The wrist is a complex structure that is particularly prone to injury in sports. Approximately a quarter of athletic injuries involve the wrist and hand (13). Some sports involve a higher risk of wrist injury than others. The overuse injuries that are common in the wrist include tendinitis, tenosynovitis, tunnel syndromes and stress fractures. The aim of this review is to provide a summary of the tendinitis and tenosynovitis conditions affecting the wrist.
The wrist joint is formed proximally by the distal surface of the radius and ulna and the attached fibrocartillage disc, and distally by the scaphoid, lunate and triquetral bones. The wrist as a region extends from the distal radius and ulna to the base of the metacarpals. The wrist positions and supports the hand and therefore has to combine strength and precision with a wide range of movement with stability.
The position of the bones of the carpus is controlled both by their bony shape and their ligamentous support. Most of the musculotendinous units that power movement in the wrist traverse the carpal bones and insert in to the base of the metacarpals, therefore indirectly controlling the position of the carpal bones. The pisiform is a sesamoid bone within the tendon of flexor carpi ulnaris that then inserts distally
into the hamate and the fifth metacarpal base. Extensor carpi radialis longus and brevis insert in to the dorsal base of the index and middle metacarpals respectively. Flexor carpi radialis inserts in to the volar base of the index and middle metacarpals and may send a slip to the scaphoid tubercle.
The wrist tendons are closely applied to the wrist bones and therefore act close to the centre of rotation of the joint. This mechanical disadvantage results in the generation of large tension in the wrist tendons to power wrist movement. Calculations of joint reaction forces in the wrist are complex but suggest a multiplication of the applied loads in the hand. It is estimated that the compressive loads at the carpometacarpal joint can reach ten times the force applied at the finger tips(1). The forces are transmitted through the articular surfaces of the wrist joint and supporting ligaments depending on the position of the joint.
The inherently unstable bony anatomy is controlled by the passive restraint of the complex intrinsic and extrinsic wrist ligaments that prevent collapse of the carpal bones. Failure of the bony structure, the joint surfaces or the ligaments causes collapse of the wrist. Any condition that affects the stability of the carpal bones or the normal function of the wrist tendons will therefore result in a marked reduction of grip strength.
The extensor tendons are held closely applied to the dorsal surface of the distal radius and ulna by the extensor retinaculum. This is a ribbon-like fascial band 2.5 cm wide that extends obliquely from the anterolateral surface of the radius across the dorsum of the wrist inserting in to the pisiform and triquetral bones, but not directly in to the ulna (3). The radius and carpus are free to rotate about the ulna without affecting tension in the extensor retinaculum. The extensor retinaculum prevents bowstringing of the extensor tendons with wrist extension, and bony attachments of the retinaculum produce six extensor compartments that control the tendons with wrist movement.
The four common sites for pain
Pain arising from musculotendinous units in the wrist originates from their bony attachments or from where they pass through tight fascial tunnels lubricated by a synovial bursa. The four common sites for pain in the upper limb are the first dorsal compartment (De Quervain's tendovaginitis), digital flexors (trigger finger), flexor carpi radialis tendinitis, and lateral epicondylitis (tennis elbow). Sites for other wrist tendinities are comparatively less common, but can occur in the wrist extensors, intersection syndrome, extensor policis longus, extensor digiti minimi, and abnormal connections between the thumb and index flexors.
Epidemiological data from work-related injury suggests that the risk of wrist tendinitis in occupations involving forceful repetitive actions is up to 29 times that of non-forceful or non-repetitive jobs(4). Sporting activities that involve forceful repetitive overuse of the wrist have a high incidence of wrist tendinitis. It is not clear, however, what level of force and repetition causes wrist tendinitis, and there appears to be a complex interaction of many factors including gender, hormonal, neurogenic and mechanical factors in the aetiology of wrist tendinitis (12).
Ergonomic considerations are paramount in the management of sports-related wrist tendinitis. They are equipment related, technique related, or a combination. Many of the advances in sport- equipment design are driven by the need to minimise the damaging forces on the wrist. For example, large racquet heads appear to have reduced the incidence of upper-limb injuries in tennis players (19).
Vibration is an important factor increasing the force required to grasp an object, decreasing the proprioreceptive input and reflexly increasing muscle contraction via a process termed the tonic vibration reflex. The threshold for motor unit recruitment is decreased by vibration, and the force of contraction is increased in the presence of vibration. Vibration also potentiates the force of contraction for subsequent contractions. The tonic vibration reflex can be decreased by cutaneous stimulation or acupuncture (16, 17, 7).
Tendons respond to increased stress by increasing collagen content and cross sectional area(14, 2). If the adaptive capacity of the tendon is exceeded, the collagen bundles are damaged(5). Damaging forces can be single or repetitive. Collagen fibres appear to be damaged by repeated application of stress below the ultimate tensile strength of the collagen. Sex differences in the mechanical properties of tendon material have been demonstrated, with female flexor digitorum profundus tendons found to be stiffer and to exhibit less creep than male tendons (11).
The repair process following injury consists of inflammation, proliferation, and maturation. The inflammation phase, characterised by swelling warmth and oedema, continues until the damaging forces cease. Continued damaging forces cause chronic inflammation, secondary adhesion and degeneration. The term tendinosis refers to degeneration of the tendon without signs of associated inflammation. The lack of signs of acute inflammation in many of the lesions may be due to their chronic nature.
Narrowing of the fibrous tissue tunnels that enclose the tendons or swelling of the tendons increases the local pressure on the tendons. Synovitic reactions within the tendon sheaths further reduce the available space causing a local increase in pressure and pain. Tendon nodules may cause a block in the normal smooth passage of the tendon as in trigger finger, but true triggering is rare in wrist tendinitis.
Wrist tendinitis diagnosis and wrist tendinitis treatment
The diagnosis and treatment of wrist tendinitis starts with a full history and physical examination. Important questions in the history include work and sporting activity, a history of previous upper-limb injury, penetrating trauma with foreign bodies, problems in the shoulder, elbow or wrist, exacerbating and relieving factors, and the functional impairment caused by the pain.
Systemic illnesses associated with tendinitis include diabetes, rheumatoid arthritis, crystal arthropathy, and connective tissue disorders. A chronic indolent infection can cause tenosynovitis and mimic benign tenosynovitis. Tumours in this region are rare, but can cause pain and loss of function, mimicking benign tenosynovitis.
Pain from wrist tendinitis is generally described as aching, provoked by exercise, and relieved by rest. Other pain patterns raise suspicions of an alternative diagnosis. Pain from an involved tendon is usually well located to that tendon, its tendon sheath or its bony insertion, making the clinical diagnosis clear. However, pain arising from the radio carpal, mid carpal or carpometacarpal joins causes pain on movement that may be reproduced by the provocative tests for each tendinitis condition.
Plain radiographs are obtained to exclude underlying bone pathology, stress fractures or joint degeneration. Soft-tissue films including oblique views of the affected area may demonstrate calcification indicative of acute calcific tendinitis.
The treatment is generally rest, splintage, non-steroidal anti- inflammatory medication, and occasionally steroid injection, with surgery reserved for severe cases that don't respond to conservative treatment.
De Quervain's tenosynovitis
This is the most common wrist tendinitis. It involves the first dorsal compartment of the wrist(8). This compartment contains the tendons of abductor policis longus (APL) and extensor policis brevis (EPB). Multiple tendon slips are present in 50% to 90% of specimens and the compartment is often subdivided(15). Failure of surgical treatment is often due to a lack of appreciation of these anatomic variants.
The clinical findings in de Quervain's tenosynovitis are of pain, swelling and tenderness over the first dorsal compartment, increased with thumb motion. Finklestein's test increases the pain on radial deviation of the wrist with the thumb in a neutral position(9).
Triggering of the thumb indicates nodule formation either in the long thumb flexor tendon or in the first dorsal compartment. This indicates a more extensive stenosing tenosynovitis often recalcitrant to conservative treatment. The condition is more common in women between 30 and 60 years of age, becomes bilateral in 30% of patients and is a particular problem with golfers.
The flexor carpi radialis (FCR) tendon runs in a sheath from it muscular origin to its insertion. It enters its own fibro-osseous tunnel at the wrist, occupying 90% of the tunnel volume. Swelling of the tendon, tendon sheath or arising from adjacent joints causes pressure on the FCR tendon. Pain is generally felt at the proximal border of the trapezium and is associated with wrist flexion. There may be a swelling of the entire tendon sheath or a localised bony constriction. This can be shown on plain radiographs (carpal tunnel views) or a CT scan. Primary tendinitis may respond to non- operative or injection treatment, but extrinsic causes often require surgical decompression(6, 10).
Flexor carpi ulnaris (FCU) tendinitis is a common problem in racquet sports that involve repetitive forced wrist flexion(20). Pain can be felt along the FCU tendon, around the pisiform or its distal insertion. Pain may arise from arthrosis of the pisotriquetral joint or instability of the pisiform.
Drummer boy palsy
Extensor policis longus tendinitis is also known as â€œdrummer boy palsyâ€. There is usually a predisposing cause found in the history such as direct trauma, or an un-displaced wrist fracture. Rupture or tendinitis usually occurs within 8 weeks of injury, but can occur many years later.
Extensor indicis proprius (EIP) tendinitis and extensor digiti minimi tendinitis are rare conditions. EIP tendinitis is associated with a muscle belly within the tendon sheath in 75% of cases.
Intersection syndrome occurs where the tendons of extensor policis brevis (EPB) and abductor policis longus (APL) cross extensor carpi radialis longus (ECRL) and brevis (ECRB), between 4 and 8 cm proximal to the wrist. Inflammation of the intervening bursa causes crepitation that is palpable and sometimes audible. Intersection syndrome is a particular problem in rowers and weight lifters. Non-operative management is generally successful, but for recalcitrant cases operative treatment including release of constrictive fascia and excision of the inflamed bursa may be required(21).
Restrictive thumb index tenosynovitis termed Linberg's syndrome is rarely a problem in athletes. It results from straining a connection between the flexor policis longus and index flexor digitorum profundus tendons that is present in 31% of the population. Symptoms are caused by attempted thumb flexion with the index finger extended. This results in pain in the distal radial volar forearm. The treatment is generally avoidance of the precipitating action with surgery rarely required.
The vulnerable sports
Sports that are prone to wrist tendinitis include golf, racquet sports, rowing, weightlifting, gymnastics, wheelchair sports and climbing. More than 50% of recreational rock climbers show signs of wrist tendinitis.18. In certain sports overuse tendinitis is considered normal and treatment is based on minimising the effects on the athlete. Peter Kormann, an Olympic gymnast stated that, â€œAll gymnasts work out and compete with ongoing problems in their upper extremities. These problems are only considered serious injuries when the gymnast can no longer competeâ€.
The successful treatment of wrist tendinitis in athletes requires prompt and appropriate medical treatment, followed by a tailored progressive training programme using high-quality sporting equipment with the correction of poor sporting techniques. This may involve the skills of sports physiotherapists, sports medicine doctors, orthopaedic surgeons, as well as sport trainers.
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