Objective: To determine conclusive indication of TFCC syndrome from a side-armed
pitcher. Background: A freshman side-armed pitcher was clinically observed due to
complaints of wrist pain. The athlete expressed a history of radiating pain around distal
ulnar for the past couple days. Pain generated during activity and symptoms slowly
diminished with rest. The pitcher had no previous history of injury or can recall of an
acute onset to the dominant hand. Grinding sensation and clicking during the follow-
thorough stage with pitching was noted. Evaluation of the elbow and shoulder confirmed
no relation to the pitcher’s symptoms. Mild swelling was localized near the distal ulnar,
but eccymosis or deformity wasn’t present. Pain was elicited with palpation at the palmar
surface around the ulnar head. Ulnar deviation with active, passive, and resistive range of
motion was limited due to pain. Passive range of motion extinguished slight pain with
wrist flexion, and resistive range of motion showed weakness during supination.
Compression test at the distal forearm was positive with pain near the injured site.
Differential diagnosis: distal radius stress fracture, carpal tunnel syndrome, dislocation
of the ulnar head. Treatment: Rehabilitation started before practice with ultrasound
being immersed in a bin of water to facilitate around the bony protuberance at the injured
site. Resistive exercises were followed to enhance strength of the forearm. Treatment
after practice included compression of ice for 15 minutes. Uniqueness: Finding of an
Injured TFCC is seen acutely during a fall on hyper extended wrist, a single traumatic
force with ulnar deviation, from distal radial fracture, or chronically with repetitive
distractive forces. Conclusion: The pitcher’s was diagnosed with mild case of TFCC
syndrome. Treatment lasted two weeks and removal from activity wasn’t necessary. It is
significant for early recognition and treatment of this injury to avoid further damage, but
correcting proper biomechanics is the right approach towards prevention. Key Words:
TFCC syndrome, distal ulnar, ulnar deviation, supination, distractive forces
The Anatomy of the TFCC originates at the distal radial medial border and inserts
into the base of the ulnar styloid. It consists of articular disc, meniscus homologue,
ulnocarpal ligament, dorsal and volar radioulnar ligament, and ECU sheath.( Wheeless )
The ligamentous attachments prevent dorsal movement of the distal ulna. The volar
ulnocarpal ligaments run from the base of the base of the ulnar styloid process across the
volar surface of the TFCC, which inserts to the lunate and triquetrum. (Wheeless) The
volar side of the TFFC prevents dorsal displacement and the dorsal aspect prevents volar
displacement.Tears of the triangular fibrocartilage causes instability of the distal
radioulnar joint.The TFCC is flexible and provides rotational movements of the
radiocarpal joint around the ulnar axis.
One of the main functions provides gliding motions across the distal radius and
ulnar for extension, flexion, and transition. Forces through the ulnocarpal axis are
cushioned by the TFCC. (Verheyden) During axial loading, the radius carries the
majority 82% of load, and the ulna a smaller load of 18%. (Wheeless) Mechanisms that
causes damage to the TFCC includes: falling onto a pronated hyperexented wrist,
distraction forces applied to the volar forearm or wrist, and distal radial fractures.
(Vereyden) Positioning the ulnar towards an increasing load would apply more stress to
the TFCC. This type of axial load which puts more force on the TFCC is a common over
use mechanism for pitchers, especially side-arm throwers.
A freshman side-armed pitcher came to the Athletic Training room with
complaints of wrist pain. The athlete was experiencing distal ulnar pain described as
radiating which continued for couple days. Pain occurs during activity and symptoms
slowly diminished with rest. He was able to continue through the practice and never felt
the need to stop activity due to pain. The pitcher had no previous history of injury or any
recall of acute onset to the right hand. The athlete also experienced grinding sensation
and clicking during the follow-thorough stage with pitching. The pitcher wasn’t taking
any kind of medication and no other pain near or around the elbow and shoulder.
The athlete was evaluated with primary complaints with pain, which was ranked
six out of ten pain scale during activity. At rest, pain was measured two from pain scale.
Slight swelling was localized near the distal ulnar, but eccymosis or any kind of
deformity wasn’t present. Pain was elicited with palpation at the palmar surface around
the ulnar head. Pain with limitation of ulnar deviation was positive with active, passive,
and resistive range of motion. Passive range of motion extinguished slight pain with wrist
flexion, and resistive range of motion confirmed positive weakness with supination.
Glide test and Phalen test was concluded a negative outcome, but compression test at the
distal forearm was positive with pain near the injured site. A neurological screening was
tested within normal limits and a radiological review wasn’t necessary due to the
conclusion of the clinical evaluation.
Due to the clinical injury report and observation of rehabilitation of the athlete’s
injury, I do believe the impression of this pathology is accurate. The pitcher is a side-arm
thrower with complaints of pain during activity that slowly diminishes with rest. This
indicates a chronic injury due to possible improper biomechanics. A negative Phalen test
concludes the pathology has no neurological relations. Negative glide test proved normal
ligament stability of the wrist. Since the athlete’s symptoms are wrist pain near the distal
ulna side and frequent clicking or popping is a clear indicative sign of a TFCC injury.
Injury to the TFCC is commonly diagnosed from a fall on hyper extended wrist, and
distraction forces from a traumatic force or repetitive motion.( Wheeless) From observing
a side-armed pitcher go through the pitching phases, I do understand how the force is
distributed near the ulnar side of the wrist. From close observation of athlete’s
biomechanics, it is difficult to uncover distinctive abnormalities during his pitching
phases. However, I do recall the freshman pitcher being stretched for the first time during
mid-season and showed signs of tightness in all areas of the lower extremity. He showed
poor flexibility while being stretched. This is significant because the lower body is
included in the pitching phases, especially during the follow –through stage whereas pain
is elicited. Assuming that the patient has poor flexibility of the upper extremity as well, I
came to a conclusion the athlete wasn’t properly conditioned to start the season. This
could be the cause of the athlete’s improper biomechanics during the pitching phases.
Although the primary mechanism that caused this pathology is repetitive distraction
forces to the ulnar side of the wrist, I believe the athlete’s lack of conditioning before the
season started makes my theory quite relevant.
Treatment began with 30 minutes before practice. Rehabilitation with ultrasound
was started by being submerged in a bin of water because of the bony protuberance at the
site of injury. Ultrasound was used for 15 minutes to increase blood flow to the TFCC.
Resistive range of motion was followed with a “foamed cylinder” shaped tool whereas
the patient grips both hands. It resists moveable motions that maximize strength during
wrists mobility. Radial deviation, ulnar deviation, elbow supination and pronation were
being performed with this modality. “Putty” was given next to the patient whom he
sculpted and molded in the palm with the injured wrist. The patient played with the
“putty” for ten minutes. This helped strengthened the muscles of the forearm. Treatment
after practice included compression of ice for 15 minutes. The athlete didn’t feel the need
to head back to ESBY team house, so the pitcher was given ice after every practice.
The freshman pitcher rehabilitation lasted for two weeks since the injury was a
mild severity. After the first three days of treatment, pain was quickly reduced after
pitching but still had some pain during activity. The athlete’s symptoms slowly
diminished during the motions of pitching. Pain mostly elicited with ulnar deviation
during the follow-through stage, but gradually diminished with rehabilitation. Since the
athlete came to the student Athletic Trainers as soon the symptoms occurred, he was able
to continue with pitching with rehabilitation. The pitcher wasn’t eliminated from baseball
practice, but was strictly informed to stop activity if symptoms started to reoccur.
The TFFC is an active site of injury commonly seen with the wrist. Mechanisms
usually seen that causes injury to the articular disk is falling on hyper extended wrist, and
distraction forces from a traumatic force or repetitive motion. The freshman pitcher
experienced clicking sensation located near the head of the ulnar, elicited pain during the
follow-through stage of pitching, and experienced signs and symptoms diminished with
rest indicates TFCC syndrome. The anatomy of the TFFC is vulnerable to degeneration if
abnormal biomechanics forces are prolonged at the site of the TFCC. Early recognition of
TFCC syndrome will overcome a faster recovery with proper rehabilitation. Discovering
early signs of improper biomechanics of athletes prevents this chronic pathology.
Nagle, D.J. “ Evaluation of Chronic Wrist Pain” Journal of the American Academy of
Orthopedic Surgeons (2000). www.jassos.org/cgi/content. 01 May 2008
Verheyden, James “Trinagular Fibocartilage Complex” eMedicine Specialities (2007).
www.emedicine.com/orthoped/topic. 25 Apr 2008
Wheeless, Clifford “Ligaments of the Wrist” Duke of Orthopaedics presents Wheeless’
Textbook of Orthopedics (2008)
www.wheelessonline.com/ortho/ligmaments_of_the_wrist . 25 Apr 2008
Wheeless, Clifford “Triangular Fibrocartilage Complex” Duke of Orthopaedics presents
Wheeless’ Textbook of Orthopedics.
www.wheelessonline.com/ortho/traingular_fibrocartilage_complex 25 Apr 2008
Hunter/ john “extensor carpi ulnaris tendon tears” BORG Collective (2003)
www.uwmsk.org/borg/stories/storyReader 24 Apr 2008