How can Physiotherapy help?

MANAGEMENT

The progression of management for an individual with a triangular fibrocartilage complex (TFCC) tear is the same for injuries diagnosed as either traumatic or degenerative. You should expect to begin with conservative treatments and rehabilitation overseen primarily by a physiotherapist and your general practitioner (GP). If your injury fails to respond to such conservative measures there are several more invasive orthopaedic surgical management strategies available that repair the TFCC tear directly and restore stability amongst the bones and ligaments that form your wrist. Ultimately all management strategies for TFCC tears aim to restore the greatest amount of function back to your injured wrist whilst preventing any further or future injury.

CONSERVATIVE MANAGEMENT

Conservative management of TFCC tears involves eight to twelve weeks (or greater depending on the extent of injury) of progressive phases of treatment that aim to enhance natural healing processes and prevent further damage at the injury site. Conservative management of TFCC tears consists of:

Immobilisation (cast or splinting)
Anti-Inflammatory Medication (NSAIDS)
Physiotherapy Rehabilitation

These three important features of conservative management are involved throughout the four phases that begin at immobilisation at the time of TFCC tear diagnosis and then progress through to the return of function. These phases are summarised below:

Immobilisation ( 3 – 6 weeks )

After diagnosis of a TFCC tear your wrist will be immobilised in a Sugar Tong Splint (http://emedicine.medscape.com/article/80127-media) that places your wrist in a protective position that places minimal stress on your TFCC and prevents forearm movements that stress the TFCC. Immobilisation occurs for a period of four to six weeks for traumatic tears and three to four weeks for degenerative tears, so to allow for optimal uninterrupted healing at the site of your injury. During this time it will be recommended to you to take anti-inflammatory medications such as NSAIDS (neurofen), that should be overseen by your GP and self-administered depending on your level of pain or symptoms.

Physiotherapy management forms an important role during the immobilisation period, particularly in educating you about the importance of movement exercises for your fingers and thumb to prevent significant muscle loss (atrophy) whilst your wrist is in the splint. You should move your fingers and thumb as much as pain permits during the day, for at least ten sets of repetitions per day. Movement of your fingers and thumb also promotes fluid movement and clearing of any swelling at your wrist or tissues back through the blood vessels in your forearm. Maintaining strength in such muscles will make functional rehabilitation after the splint is removed easier as it will assist the muscles that move your wrist that will have lost strength after being disused in the splint. During this phase your physiotherapist will gain an understanding of your injury that will optimise their planning of a rehabilitation program for you to regain your wrist function after the splint is removed (phase two).


Splint Removal & Early Physiotherapy Rehabilitation ( 4 – 6 weeks)

Once your splint has been removed after the approval and satisfaction of your medical professional in the results of the period of immobilisation healing, physiotherapy becomes the most important influence on your rehabilitation. Your physiotherapist should conduct a full physical examination of your wrist in particular and the other joints of your arm before any treatment is started to identify your main functional losses such as active range of movement of your wrist (AROM), muscle strength and length in your forearm whilst assessing for stiffness, scarring and swelling in your joints and any areas or movements that are painful. Assessment of the wrist and arm’s function is vital in developing the exercise program that will form the core of your rehabilitation as well as indicating other treatment techniques such as massage or electrical physical agents (such as ultrasound).

Your physiotherapy rehabilitation should involve exercises that regain movement, strength, flexibility, coordination and function of your wrist, improve circulation, decrease swelling and ease discomfort whilst also incorporating functional tasks relevant to your goals or occupation. Education is again an important feature of this phase as your physiotherapist should inform you how to protect your joints during certain activities or job duties, whilst also advocating the importance of now wearing a removal splint for such protection, especially during sleeping.

Recommendations for exercises/techniques in your initial rehabilitation program should include:

AROM and Assisted AROM exercises – wrist (flexion / extension, ulnar / radial deviation), fingers/thumb (flexion / extension), forearm (pronation / supination), elbow (flexion/extension)
Tendon Glide exercises – differentiate wrist from finger tendons, increase their movement
Functional exercises – fist formation, opposition and grip
Massage – reduce swelling and scarring/adhesion formation
Passive Accessory Movement Glides – particularly wrist (AP, PA and Med/Lat) and DRUJ (AP/PA)
Pain management – GP may inject cortisone / steroids

These techniques aim to achieve the main goals of initial physiotherapy rehabilitation of decreasing swelling and increasing ROM. Such exercises should be prescribed in sets of 3-5/day with the amount of repetitions and sets adjusted according to your level of function. AROM exercises should performed slowly with the physiotherapist applying a gentle stretch at the end of movement to encourage stretching. Finger movement should be encouraged to remain at as often as possible with pain permitting to maintain hand function. It is important that your physiotherapist educates you about why you are performing these exercises and should supplement your therapy sessions with handouts that demonstrate the exercises and also about how swelling is a normal and necessary response to injury and the way to best manage it. This initial phase of rehabilitation should typically last four weeks, progressing in the range of exercises from gentle AROM to beginning strengthening exercises (phase three).


Continued Physiotherapy Rehabilitation

Once ROM has begun to sufficiently improve from the initial assessment values, your physiotherapist should start to focus more on improving the strength and endurance of the muscles that move your wrist depending on level of healing of your TFCC healing as indicated by your GP and physiotherapist. If ROM improvement has plateaued before reaching functional ROM, it is recommended that a dynamic or static progressive splint should be used, that promotes increases in movement in desired directions by placing the targeted joint in a gentle stretch. Typically such splints are applied in a forearm supination or wrist extension position.

Strengthening prescription should begin after twelve weeks post diagnosis with isometric exercises for the wrist, forearm, hand, elbow and shoulder against the physiotherapist then progressing onto more resistance-based exercises as tolerated starting at minimal weight. In particular grip strength should be addressed due to its critical functional value in most daily activities and occupational duties. Weight bearing on hands should be avoided at all times, your physiotherapists will eventually incorporate weight bearing on gym balls under supervision if it is a functional activity involved in your occupation or sport after sufficient resistance strengthening.

Recommendations for strengthening program:

Pronation / Supination – hold a hammer in your hand and perform movement both concentric and eccentrically
Wrist Flexion / Extension – Small dumbbell (500g then progress to higher masses) perform movement
Elbow / Shoulder Strengthening – Start minimal weight and progress to larger mass, in ROM that require strengthening

Prescription of such exercises should be based on initially building muscle mass, using moderate repetitions (6-10 reps) and eccentric loading (3 seconds down and 1 second up phase) for initially 3-5 sets/day, depending on progression of increases in strength. For endurance you should be performing high repetitions (>10 reps) of a low weight, pain permitting, in between or after strength exercise sets.

The use of removal splinting should continue to be encouraged during sleeping and daily activities that may re-injure the TFCC, as protecting your injury also continues to facilitate your healing and also rests your wrist and forearm.

Another focus of this phase is the incorporation of more functional activities as apart of exercise prescription, in preparation for returning you back to normal independent functioning depending on your goals. Such more functional activities can involve:

Folding washing
Using cutlery
Using tools such as screwdrivers
Other occupational/sport specific tasks

These activities should progress the rehabilitation of your wrist to a level of pain free function that can enable your integration back into independent living (phase four), depending upon the approval of your physiotherapist’s assessment of your wrist.


Return to Function

This is the end phase of your rehabilitation journey with your physiotherapist under conservative management where hopefully your injury has responded sufficiently and your function permits you to return to work, sport or independence. Throughout this phase education and reassessment of your wrist are the main management focuses that your physiotherapist will use to ensure that the activities you are participating are not causing reinjury of your TFCC and that you know how to protect your wrist.

However if the TFCC tear fails to respond to conservative management, surgery is the next and final option available to repair your injury. There are several surgical procedures available ranging from key hole surgery to full open surgery to repair your TFCC. Selection of your procedure depends on the nature of your injury (traumatic or degenerative) as based upon the TFCC tear classification system, whether there is any bony or ligamentous instability and the preference of your surgeon.

The recommendations for protocols for conservative management of TFCC tears was interpreted from the text, Fundamentals of Hand Therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity, Cooper, C. (2007).

EVALUATION

Conservative measures have been shown to be a successful management strategy for TFCC tears post functional physiotherapy rehabilitation, as a study of 133 individuals with TFCC tears who undertook conservative management were asymptomatic 9.5 years post injury (Osterman et al., 1991). However they are highly dependent on the extent of the tear and several factors specific to the individual involving their level of motivation, healing ability, comorbidities and adherence to the rehabilitation programs. Due to the relatively avascular nature of the TFCC surgical procedures are more highly preferred strategies for repairing TFCC tears with the success of conservative measures being more attributed to post surgery rehabilitation using the same progression of management.