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INJURY EVALUATION
AND MANAGEMENT
Recognition and Management of Triangular
Fibrocartilage Complex Injury
Gary E. McIlvain, EdD, LAT, ATC; Neil A. Evans, PT, DPT, OCS, CSCS; and Suzanne M. Konz,
PhD, ATC, CSCS • Marshall University; Timothy A. Tolbert, PhD, ATC • Georgia Gwinnett
College; John J. Jasko, MD and Charles E. Giangarra, MD, FAAOS • Marshall University
O
ne of the most common wrist complaints
is vague ulnar-side pain.1-3 In many cases, a
single traumatic event is the cause of pain,
which may delay diagnosis of the cause.1-5
When evaluating the wrist, an athletic trainer
should use a systematic process, since triangular fibrocartilage complex (TFCC) injury is
often missed when it first occurs. A nonspecific diagnosis of wrist sprain is often associated with subsequent
development of chronic
Key Point
ulnar-side wrist pain.
Complaints of clicking,
Triangular Fibrocartilage Complex (TFCC)
popping, worsened pain
injury is often dismissed as a wrist sprain.
over time, ulnar-side pain
Vague ulnar-side wrist pain may be the
elicited by functional utiresult of TFCC injury.
lization (e.g., attempting
a hockey goal shot), grip
Isolated ulnar styloid process fracture often
strength weakness, and
involves TFCC injury.
unstable sense of instability are common. TFCC
injury is sometimes referred to as the “wrist
sprain that never goes away.” Acute TFCC
injury is typically caused by a fall on a pronated
and outstretched arm, which forces the wrist
into extension. Some athletic activities, such as
gymnastics, repetitively impose axial loading
on the ulnocarpal, and radiocarpal joints may
injure the TFCC, but sports that load the wrist
during open-chain function, such as hockey,
baseball, basketball, and football, can also
damage the structure.2,3,5,6-9
A risk factor for TFCC injury is positive ulnar variance, which is a more distal
position of the ulna in relation to that of
the radius. Positive ulnar variance normally
occurs during pronation of the forearm.
Some athletes exhibit a positive ulnar variance in any position, however, which may be
due to genetics or a previous fracture of the
distal radius. This abnormal structural alignment has been associated with thickening
of the TFCC and an altered distribution of
forces created by rotational and compressive
loads.10,11 Werner et al.12 reported that as little
as 2.5 mm of ulnar length increase elevates
compressive load-bearing on the ulnar side of
the wrist by 18.4% to 41.9%. Because positive ulnar variance is a major predisposing
factor for TFCC injury, a thorough history of
previous wrist injuries and a clear description of the exact mechanism that caused an
acute wrist injury may create a high index
of suspicion that TFCC damage has occurred
(Figure 1).
Anatomy and Function
The bony structure of the wrist includes the
distal portions of the ulna and radius and
the eight carpal bones. The proximal row of
carpals and the transverse carpal ligament
define the boundaries of the carpal tunnel.13
Many elongated soft tissue structures cross
© 2013 Human Kinetics - IJATT 18(3), pp. 37-42
international journal of Athletic Therapy & training
may 2013  37
the wrist, and numerous fibrous tissues stabilize the
joints that collectively contribute to wrist function. Key
passive stabilizers include the palmar and dorsal carpal
ligaments, ulnocarpal ligaments, radiocarpal ligaments,
and the TFCC.13
The three-dimensional structure of the TFCC
is comprised of the dorsal and palmar radioulnar
ligaments, the ulnar collateral ligament, the annular
(articular) disc, the meniscus homologue, and the
tendon sheath of the extensor carpi ulnaris muscle
(Figure 2).1,5,17-20 The TFCC primarily stabilizes the
distal radioulnar joint and helps to stabilize the ulnocarpal joint. The structure also dissipates axial loads
and translational forces, transfers loads from the carpal
bones to the ulna, and guides complex movements of
the wrist.2,14-18
Identification of TFCC
Because an athlete with a TFCC injury may relate a
vague history and often cannot identify a clear mecha-
nism of injury (MOI) associated with a single traumatic
event, such an injury tends to be perplexing and is
often treated as a simple wrist sprain.1-6 The athletic
trainer should include TFCC injury in the differential
diagnosis when gathering information about the history of the injury and attempting to identify the MOI.
A detailed history of all previous wrist injuries is important to consider. Injury to the TFCC often involves a
cycle of initial pain, resolution of pain, and recurrence
of pain that coincides with return to normal activity.
This pattern should create a high index of suspicion
that a TFCC injury may have occurred, and the condition should be included in the differential diagnosis
with fracture, sprain, strain, and carpal dislocation/
instability.9,14,21 TFCC injury can be degenerative in
the older populaton.2 A classification system for TFCC
tears was developed by Palmer,2 who reported that
acute tears typically occur in patients who are less
than 30 years of age, whereas degenerative injury is
more common among patients who are older than 30
years of age.
Figure 1 (A) depicts a negative ulnar variance, (B) depicts a neutral ulnar variance,
while (C) depicts a positive ulnar variance.
Figure 2 The TFCC. Used by permission. Illustrations by Dr. Michael E. Stadnick, MD.
Http://www.radsource.us/clinic/0507.
38  may 2013
international journal of Athletic Therapy & training
Physical Exam
Acquisition of a detailed history is crucial for determination of the likelihood that the TFCC has been injured,
which may require an athletic trainer to ask the same
questions in a variety of ways by using different terminology.9,13,14 Typically, the patient will report pain
when he or she tries to grip, pronate, or supinate the
forearm (e.g., turning a doorknob or putting a spin on
a basketball when bounce passing).
Observation of the wrist should include a visual
search for any evidence of pallor, edema, ecchymosis,
or structural deviations, including assessment of the
alignment of the metacarpophalangeal joints (Figure 3).
Palpation of bony structures is important for determination of any specific sites of point tenderness. TFCC
pain might not be elicited by palpation, but the space
beyond the distal end of the ulna that is between the
extensor carpi ulnaris and flexor carpi ulnaris tendons
may be painful. Active ROM is often limited in the
presence of a TFCC injury, which primarily restricts
extension and ulnar deviation. Specific clinical tests
may be helpful in differentiating a TFCC injury from
other wrist pathology.3,11,12,18 The TFCC Compression
Test involves axial loading, ulnar deviation, and rotation, which is also referred to as loaded circumduction (Figure 4). The Active Pronation/Supination Test
involves repetitive performance of active pronation
and supination of the forearm while the examiner
palpates the distal radioulnar joint for snapping and
popping (Figure 5). The Active Press Test is performed
by the patient through an attempt to vertically lift his
or her body mass from a seated position (Figure 6).
The Ulnomeniscal-Triquetral Dorsal Glide Test involves
the examiner’s attempt to manually displace the triquetrum dorsally, while stabilizing the distal ulna (Figure
7). The Ballottement Test involves manual translation
of the distal ulna and radius in opposite directions
within the saggital plane (Figure 8).9,14
Diagnosis
Diagnostic imaging is necessary to conclusively establish a diagnosis of TFCC injury, and MRI is considered
to be the best method.4,14 Leakage of injected dye into
the substance of the TFCC, or leakage from the carpus
into the distal radioulnar joint, will confirm the diagnosis (Figure 9). Because the TFCC has an attachment to
Figure 4 TFCC Compression Test. The examiner axially loads the
patient’s wrist, passively ulnar deviates the patient’s wrist, and circumducts the wrist.
Figure 5 Active pronation/ supiFigure 3 Murphy’s Sign — A visual appearance of depressed 3rd MCP,
typically associated with a Lunate dislocation or Metacarpal fracture. In
this normal 2–4 MCP curvature, if the 3rd MCP would drop to or below
the dotted line, it would be considered positive.
international journal of Athletic Therapy & training
nation test. Examiner palpates
the radioulnar joint while the
patient actively pronates and
supinates noting any popping
or clicking.
Figure 6 Active press test.
Patient attempts to lift him/
herself vertically off of a surface.
may 2013  39
Figure 7 Ulnomeniscal-Triquetral Dorsal Glide Test. With the forearm in
neutral, the therapist places his/her same thumb on the head of the ulna
and the 2nd/ 3rd distal phalange on the pisiform/triquitrum. The examiner
then applies a pinch grip moving the pisiform/triquitrum dorsally with the
2nd/ 3rd finger while stabilizing the distal ulna with the thumb. A positive
test is indicated by laxity of the TFCC and pain on or near the patient’s
pisiform/triquitrum.
Figure 8 Ballottement Test. Grasping the uylna and radium (1) attempt
to translate the ulna anteriorly and the radium posteriorly simultaneously, then (2) attempt to translate the ulna posteriorly and the radius
anteriorly simultaneously (oscillating the ulna a radius in opposite
directions stressing the TFCC).
the styloid process of the ulna, evidence of an isolated
ulnar styloid process fracture on a plain radiograph
should create a high index of suspicion that a TFCC
injury exists.22
Treatment of TFCC
Conservative treatment of a peripheral TFCC injury that
resulted from an acute traumatic event often involves
immobilization for 4–6 weeks, which is followed by
a rehabilitation program (Table 1). Acute tears of the
peripheral portion have an adequate blood supply to
permit tissue healing.8,15,16 If conservative treatment
is not effective, or the injury to the TFCC is located
in the central portion, arthroscopic or open surgery
is often warranted.16,23-26 Postsurgical rehabilitation
differs on the basis of surgical debridement versus
TFCC repair. Any type of surgical repair requires up
to 6 weeks of cast immobilization, whereas postsurgical management of a debridement procedure simply
requires splinting in a neutral position for 2 weeks
40  may 2013
Figure 9 Arthrogram MRI. (A) shows a TFCC tear while
(B) shows dye that has leaked from the wrist space into
the distal radioulnar joint space
(Table 2). Recently, platelet-rick plasma injection has
been advocated as a treatment option, but insufficient
research evidence currently exists to establish the clinical effectiveness of the procedure.8, 27-30
Nonsurgical management of a TFCC injury generally consists of a period of immobilization, which is
followed by emphasis on restoration of normal ROM.
Active-assistive ROM exercises are initially used, which
are followed with passive ROM exercises. Strengthening is progressed from isometric exercises to isotonic
open-chain exercises and gradual progression to
the application of weight-bearing loads to the upper
extremity during a late stage of the rehabilitation process. Compressive loading in a position of forearm
pronation should be avoided for a period of 8–10 weeks
due to the positive ulnar variance that is produced.28
With proper rehabilitation, an athlete should be able
to return to play around 12–14 weeks postinjury.29-31
Shih and Lee32 reported that 90% of patients reported a
good to excellent outcome following proper treatment.
Conclusion
Persistent ulnar-side wrist pain should prompt a
thorough assessment for the possible existence of a
TFCC injury. TFCC injury may result from an acute
wrist sprain and may be associated with a fracture,
but it can also result from repetitive trauma cannot
be related to a single traumatic event.2,3,5-9 It is often
overlooked or misdiagnosed as a wrist sprain until
recurrent pain motivates the patient to seek further
care. The patient will typically complain of ulnar-side
wrist pain during activity, which resolves when activity
international journal of Athletic Therapy & training
Table 1. Nonsurgical Rehabilitation
Week
Exercise
1-6
Splinted in neutral
7
Active-Assistive ROM for wrist and forearm
8
Passive ROM for wrist and forearm. Weighted static stretches. Isometric strengthening for wrist
and forearm
9
Continue ROM. Begin PRE strengthening with putty and/or hand grip strength exerciser
10-18
Continue ROM. Begin isotonic PRE exercises for wrist and forearm
Baseball and Softball Sport Specific Progression
11
Begin swinging light bat and short throwing
12
Begin swinging regular bat and increasing throwing distance gradually
13
Begin hitting off of a tee and increasing throwing distance and speed
14
Increase hitting/throwing repetitions and progress intensity
15
Progress to hitting live pitches (only making contact and swinging through)
16-18
Progress to full batting and pitching/throwing
Table 2. Postsurgical Management of a Debridement Procedure
Central Debridement
Peripheral Repair
Week
Exercise
Week
Exercise
1
NONE; focus is on wound care, pain control, and
immobilization.
1-6
Casted in neutral
2
Active-assistive ROM for wrist and forearm.
7
Active-assistive ROM for wrist and forearm.
3-4
Passive ROM for wrist and forearm. Weighted
static stretches.
8
Passive ROM for wrist and forearm. Weighted
static stretches. Isometric strengthening for wrist
and forearm.
6
Continue ROM. Begin PRE strengthening with
putty and/or hand grip strength exerciser.
9
Continue ROM. Begin PRE strengthening with
putty and/or hand grip strength exerciser.
7-14
Continue ROM. Begin isotonic PRE exercises for
wrist and forearm.
10-18
Continue ROM. Begin isotonic PRE exercises for
wrist and forearm.
Baseball and Softball Sport Specific Progression
Baseball and Softball Sport Specific Progression
8
Begin swinging light bat and short throwing.
11
Begin swinging light bat and short throwing.
9
Begin swinging regular bat and increasing throwing distance gradually.
12
Begin swinging regular bat and increasing throwing distance gradually.
10
Begin hitting off of a tee and increasing throwing
distance and speed.
13
Begin hitting off of a tee and increasing throwing
distance and speed.
11
Increase hitting/throwing repetitions and progress intensity.
14
Increase hitting/throwing repetitions and progress intensity.
12
Progress to hitting live pitches (only making contact and swinging through).
15
Progress to hitting live pitches (only making contact and swinging through).
13-14
Progress to full batting and pitching.
16-18
Progress to full batting and pitching/throwing.
international journal of Athletic Therapy & training
may 2013  41
is stopped, and he or she often cannot relate it to any
specific incident.1-3Diagnosis of a TFCC injury requires
a systematic physical examination, which guides referral for appropriate diagnostic imaging. Conservative
treatment is not always successful, but surgical management and proper rehabilitation typically produce
a favorable outcome. 
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Gary McIlvain is an associate dean for the College of Health Professions, Chair of the School of Kinesiology, and an associate professor
at Marshall University in Huntington, WV.
Neil Evans is an assistant professor in the School of Physical Therapy
at Marshall University, Huntington, WV.
Suzanne Konz is the Director of the Biomechanics Laboratory and an
assistant professor in the School of Kinesiology at Marshall University,
Huntington, WV.
Timothy Tolbert is an assistant professor in the School of Science and
Technology at Georgia Guinnett College in Lawrenceville, GA.
John J. Jasko is an orthropedic surgeon and a team physician for
Marshall University Athletics and an assistant professor in the Joan
C. Edwards School of Medicine Department of Orthropedic Surgery,
Marshall University in Huntington, WV.
Charles Giangarra is Chief of Marshall Athletics and Orthopaedic
Sports Medicine and a professor in the Joan C. Edwards School of
Medicine Department of Orthopedic Surgery, Marshall University in
Huntington, WV.
Monique Mokha, PhD, ATC, Nova Southeastern University, is the report
editor for this article.
international journal of Athletic Therapy & training