Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendonitis

By admin On Dec 7, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Kevin Eerkes

Basics

Description

Flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) tendons are located on the radial and ulnar aspects of the wrist, respectively.
Tendonitis of these tendons may occur from trauma or repetitive use.

Epidemiology

FCU tendonitis is more common than FCR tendonitis.
FCR tendonitis is considered rare.

Risk Factors

Diabetes mellitus
Sports with grip: Tennis, racquetball, golf, cycling, weightlifting, etc.

Etiology

Anatomy and function:
- FCR inserts on the volar aspects of the trapezium and 2nd and 3rd metacarpal bases.
  - It is difficult to palpate the insertion point owing to overlying thenar muscles.
  - It palmar flexes and radially deviates the wrist.
- FCU inserts mainly on the pisiform, with some fibers extending to the hamate hook and bases of the 4th and 5th metacarpals.
  - The pisiform is a sesamoid imbedded in the FCU tendon.
  - It palmar flexes and ulnarly deviates the wrist.
Pathology:
- With trauma or repetitive use, the synovium of the tendon can become inflamed.
- Even though the term tendonitis is commonly used, tenosynovitis is a more appropriate term.
- Over the long term, trauma and overuse can cause the tendon to degenerate, a condition called tendinosis.
Etiology of tendonitis:
- Direct injury can trigger tendonitis.
- A single macrotraumatic event or
- Repeated microtraumatic events (eg, racquet sports, baseball, golf, hammering, typing, mousing)
- Improper technique can cause tendonitis.

Commonly Associated Conditions

Other overuse injuries of the wrist and hand
Median nerve irritation because of close proximity of FCR tendon to the median nerve

Diagnosis

History

Pain and possible swelling on volar aspect of wrist
Increase in pain with activity and gripping
Limited motion
Possible crepitus at the site with movement or palpation
Possible acute or repeated trauma to the area
Overuse:
- Repetitive and forceful activity
- Sudden increase in activity
- Change in technique or equipment
FCR tendonitis: Pain radially, may radiate into forearm or thumb
FCU tendonitis: Pain ulnarly

Physical Exam

Possible swelling at the volar aspect of wrist
Tenderness near insertion points:
- FCR tendonitis:
  - Locate the FCR tendon to the ulnar side of the scaphoid tubercle.
  - Follow the course of tendon about 3 fingerbreadths distally to find the approximate insertion point.
- FCU tendonitis: Tenderness at the pisiform or just distal at the 4th and 5th metacarpal bases
Pain with active contraction:
- FCR tendonitis: Palmarflex and radially deviate the wrist.
- FCU tendonitis: Palmarflex and ulnarly deviate the wrist.
Also may have pain with passive dorsiflexion of the wrist
Pain with pisotriquetral grind test may suggest osteoarthritis of the pisotriquetral joint.

Diagnostic Tests & Interpretation

Imaging

Radiographs:
- Usually not needed for diagnosis
- Views: Posteroanterior, lateral, oblique, and lateral in slight supination of wrist
- Usually normal but may see:
  - Degenerative changes in the pisotriquetral joint
  - Calcium in the tendon in calcific tendonitis
MRI:
- Use when diagnosis is unclear (especially for ulnar-sided wrist pain)
- Use when not improving with conservative treatment
- Findings:
  - High fluid signal within the tendon sheath
  - Tendon sheath thickening
  - Tendon may be enlarged.
US:
- FCR tendonitis: Fluid distending the synovial sheath
- FCU calcific tendonitis: Calcium deposition in the tendon proximal to the pisiform
- FCR/FCU tendinosis:
  - Hypoechoic thickening of tendon
  - May show neovascularization on color-flow Doppler

Diagnostic Procedures/Surgery

Pain relief with lidocaine injection into the tendon sheath aids in diagnosis.

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Differential Diagnosis

Radial side of wrist:
- Fracture of scaphoid, trapezium, or 1st or 2nd metacarpal bases
- de Quervain tenosynovitis
- Osteoarthritis at 1st carpometacarpal joint or other joints of the carpus
- Strain or tendonitis of thenar muscles
- Ganglion: Usually located to the radial side of the FCR tendon
- Carpal tunnel syndrome
Ulnar side of wrist:
- Fracture of pisiform, ulnar styloid, hamate hook, or other carpal bone
- Triangular fibrocartilage complex tear
- Osteoarthritis of the pisotriquetral joint or other nearby joints
- Strain or tendonitis of hypothenar muscles
- Hypothenar hammer syndrome
- Ulnar nerve entrapment in Guyon canal
Miscellaneous:
- FCR/FCU tendinosis
- FCR/FCU tendon rupture
- Tenosynovitis from rheumatologic disorder

Treatment

Initial treatment:
- Avoiding provocative activities
- Wrist splint in 25 degrees of palmar flexion (1)[C] × 1–2 wks or until symptoms improve
- Icing
- NSAIDs
Subsequent treatment as condition improves:
- Occupational therapy:
  - Stretching and strengthening program
  - Ergonomic improvements
- Coaching:
  - Improve technique/mechanics.
  - Consider changing racquet grip (2)[C].
Refractory cases: Injection of steroid and local anesthetic into tendon sheath:
- Resolution of symptoms in 35–40% of patients (3)[C]
- Calcific tendonitis responds particularly well to steroids.

Surgery/Other Procedures

If symptoms are prominent and not responding to nonoperative treatment, consider surgical consultation.
Surgical procedure:
- Surgical release of the tendon
- Excision of inflamed tenosynovium
- Z-plasty lengthening if needed
- Pisiform excision
Surgery is usually curative, with return to racquet sports in 6–8 wks (3)[C].

Ongoing Care

Patient Education

When introducing a new activity or increasing a current activity, do so slowly to help prevent an overuse injury.
Allow time for recovery between practices and competition.
Warm up the area well before playing.
Maintain proper strength, flexibility, and endurance of the forearms, wrists, and hands.
Use proper technique.

Prognosis

Usually resolves with conservative treatment within 6 wks

References

1. Rettig AC. Athletic injuries of the wrist and hand: part II: overuse injuries of the wrist and traumatic injuries to the hand. Am J Sports Med. 2004;32:262–273.

2. Tagliafico AS, Ameri P, Michaud J, et al. Wrist injuries in nonprofessional tennis players: relationships with different grips. Am J Sports Med. 2009;37:760–767.

3. Palmieri TJ. Pisiform area pain treatment by pisiform excision. J Hand Surg [Am]. 1982;7:477–480.

Additional Reading

Bencardino JT, Rosenberg ZS. Sports-related injuries of the wrist: an approach to MRI interpretation. Clin Sports Med. 2006;25:409–432, vi.

Osterman AL, Moskow L, Low DW. Soft-tissue injuries of the hand and wrist in racquet sports. Clin Sports Med. 1988;7:329–348.

Parellada AJ, Morrison WB, Reiter SB, et al. Flexor carpi radialis tendinopathy: spectrum of imaging findings and association with triscaphe arthritis. Skeletal Radiol. 2006.

Young D, Papp S, Giachino A. Physical examination of the wrist. Orthop Clin North Am. 2007;38:149–165.

Codes

ICD9

727.05 Other tenosynovitis of hand and wrist