Lumbar Loading for Hip Mobility

In “traditional” manual therapy, the painful or tight side lumbar spine and hip is gapped or unloaded in a lumbar roll mob/manip. That works, but it seems much faster to use a novel loading strategy. The patient and often most clinicians they have seen in the past in usually already “stretching” or unloading the involved side. 

Think of having high tone in a neuro patient, you wouldn’t stretch it as hard or as fast as you could. The painful and/or tight side usually already has guarding, so if and when gapping works, it’s usually due to fatigue. Slacking or loading is a much more novel and therefore faster strategy in many cases. This video is an example for right hip flexion/IR mobility limitations. It is already cleaned up a bit from sidegliding in standing to the right (pushing hips to the left) in the previous lab session.
For the full explanation and 10 min video, check out MMT Premium by clicking Learn More below!
Lumbar Loading for Hip Mobility


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic…

Advertisements

Wendy’s #justkeepmoving…on a volcano

Accidental Physical Activity: A holiday in Naples, Italy

5 days in Naples doesn’t sound like it’s going to involve a lot of physical
activity/exercise, but without even trying the reality is different…
Of course, any city holiday can easily involve a good deal of “pounding the streets”; wandering around, guidebook and map in hand, seeing all the sites without even noticing just how far you’re walking. And Naples was perfect for that, as the weather was warm but not too hot, and there are so many things to see: 3 impressive castles, a host of magnificent churches, beautiful palazzos & a gorgeous coast line.
So I wasn’t surprised that my husband’s iPhone reported several miles of walking each day.

One day we left the city to visit the Roman remains at Herculaneum, and then went on to climb Vesuvius. It’s a pretty steep climb for the last 800 metres or so, & can only be done on foot – & of course a steep climb is excellent aerobic exercise. To be able to peer over into the crater of a volcano was brilliant – it felt rather surreal, although there was no
bubbling of lava so we never felt in any danger. My husband’s iPhone report for the volcano climb shows that it is equivalent to climbing 67 flights of stairs.

A holiday doesn’t have to be a “walking holiday” to involve exercise: grab your guide & your map, & explore…

Top 5 Fridays! 5 Steps to Success As a New Grad PT

When you’re just beginning your physical therapy career, there are so many paths you can take, it can feel a bit overwhelming. Some people will advise you to become a generalist, while others encourage you to find a niche as soon as possible. Others will tell you to do whatever it takes to pay off your loans ASAP.
It’s OK! Take a step back, breathe, and smile. You’re entering a career with endless opportunities to improve others’ lives and find personal fulfillment. There’s no one prescription for success, but there are certainly steps you can take to ensure you build a successful, enjoyable career as a PT.
Here are five steps to take to find success in the ways that matter to you.

1. Take Time for Introspection

Pretty much everyone has an opinion about what a new grad physical therapist should do, but the only one that really matters is your own. Take some time to consider who you are, and make your career decisions based on what you will find most fulfilling in your career. Questions like the following can help guide your process:
  • What do you want out of your career?
  • Are you seeking achievement? Work-life balance? Financial independence? Leadership opportunities?
  • What makes you feel passionate and capable? Is it a particular setting? Patient population?
  • Do you enjoy the marketing aspects of practice? Are you an educator at heart?
  • What are some absolute deal breakers?
  • Do you refuse to see more than 16 patients per day?
  • Are you fundamentally opposed to using ultrasound or working on Saturdays?
These are just a few of the many questions to ask yourself at the beginning, and it’s OK if you don’t have all the answers this moment. Introspection should be an ongoing process, where you continually check in with yourself and your loved ones; this ensures that you’re always making decisions that are true to who you are at your core.
Finding the right leadership opportunities can be challenging when you’re a new grad, but MedBridge has created a 5-part leadership series. It’s an ideal way to kick-start your confidence and polish up your resume as you work toward your professional goals.
We’ve partnered with MedBridge to bring you unlimited CEUs from the comforts of your home or office. Use promo code OMPT or click here to save subscribe to a yearly rate of only $250, saving you $175/year! MedBridge has seminars for PTs, OTs, DCs, ATCs and SLPs!

The Eclectic Approach is on MedBridge!

The Eclectic Approach has 4 courses on MedBridge, you can check them out here! If you’ve ever wanted to take one of my courses, but couldn’t make them live, these are the next best thing, plus you get CEUs for them!

The course pages are here

The Eclectic Approach to TMD Part and B
The Eclectic Approach to Clinical Neurodynamics Part and B

Keeping it Eclectic…

Treating Runners? The Test You May Be Missing

Treating runners can be a difficult task.  There are many types of injuries and they originate from a number of different areas. Is it a running form error? Is it weakness? Maybe something is too stiff?  The number of possibilities is partially why so many runners struggle to return to activity.  I discussed this breakdown in a previous post and how we use the ACE Running Movement Screen to identify the “weak link(s)”.

Here, I wanted to talk about the Unilateral Hip Bridge Endurance Test¹ and its amazing utility in runners with knee pain, back pain, and many other issues.  If you’re not familiar with the test, you can watch me explain it below.  On the surface, the test appears to be a simple test of the glute max, but as you look deeper, the knowledge you can gain from this is extraordinary.

The first step of the test is to perform a bilateral bridge.  At this point you gain a few points of knowledge:

  1. Is the runner not able to lock out the hips? It could be strength.  It could be a range of motion limitation.
  2. Does the runner hyperextend at the lumbar spine? This could be a clue into a motor control deficit that may contribute to back pain.

During the next step, the runner lifts one leg in a marching action.  Again, you gain the next insight:

  1. Does the entire body drop in the sagittal plane? This points you towards the glute max in the sagittal plane.
  2. Does the pelvis rotate in the transverse plane? This points you towards an inability to control the pelvis in the transverse plane and it may show up in a runner who demonstrates a high level of excessive rotation during running.

A passing test would be the ability to perform the bridge with a leg lift, while maintaining a locked out hip and no deviation in the transverse and sagittal planes.  Then you must hold this position for 10 seconds. Can you complete this seemingly simple task?  If not, it could be a flag to work on with you or your runners.

If you aren’t using the Unilateral Hip Bridge Endurance Test as part of your screen with your runners and athletes, you can start now.  You will find the best outcomes when it is used as part of a larger overall screening process, such as the ACE Running Movement Screen.

If you find the test difficult, try the corrective activities to the right.  Once you get comfortable with performing the test, work on determining where the deficit is during the test.  Was it motion?  Was it strength?   Was it something else?  This will allow you to treat that athlete’s specific deficit and fix them more quickly!.

Want to learn more about running gait analysis and the ACE Running Movement Screen?  Stay up-to-date on course offerings and receive tips on treating runners here.

 

  1. Butowicz CM, Ebaugh DD, Noehren B, Silfies SP.  Validation of two clinical measures of core stability.  IJSPT.  2016;11(1):15-23.

Therapy Insiders: Continuing Education, Cervicogenic Dizziness, and Creating Value

Download file | Play in new window

The only way to grow is by continuing to learn.

How do you decide which is the best option for continued learning?

Continuing education (con-ed) for physical therapy is a necessity. You need to do it to maintain your license. You need to do it to maintain your skillset. You need to do it to simply keep up. How do you choose which con-ed courses to attend? They are often expensive, require travel and integration.

Listen in for the answers.

What do you do when a patient presents with cervicogenic dizziness? How do you go about addressing the problem? How do you keep the patient comfortable? Answers in the podcast.
Is cash physical therapy better than traditional physical therapy? Is spending MORE time with someone equal to spending BETTER time with them? Is there any data to show that more time is better time? Discussion in the podcast.

Keeping it Eclectic…

Outside Perspective: Positioning the Value of PT for Consumers and Referrers

With the rising costs of health care—and the increase in high-deductible health plans (HDHPs)—patients are assuming a greater portion of their healthcare bills than ever before. So, it’s no surprise that they’re beginning to exhibit many more consumer-like behaviors, including performing online research to assess the value of potential healthcare providers and treatments rather than blindly accepting referrals from their primary care physicians. And it’s not just these patient-consumers who are redefining value in the healthcare space; referrers and payers are evaluating providers against new standards as well. While price is certainly still a factor, it’s far from the only one. So, providers in all disciplines—especially specialists such as rehab therapists—must adapt their value propositions to match their audience’s needs. And that starts with discovering the role value plays across all five of these important categories:

  1. Brand;
  2. Relationship;
  3. Quality;
  4. Convenience; and
  5. Price.

Brand

While it’s gotten better in recent years, physical therapy still has a branding problem. Most people in the general public—and even some of our peers in other disciplines—don’t really understand what we do. And no one is going to be able to change that but us. While creating a stellar brand at the individual clinic level has its own benefits—like attracting more of the right customers and building a better reputation in the community—we can also use our individual brand power as a launching pad to develop a unified brand for the profession as a whole.

So, what separates a good brand from a not-so-good one? Good brands connect people, elicit feelings, address pain points, and create impressions of culture. If your clinic’s brand doesn’t do that—if it doesn’t provide your patients, peers, and referrers with a sense of who you are from the get-go, or if the brand that you’ve created doesn’t align with what those parties perceive as valuable—then it’s time reconsider your clinic’s persona internally and online. The latter channel is especially important today, as more and more patients are interacting with your clinic for the first time via your website or social media pages. That means every aspect of your online presence should be optimized to tell the story of your value.

Relationship

Most healthcare providers—especially rehab therapists—understand the importance of the patient-provider relationship. We all know that the quality of our relationships with our patients directly correlates with their ability to achieve the desired clinical outcomes, fully engage in their course of care, and experience the full value of the care we provide. While many small practices are able to achieve success by prioritizing the patient relationship and patient experience, it can become increasingly difficult to deliver that level of one-on-one attention as a practice grows—especially when the time devoted to fostering patient relationships gets replaced with things that feel more urgent (like discussing symptoms).

However, there is a way to scale relationship-building efforts to ensure patients feel cared for as individuals—without burning yourself or your staff out: namely, leveraging patient relationship management software. I urge all practice owners—and especially those whose clinics are growing—to adopt a PRM platform that:

  • enables providers to effectively connect with patients between sessions and after discharge by providing relevant value-add content at optimal intervals;
  • collects valuable patient feedback providers can use to address patient concerns in (near) real-time and identify trends that may be impacting the patient experience on the whole; and
  • leaves you—and your staff—with enough extra time and energy on your hands to get to know your patients as people.

Quality

In today’s patient-centric, value-based healthcare paradigm, more and more focus is being placed on the quality of care we provide—and rightfully so. Patients, payers, and referrers are coming to expect the very best as a baseline. Thus, it’s imperative that we all step it up a notch and ensure that we truly are practicing at the top of our licenses—which means not only choosing the continuing education classes that best enable us to support our patients and our practices (no shoddy, free CEUs), but also diligently tracking outcomes in order to foster quality care delivery. After all, tracking outcomes via patient satisfaction surveys and outcome measurement tools is the best—and only—way to truly know if the plans of care you’re prescribing are the best ones available. Just be sure that the data you choose to collect is risk-adjusted and that all members of the greater healthcare community can readily share and understand it. Collecting data in silos isn’t going to help our individual practices—or our profession.

Quality doesn’t apply only to in-clinic practices, either. Your home exercise program is another way to demonstrate the quality of your services—or the lack thereof. If you’re still relying on difficult-to-follow paper exercise sheets, you’re missing out on a wonderful opportunity to serve your patients, demonstrate your value, and—as an added bonus—differentiate yourself from other providers. Just think: if your patients can piece together a higher-quality exercise program from YouTube videos than the one their expert-level provider is giving them, they may very well ditch your services—and perhaps physical therapy altogether. Instead, adopt a brandable, interactive, multimedia HEP that makes it easy for patients to complete their home exercises safely and provide you with feedback along the way. That way, you can make changes to the program in real time—instead of waiting until the patient returns for another session. The best HEPs also come complete with a secure patient-provider messaging platform you can use to answer questions, provide additional instructions for exercise completion, and cheer on your patients for jobs well done.

Want to learn how to discover value in the last two categories—convenience and price—as well as learn strategies for communicating your value to patients, referrers, and payers? Check out this free webinar in which Tannus Quatre, PT, MBA, and I discuss the art of discovering and selling your value. It’s high-time that every physical therapist learned how to tap into his or her potential—and articulate that potential in a way that aligns with his or her audience’s perception of value. It’s the only way we’re going to thrive in this new era of healthcare—as individuals and as a profession.

 

About the Author

Heidi Jannenga is co-founder and president of WebPT, the leading physical therapy software platform for enhancing patient care and fueling business growth. She has more than 15 years of experience as a physical therapist and clinic director, and she’s an active member of the sports and private practice sections of the APTA as well as the PT-PAC Board of Trustees.

TFCC & Ulnar-Side Wrist Injuries

Ulnar-side wrist pain can be caused by injury to the various tissues found between the radiocarpal joint and distal radioulnar joint. The term triangular fibrocartilage complex (TFCC) is used to describe a complex of fibrocartilage and ligamentous tissue located on that lateral aspect of the wrist(Nakamura, Yabe & Horiuchi., 1996). It consists of  “the disc proper, the meniscus homologue, the ulnolunate ligament, and the ulnotriquetral ligament” (Nakamura, Yabe & Horiuchi., 1996, p.582)
  • The TFCC originates from the distal radius (sigmoid notch on the ulnar border of the articular surface of the distal radius) and ulnar head (ulnar styloid and fovea of the ulnar head) binding the distal radioulnar joint together.
  • It travels distally to the proximal row of carpal bones (lunate, triquetrum, hamate, and base of fifth metacarpal) (Ko & Wiedrich., 2012, p.308).

THE ARTICULAR DISC

The articular disc is a “horizontally oriented structure that is avascular, thin, and triangular in shape, lying between the ulnar head, the lunate, and the triquetrum.” (Ko & Wiedrich., 2012, p.308). Only the peripheral 10-40% of the disc receive a vascular supply from the dorsal and palmar radiocarpal branches of the ulnar anterior, and the palmar branch of the anterior interosseous artery. “Therefore, the palmar, ulnar, and dorsal components of the TFCC possess inherent healing potential, whereas the central and radial portions of the TFCC are largely avascular, which significantly limits the ability of these regions to heal in the setting of injury.” (Ko & Wiedrich., 2012, p.308).
 Representation of the anatomy of the ulnar side of the wrist (Ko & Wiedrich., 2012, p.308).
Representation of the anatomy of the ulnar side of the wrist (Ko & Wiedrich., 2012, p.308).

DYNAMIC STABILITY

  • The function of the TFCC is to stabilize the ulnarcarpal and distal radioulnar joints (DRUJ).
  • The TFCC is a load-bearing structure between the ulnar head, and lunate and triquetrum bones, which makes it susceptible to acute traumatic and degenerative overload injuries (Ko & Wiedrich., 2012, p.308).
  • It is believed to take about 18-20% of the load of the wrist (Ko & Wiedrich., 2012, p.309).
Not all of the TFCC contributes equally to stability of the DRUJ. The central and avascular portion of the disc is not a major stabiliser of the DRUJ (Ko & Wiedrich., 2012, p.308).
  • The part of the TFCC which inserts into the ulnar carpal bones is hammock-like in shape and structure, and allows smooth motion of the bones during flexion, extension, radial deviation and ulnar deviation by accomodating twisting movements. (Nakamura, Yabe & Horiuchi., 1996)
  • There is little deformity seen in the disc proper during pronation and supine” (Nakamura, Yabe & Horiuchi., 1996, p.585).
  • During supination & pronation the deep dorsal and superficial volar radio-ulnar ligaments tighten to prevent further dorsal displacement of the ulna. These extrinsic ligaments (ulnotriquetral and ulnolunate) act as stabilizers between the distal ulna and volar carpus.” (Sachar., 2008, p. 1669).
  • Don’t forget that pronator quadratus and the extensor carpi ulnaris are also dynamic stabilizers of the distal part of the ulna.

CLINICAL PRESENTATION

“To make an accurate diagnosis of the etiology of ulnar-sided wrist pain, one must take an adequate history, perform a detailed physical exam, and accurately interpret appropriate diagnostic tests.” (Sachar, 2008., 1670). Specifically, try to isolate information about the following factors.

1. LOCATION OF PAIN

“TFCC injury should be suspected when an athlete presents with vague ulnar-sided wrist pain or
tenderness, possibly associated with an audible or palpable click on forearm rotation.”  (Ko & Wiedrich., 2012, p.307). 

2. MECHANISM OF INJURY 

The wrist moves through flexion, extension, radial and ulnar deviation, and various degrees of forearm pronation and supination. Each of these movements can be performed with varying levels of grip force. Therefore, knowing the motion of the wrist, the amount of weight bearing or grip loading is important to understanding the MOI and structures involved. 
Ulnar deviation, grip, and pronation are all movements that stress the TFCC when swinging a baseball bat, tennis racquet, or golf club” Other sports that stress the TFCC through axial loadinginclude gymnastics, and boxing. (Ko & Wiedrich., 2012, p.309)
Acute injuries are generally accompanied with a specific event that the patient can remember such as swinging a bat, falling onto a pronated outstretched hand, and usually have a degree of wrist extension and hyperpronation (Sachar, 2008, 1670).
  • ** Wrist extension injuries will impact the lunotriquetral ligament
  • ** Dislocation of the DRUJ may be associated with a pop or noise and immediate visible deformity (Sachar, 2008, p1670).
Chronic injuries due to repetitive overload won’t have the same recognisable moment in time.

PHYSICAL EXAMINATION

Given the complex anatomy of the TFCC described above, it is important to identify what structures are likely to be contributing to ulnar-side wrist pain. This requires the clinician to perform a battery of tests. It is important to note though that there remains “little evidence of the accuracy of these tests” (Prosser, et al., 2011, p. 247). As clinicians you will need to rely on your clinical reasoning to understand the meaning of the findings from your physical exam. 
Observe for swelling and deformity first, to rule out a fracture or dislocation. When observing both wrists, if the ulna is more prominent dorsally this may indicate an injury to the DRUJ. (Sachar, 2008)
Range of movement of wrist flexion, extension, radial deviation, ulnar deviation, pronation & supination.
 Blue (TFCC), green (lunotriquetral interval), pink (scapholunate interval), and orange (DRUJ).
Blue (TFCC), green (lunotriquetral interval), pink (scapholunate interval), and orange (DRUJ).
Palpation:
  • “The lunotriquetral interval (lime green) is palpated dorsally between the fourth and fifth compartments one finger breadth distal to the DRUJ and with the wrist in 30 degrees of flexion” (Sachar, 2008, p. 1671).
  • The TFCC (light blue) is best palpated in the soft spot between the ulnar styloid, FCU and volar surface of the ulnar head. This is known as the ulna fovea sign (Ko et al., 2012; Sachar, 2008; Tay et al., 2007). 
  • The fovea sign test has a 95.2% sensitivity and 86.5% specificity (Sachar, 2008, p.1671; Tay et al., 2007, P483). That is, it is sensitive and specific in detecting foveal disruption of the distal radioulnar ligament and ulnotriquetral ligament injuries (Tay et al., 2007).
  • UT ligament injuries are typically associated with a stable DRUJ and foveal disruptions are associated with an unstable DRUJ (Tay et al., 2007, p. 438).

PAIN PROVOCATION TESTS

Prosser et al (2011) suggest the following provocative tests to diagnose wrist ligament injuries:
  1. The scapholunate ligament is tested by applying pressure through the examiner’s thumb to the scaphoid tubercle.
  2. The lunotriquetral joint/ligaments can be evaluated with 3 tests (Sachar., 2008, p. 1671; Sachar., 2012, p.1491-1492)
    1. The Regan shuck – a sheering test between the lunate and triquetrum. Move the lunate in a volar and dorsal direction while moving the remaining wrist in the opposite direction.
    2. The Kleimman Shear test – a similar sheering test for the LT ligament but with more fine hand placement than the Regan shuck test. One thumb and index finger is placed over the pisiform and triquetrum while the other hands stabilises the lunate and radial column of the wrist.
    3. LT ligament ballottement /compression. Stabilise the hand while the thumb applies a radial force driving the triquetrum into the lunate.
  3. The arcuate ligament is tested with the midcarpal stress test and considered positive if there was a catch up clunk in the midcarpal joint in the addition to pain reproduction.
  4. The distal radioulnar joint (DRUJ) – piano key test
    1. “This test is performed with the patient’s palp flat on the table. The test is performed by applying a dorsal to volar load across the ulna 4cm proximal to the DRUJ. Pain should be reproduced at the DRUJ joint level.” (Sachar, 2012., p. 1492).
    2. If the deep dorsal fibers have been severely sprained or detached from the fovea, performing this maneuver may cause subtle subluxation or gross instability of the DRUJ (and pain).
    3. Laxity in both supination and pronation potentially represents a multiplanar tear of both deep dorsal and palmar fibers of the ligamentum subcruentum. (Ko et al., 2012, 310)
  5. The TFCC is tested with a stress test (wrist is in ulnar deviation while applying a shear force across the ulnar complex of the wrist) and compression test (as per stress test but with compression). 
  6. The GRIT test is used to evaluate the integrity of the lunate cartilage (ulnar impaction syndrome) using a grip measurement in neutral, pronation and supination.  
  7. ECU (extensor carpi ulnaris) is examined by resisted movement into ulnar deviation (MMT). This is performed with the forearm in supination and elbow flexed to 90 degrees.
  8. Weight bearing on the wrist in extension – the press test.
  9. Combined pronation, ulnar deviation and compression – reproduce clicking sounds.

OUTCOME MEASURES

Patient-rated wrist and hand questionnaire is described in further detail here

CLASSIFICATION FOR DIAGNOSIS

As you can see from the assessment and anatomy sections above, there are many causes of ulnar-sided wrist pain from structures other that the TFCC. Differential diagnosis of ulnar sided wrist pain includes: “synovitis, lunotriquetral ligament injuries, extensor carpi ulnaris subsheath injuries, ulnar extrinsic ligament injuries, and TFCC tears” (Park, Jagadish, & Yao., 2010, p. 3).
In general, a wait and see approach with immobilisation is used for acute wrist injuries, however in the athletic population, early detection of a TFCC injury is necessary to determine what course of treatment is most appropriate. 
“The gold standard for diagnosing TFCC disorders remains wrist arthroscopy.” (Ko & Wiedrich., 2012, p.311; Prosser et al., 2011). The following classification system is widely recognised and used during arthroscopy to help direct the best course of treatment.

PALMER CLASSIFICATION SYSTEM

Screen Shot 2018-04-02 at 10.25.34 AM.png

DIRECTIONS FOR SURGICAL TREATMENT

The role of surgery is dependent on the classification of injury.
  • “Arthroscopic debridement is the treatment of choice for IA lesions, with biomechanical studies showing that up to 80% of the articular disc can be removed without creating instability.” (Ko & Wiedrich., 2012, p.312).
    • Splinted for 1 week
    • Most athletes return to sport at 4-5 weeks.
    • Success is 66-87%
  • “Lesions of the ulnar, vascular side of the TFCC (IB lesions) are most amenable to arthroscopic or open repair, and early arthroscopic intervention should be encouraged in the elite athlete.” (Ko & Wiedrich., 2012, p.312-313).
    • Splint for 6 weeks
    • ROM for 6 weeks
    • Return to sport around 3 months post surgery
  • “Although IC tears are diagnosed arthroscopically, they are generally repaired using an open technique.” (Ko & Wiedrich., 2012, p.313). The postoperative regime is similar to IB repairs.
  • “Radial avulsions of the TFCC at the sigmoid notch are often associated with distal radius fractures and can lead to DRUJ instability (ID lesions).” (Ko & Wiedrich., 2012, p.315)
    • ‘A critical step necessary for healing of the repaired ID lesion involves introducing a burr into the sigmoid notch and a 16-mm (0.062-inch) K-wire is advanced through the distal aspect of the sigmoid notch and out through the radial wrist incision.’
    • The postoperative regime is similar to IB repairs.
  • “The athlete with a IIA or IIB lesion presents with an insidious onset of ulnar-sided wrist pain that is worse with activity and relieved with rest. Plain radiographs should be obtained to evaluate for DRUJ arthritis and assess ulnar variance, including the pronated grip view. High-performance athletes will most likely not agree to a conservative treatment regimen, so ulnar-shortening osteotomy should be offered to the athlete with ulnar-neutral or ulnar-positive variance.” (Ko & Wiedrich., 2012, p.316-18).
  • IIC lesions “should be treated by either arthroscopic debridement and wafer resection or formal ulnar shortening in athletes with ulnar- positive variance.” (Ko & Wiedrich., 2012, p.318).
  • IID & IIE lesions are treated similarly to IIC lesions, however there is a focus on determining in lunotriquetral instability exists or not. If there is instability, “then a wafer procedure is not recommended because it does nothing to address the lunotriquetral instability. Instead, the ulna should be shortened, which tightens the ulnocarpal ligaments and thereby helps to stabilize the lunate and triquetrum. If the lunate and triquetrum are still unstable, then a lunotriquetral arthrodesis may be necessary at a later date if the patient does not respond to ulnar shortening.” (Ko & Wiedrich., 2012, p.318).
Patient outcomes long term & RTS:
As you can see from above, the type of surgery performed depends heavily on the injury which is diagnosed. This explains why many athletes with acute injuries with have early arthroscopy to help with diagnosis and determining treatment direction.
  • Generally, a ‘good to excellent’ outcome is achieved in 63% (Reiter et al., 2008).
  • 1A debridement specifically achieved a 66% to 87% successful outcome (Ko & Wiedrich, 2012).
  • 1B repairs specifically achieved a better result with 94% of patients reporting they were satisfied or very satisfied with their surgery (deAraujo et al., 1996).
  • Ulnar shortening osteotomy resulted in 92% complete pain relief or occasional mild pain (Minima & Kato, 1998).
  • Traumatic TFCC tears which are frequently seen together with distal radius fractures do not affect the long-term functional results. Therefore, further diagnostic tests and treatment of TFCC tears in patients with stable distal radius fractures may be unnecessary.

ROLE OF PHYSIOTHERAPY

Conservative management is the best choice for acute cases (Lubiatowski et al., 2006). This includes immobilisation, NSAIDS or CSI and occupational therapy (Ko & Wiedrich., 2012). Immobilisation for a minimum of 4 weeks should be trialled before pursuing further imaging (Park et al., 2010). Don’t rush for an MRI. If you need to rush, send them to an orthopedic specialist who can perform an arthroscopic evaluation. 
Treatment will be directed by degree of pain, severity of injury, competitive level of the athlete and the presence of DRUJ instability. Early diagnosis is of the utmost importance! Clinicians need to understand the sport, position played and level of competition to accurately decided on the best direction for treatment. 
TFCC injuries can often be managed conservatively, however failing this or under some circumstances surgery should be considered as an option. Immobilisation may allow for partial peripheral tears without DRUJ instability to heal. The central disc is avascular and less likely to heal with immobilisation.
There is a need for more research to better direct treatment. From experience, the following are points to consider during treatment planning. 
  • Passive mobilisation can help with pain – treat the dysfunction you find!
  • Help to restore pain free ROM.
  • Need rotational control- pronator quadratus and ECU (attachments into the complex) are important- isometric and dynamic.
  • The pronator quadratus actively stabilizes the joint by coapting the ulnar head in the sigmoid notch, particularly in pronation, and it passively stabilizes the joint by viscoelastic forces in supination. An intact extensor carpi ulnaris and fibro-osseous tunnel partially stabilize the distal radioulnar joint even after the triangular fibrocartilage and other ligaments are sectioned (Szabo, 2006).
Sian

    REFERENCES

    Cleland, J. (2005). Orthopaedic clinical examination: an evidence-based approach for physical therapists: WB Saunders Co.
    Deniz, G., Kose, O., Yanik, S., Colakoglu, T., & Tugay, A. (2013). Effect of untreated triangular fibrocartilage complex (TFCC) tears on the clinical outcome of conservatively treated distal radius fractures. European Journal of Orthopaedic Surgery & Traumatology, 1-5
    Ko, J. H., & Wiedrich, T. A. (2012). Triangular fibrocartilage complex injuries in the elite athlete. Hand clinics, 28(3), 307-321.
    Nakamura, T., Yabe, Y., & Horiuchi, Y. (1996). Functional anatomy of the triangular fibrocartilage complex. Journal of Hand Surgery, 21(5), 581-586.
    Park, M. J., Jagadish, A., & Yao, J. (2010). The rate of triangular fibrocartilage injuries requiring surgical intervention. Orthopedics, 33(11).
    Prosser, R., Harvey, L., LaStayo, P., Hargreaves, I., Scougall, P., & Herbert, R. D. (2011). Provocative wrist tests and MRI are of limited diagnostic value for suspected wrist ligament injuries: a cross-sectional study. Journal of physiotherapy, 57(4), 247-253.
    Sachar, K. (2008). Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. Journal of Hand Surgery, 33(9), 1669-1679.
    Sachar, K. (2012). Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. Journal of Hand Surgery, 37(7), 1489-1500.
    Szabo, R. M. (2006). Distal radioulnar joint instability. JBJS, 88(4), 884-894.
    Tay, S. C., Tomita, K., & Berger, R. A. (2007). The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. The Journal of hand surgery, 32(4), 438-444.

    Sian is an Australian physiotherapist and Clinical Pilates Instructor licensed in both Australia and California. Sian currently lives in San Francisco, California.  Prior to moving to the US in early 2015, Sian worked for four years at Physica Spinal and Physiotherapy Clinic in Ringwood, Melbourne, Victoria.  In 2013, Sian has graduated with a Masters in Musculoskeletal Physiotherapy from Melbourne University. Sian completed her undergraduate degree in Bachelor of Physiotherapy from La Trobe University in 2009. Her interests include the management of neck and back pain, sporting injuries and women’s health. As well as individual consultations, she enjoys teaching clinical Pilates and functional rehabilitation programs. Sian’s goal as a therapist is to understand each individual’s problem, and teach them the knowledge required to empower them to rehabilitate themselves. This is often done in a supervised class format or through an individualised independent program. Sian enjoys working with a very wide range of conditions and levels of function, including early post operative rehabilitation or acute injury management, through to increasing athletic performance.

    Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

    Keeping it Eclectic…