September 15

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Wrist Pain Cartilage Injuries with Wil Seto

By Wil Seto

September 15, 2022

wrist pain

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Wil Seto of Insync Physiotherapy in Vancouver. They're sports physiotherapy experts. And we're gonna talk today about wrist pain and cartilage injuries in your wrist. How you doing Wil? 

Wil: Hey, I'm doing good, thanks Mark. 

Mark: What's going on with this kind of stuff in your wrist? I got such a sore wrist, man. 

Wil: Yeah. I wanted to actually touch base on this because it seems to be something that's also more prevalent with a lot of rock climbers. And we treat a lot of rock climbers in our clinic and myself being a rock climber. And I have a lot of friends at rock climb that quite often you know, end up injuring this part of the wrist and they'll have the wrist pain and then it goes away and it's sometimes undiagnosed.

But the recovery of the type of injury is quite good. So basically, what we're talking about specifically is the cartilage portion on this side of the wrist and the cartilage, it's actually more accurately called the triangular fibrocartilage complex. So in the abbreviated form, we call it the TFCC or EFCC injuries, the triangular fibrocartilage injuries, or cartilage complex injury.

And the reason why we call it that is because it's made up of the cartilage, the ligaments and the capital, and then there's also the bony structures in there that houses it that actually impact it quite a bit as well.

And so quite often with rock climbing, it totally fits that presentation in terms of the mechanisms of injury. But like, I'll talk about a little bit about the presentation of the type of injury as well. And mostly like I was saying, the complaint of the symptoms are usually on this side and it gets worse when you're moving it or going back into climbing and trying to stress it.

There may also may be like weakness in that whole hand, in the grip strength and it'll click maybe. And there might even be some instability in the wrist. Some actual instability and perceived instability. It's usually directly related to some kind of trauma. So like with rock climbing, you know, it's that hyper extension sort of like if they're like mantling and pushing off in a really, really extended wrist position and trying to push off, they might injure that part of the cartilage.

Or if they're doing a hand jam or you're doing like jamming into a crack, but then you're like, not just jamming like this, but then you're like this, and now you're putting all your weight on that wrist now. So that's another way of injuring it. Give you some other examples from like you know, baseball or whatever.

Like you're trying to throw the ball and you end up cocking it or you're doing like a certain throw and then you flick it or whatever, and you hyper extend and put too much compression on the side of the joint that can cause it to basically compress. If you injure the ligament in there too, because then it's infinitely connected with that cartilage area. 

The other thing that actually is interesting is on a sort of more structural level so you have two bones that make up the forearm. And the inside bone is called the ulna, and that ulna bone, basically what the ulna and the other bone here called the radius.

They both connect to your wrist bones, you have eight muscles that make up wrist bones, and they kind of basically go in two rows. Like the first row is four and then another row four on top kind of thing. And so typically, if there is a change in the anatomical length of your ulna bone, then that can also add more compression, it'll put a little change, how your wrist can move physiologically. And so that's another thing to look for too. So they call that in a physiological term, like a positive ulna variance. 

And stuff like gymnastics, you know, a lot of impact, you know, you're doing all these flips and stuff like that where you land and you're compressing. So that's another way of injuring it. So usually you feel like it gets inflamed. You know, it feels really inflamed in there. And some people can experience it like, oh, maybe I got tendonitis. So anything that's involved in gymnastics, you're on those bars. 

Or you're doing anything where you're like repetitively, like say you're carpenter. It's that competitive where, oh, you start to feel pain in there and they think it's a tendonitis and you could often misdiagnose it as just a wrist overuse or a wrist, like a ligament sprain. But you know, it's usually a little bit more involved. 

Mark: So diagnosing this, what are the steps to kind of narrow it down to what exactly is going on?

Wil: Yeah. So there's a couple of really specific tests that you can do for the TFCC. You can do what's called a compression test. Where you have the arm in a certain position and then you try and move basically the ulna, like basically relative to the little wrist bone in here called the pisiform to see if it actually produces any symptoms. So that's like a compressions test and we can do other stress testing on that TFCC. The triangular fibrocartilage complex. By applying that force through that ulna bone. 

You can do other rotational tests. We call the supination test and whatnot, and basically grabbing the underneath side of the table. You can do a little home test where you rotate, that's called supination, and then grab the under side of the table and that load of just doing that, if that causes pain in there, then that may be an indication that you have some kind of tear or pathology in that TFCC. 

There's also another test where you look at, so this is kind of like a more growth instability, which is called a piano key test where you try to press the hands on the table. And then as you're pressing the hands, if that ulna bone that I talked about on this side, if it pops up, then like, oh, there's something going on there. And then if there's instability plus positive symptoms, then that's another indication of a positive test. 

And then there's like other tech where you're just compressing, grinding the radial portion and the ulna portion where you're just trying to really reproduce the symptoms of that TFCC. So if there's a tear in there and you're grinding and may indicate that yeah, there's something going on, but maybe degenerative process or something like. 

Mark: So what's the typical course of treatment once you've narrowed down to what's going on? 

Wil: Yeah, so it's it's something that's really rehabitable. So it's really good with rehabilitation. Prognosis is usually really good. Especially with minor ones. We've seen some success with definitely more mild ones. And then where, you know, you get into for more of the extreme ones where people can't even like, it's really swollen and an acute injury. And it's looking you know, probability of it being really high that it's TFCC injury. Then as we get the swelling down, then you know, on some of these more rare cases, or I guess on the lower percentages where it's more serious than maybe getting medical intervention where surgery may be an option. To repair it, to debride it or to do something if it's like a physiological thing, then doing something with the bone. It is a very good success in terms of the actual surgical procedure as well. 

The rehab is also very, very successful. It is a bit length when you're looking at considerative treatment because of it being a cartilage tear and the fact that you're using your hands all the time and also the nature of the injury. And especially if it's something that's causing a lot of swelling in there. Because usually if there's swelling and especially if there's any kind of bruising and bleeding from the trauma, then it usually indicates that there's a little bit more soft tissue injury involved. 

So really let me just sum up. Basically, number one, you really wanna look at being able to immobilize it for the first week, if it's any kind of injury that has swelling and is more than just mild because you need to really give it a chance to heal and let the swelling settle down.

Getting a brace for it would be really helpful to not use it because you really wanna just let that settle right down. That's super important. So no using it. No playing sports with it. And once it's settled down for maybe even two weeks or three weeks, then you can start to you know, do a functional splint where you're now able to do some stuff. And then maybe at this point you start to actually work on the range, start to work on the strength. 

If it's more mild, then you might not even need a splint or a brace at all from the get go. And we want to address the mobility right away. We wanna address the strength issue right away. We do a lot of things to activate the core of wrist. Just like in the neck and your lower back, you have core stability muscles of your wrist. So you wanna work on these muscles that help rotate your arm and stabilize the wrist. 

Now here's been a really interesting thing that a lot of people don't really realize when you have an injury in there because there's tendon attachments down into that wrist area. And this is why people quite often think that it may be a tendonitis or an overuse injury, or it gets misdiagnosed as an overuse injury, because what happens is that we get really tight too. But then if we actually accurately diagnose it and look at well, what is the true cause of your wrist pain? And we figure it's that, you can still have this adjacent or this combined tightness into your forearms because of its intimate connection with that wrist joint and TFCC. 

So what can happen is that you may not actually have a dysfunction in this forearm muscle or the forearm muscles, there's more than one here. Like your flexor carpi ulnaris muscle, for example, or your flexor digitorum superficialis or the flexor digitorum profundus. So these are just some of the muscles I'm naming here that are getting more specific here, that can be involving it really tight. Now why I'm mentioning this is because if that gets really tight, especially that one that's connected to the wrist, then it can cause more compression.

Then it can actually impact the healing and the rehab of that wrist injury of the TFCC. So then what that means is that we have to address the tightness here, to allow this to decompress, give it more space, more of a chance to work on that mobility because when things start to compress, then it's just gonna irritate that a little bit more. So that's another thing to consider. 

Another thing to consider too, is what caused all that to begin with? Why did you have to start to hyper extend like with whatever sport, activity that you're doing. If you're a carpenter, are you getting issues in your neck and shoulder that is causing you to really get into the hyper ulnar deviation, is the motion right? That then you can't bring your shoulder right up because maybe there's an existing shoulder issue that was never really addressed by yourself or by even acknowledging that there's something there going on maybe. So those kind of things, to really take into consideration. 

Mark: How's your wrist really? If it's hurting, get into Insync Physio. They can help you. You can reach them at their website insyncphysio.com. They have two offices to serve you .One in Vancouver, one in North Burnaby. You can call them the Cambie office is at (604) 566-9716 to book or in North Burnaby, (604) 298-4878. Get expert help for your wrist pain. It can heal. So get in there and get some help. Thanks Wil. 

Wil: You bet, Mark. Thank you.

Wil Seto

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