra-articular administration of gadolinium, may be 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 (MRA) is an extremely useful tool when correlated with history, physical examination, and plain radiographic findings that suggest a specific injury. However as with any imaging modality, MRA is not 100% sensitive, and may be negative in the setting of true pathology. Thus imaging must be taken into account with physical exam when determining clinical significance.

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

De Quervain Tenosynovitis

Tendinopathy of the first dorsal compartment involves the APL and EPB tendons. It is more common in women than in men, as has been associated with pregnancy and the postpartum period, but has also been noted with certain sports, especially rowing and racquet sports. De Quervain tenosynovitis has also been described in volleyball players and should be suspected in any athlete who uses repetitive forceful wrist motions. The area deep to the extensor retinaculum, which overlies the radial styloid, may be swollen and markedly tender. When performing Finkelstein's test, the examiner holds the patient's thumb inside a closed fist and the examiner then passively, ulnarly deviates the wrist. This maneuver reproduces pain in persons with de Quervain tenosynovitis. In the Eichhoff test, the patient is asked to clasp his or her thumb inside the flexed fingers of the hand and then ulnarly deviate the wrist ( Fig. 71.2 ). Specific tenderness is elicited when digital pressure is placed over the radial styloid area.

Imaging can be helpful in the diagnosis of de Quervain tenosynovitis. Plain radiographs can reveal the presence of a bony spur in the floor of the first dorsal compartment. MRI can demonstrate both intrinsic tendon changes and extrinsic inflammation ( Fig. 71.3 ). Ultrasound may demonstrate thickening involving the tendons and their sheaths as well as any instability.

Treatment Options

The treatment of de Quervain tenosynovitis begins with immobilization in a thumb spica splint or cast. NSAIDs are also useful. Injection of a corticosteroid into the first dorsal compartment is another option although patients should be cautioned over the risk of skin hypopigmentation and atrophy if placed too superficial. Avci and colleagues compared the efficacy of cortisone injection with that of splinting in pregnant or lactating women and found that cortisone injection was superior in alleviating symptoms. Lastly, when these treatments are not effective, surgical release of the first dorsal compartment may be indicated. During this procedure, care must be taken to identify both the APL and EPB based on tendon actions.

Authors’ Preferred Technique

De Quervain Tenosynovitis

We prefer a stepwise treatment plan for persons with de Quervain tenosynovitis. The diagnosis is largely clinched by history and physical examination findings, as previously noted. Radiographs may help distinguish de Quervain tenosynovitis from problems related to the thumb carpometacarpal, scaphotrapeziotrapezoidal, or radiocarpal joints. Our initial treatment is oral administration of an NSAID, coupled with use of a thumb spica splint or cast and activity modification. We provide a corticosteroid injection if a patient continues to have symptoms after 4–6 weeks of wearing a splint. We use 1 mL of dexamethasone (10 mg/mL) mixed with 1 mL of 1% lidocaine without epinephrine. Patients who have persistent pain despite 3 months of nonoperative management are offered elective release of the first dorsal compartment ( Fig. 71.4 ). We prefer making a 2-cm transverse incision centered approximately 1 cm proximal to the radial styloid. Care is taken to identify and protect branches of either the superficial branch of the radial nerve or the lateral antebrachial cutaneous nerve, which are inevitably encountered during the subcutaneous dissection. The investing extensor retinaculum overlying the first compartment is incised from distal to proximal under direct visualization, cheating dorsally (i.e., staying more dorsal to the midaxial line with the retinacular incision) thereby preventing volar subluxation of the tendons with wrist flexion. We ensure that the tendons are fully released by using a small retractor to pull on the tendons, ascertaining that both the APL and EPB tendons have been released independently. Based on passive extension of the thumb metacarpal and proximal phalanx when the appropriate tendon is pulled, full release of both tendons is thus verified. We believe this step is important because the APL may have multiple tendon slips, and a vertical septum may separate the smaller EPB tendon into a separate “chamber” within the first dorsal compartment. These anatomic aberrancies have been historically cited as predisposing persons to this condition.

Postoperative Management and Return to Sports

A plaster thumb spica splint is placed immediately after surgical treatment for de Quervain tenosynovitis, and the patient is seen 10 to 14 days after surgery for suture removal and placement of a removable thumb spica splint. Athletes who require surgical release for refractory de Quervain tenosynovitis typically require 6 weeks of postoperative splinting to allow symptoms to resolve. Return to sports is allowed once ROM of the thumb and strength return. For athletes who do not require surgery, return to sports is permissible with use of a functional brace or cast when practical. Use of a functional brace or cast may be virtually impossible in sports such as basketball or gymnastics that require freedom at the wrist. Otherwise, athletes are allowed to return to sports when symptoms resolve and return of motion and strength are demonstrated.

Intersection Syndrome

Intersection syndrome has been associated with sports that involve repetitive extension and radial deviation of the wrist, such as skiing, weightlifting, rowing, and racquet sports. Radial-sided dorsal wrist pain is the hallmark symptom, but it is typically perceived as more proximal than the pain associated with de Quervain tenosynovitis ( Fig. 71.5 ). Athletes may refer to intersection syndrome as “crossover tendinitis” because it occurs in the region of the distal forearm where the tendons of the first dorsal compartment intersect, or cross over, the tendons of the second dorsal compartment (extensor carpi radialis longus and brevis). The inflammatory component is located within the second dorsal compartment. Clinical findings include localized tenderness and, in more severe cases, crepitus with wrist extension at this intersection, approximately 4 cm proximal to the wrist joint. There may be a “wet leather sign” with wrist extension versus resistance, where a sound often described as the one made when rubbing wet leather is heard. MRI is a useful adjunct in making the diagnosis, with increased peritendinous signal evident on T2-weighted images at the offending location.

Treatment Options

Treatment is directed at resting the involved tendons in a thumb spica cast or brace, with oral administration of NSAIDs and cessation of the exacerbating activity. Grundberg and Reagan demonstrated that the pathologic anatomy is a stenosing tenosynovitis of the investing sheath of the extensor carpi radialis longus and extensor carpi radialis brevis tendons. Refractory cases may require release of the stenotic sheath of the second dorsal compartment and débridement of associated tendinosis and hypertrophic tenosynovium.

Authors’ Preferred Technique

Intersection Syndrome

Rest, ice, and a forearm-based thumb spica splint are the cornerstones of management. NSAIDs are also prescribed. Corticosteroid injections are infrequently necessary. Use of nonoperative management without the need for surgery has been the experience of most wrist specialists treating this condition. Though we have never had to surgically treat intersection syndrome, we agree with Green's Operative Hand Surgery adaptation of the Grundberg and Reagan approach to surgical treatment of intersection syndrome. In this method, a longitudinal incision is made from the area of swelling distally to the radial wrist extensors. The deep fascia overlying the second dorsal compartment is then released and the tendons débrided of any tenosynovitis.

Return to Sports

Athletes are allowed to return to sports once the symptoms have dissipated, or alternatively while still wearing a thumb spica cast or splint if practical for the sport in question.