Extensor Carpi Ulnaris Tendinitis

Extensor Carpi Ulnaris Tendinitis

Extensor carpi ulnaris tendinitis is inflammation of the long, thin muscle that is located on the outer side of your forearm (extensor carpi ulnaris).

It is a common sports-related injury.

Extensor carpi ulnaris tendinitis is being seen with increasing frequency in clinical practice as golf and racquet sports have increased in popularity. The extensor carpi ulnaris tendon is susceptible to the development of tendinitis at the distal portion. The extensor carpi ulnaris tendon is subject to repetitive motion that may result in microtrauma, which heals poorly because of the tendon’s avascular nature. Exercise is often implicated as the inciting factor of acute extensor carpi ulnaris tendinitis, with improper grip of golf clubs and tennis racquets a common inciting cause.

Tendinitis of the extensor carpi ulnaris tendon frequently coexists with bursitis, creating additional pain and functional disability. Calcium deposition around the tendon may occur if the inflammation continues, making subsequent treatment more difficult. Continued trauma to the inflamed tendon ultimately may result in tendon rupture.

What are the causes?

This condition is caused by:

• Putting repeated stress on your wrist.
• Using an improper technique while playing sports like golf and tennis.
• Weakening of the tendon due to age or a health problem.

What increases the risk?

This condition is more likely to develop in people who:

• Play sports like golf, tennis, or rugby.
• Are middle-aged or older.
• Have an inflammatory condition, such as rheumatoid arthritis.

What are the symptoms?

Symptoms of this condition include:

• Pain along your forearm when moving your wrist.
• A constant ache on the pinkie side of your wrist.
• Feeling like your grip is weaker than usual.
• A popping or tearing feeling in your wrist.
• Swelling.

The onset of extensor carpi ulnaris tendinitis is usually acute, occurring after overuse or misuse of the wrist joint. Inciting factors include playing tennis, playing golf, and prolonged use of a heavy hammer. Injuries ranging from partial to complete tears of the tendon can occur when the distal tendon sustains direct trauma while the wrist is in full radial deviation under load or when the wrist is forced into full radial deviation while under load.

The pain of extensor carpi ulnaris tendinitis is constant, severe, and localized in the dorsoulnar aspect of the wrist. Significant sleep disturbance is often reported. Patients with extensor carpi ulnaris tendinitis exhibit pain with resisted radial deviation of the wrist and will exhibit an ECU synergy test.

A creaking or grating sensation may be palpated when the wrist is passively deviated radially. As mentioned, the chronically inflamed extensor carpi ulnaris tendon may rupture suddenly with stress or during vigorous injection procedures inadvertently injected into the substance of the tendon.

How is this diagnosed?

This condition is diagnosed based on your symptoms, your medical history, and the results of a physical exam. During your exam, your health care provider will check the strength of your grip and may ask you to bend your wrist. Your health care provider may also order an MRI or ultrasound to check for tears in your ligaments, muscles, or tendons.

Plain radiographs, ultrasound imaging, and magnetic resonance imaging (MRI) are indicated for all patients who present with ulnar-sided wrist pain.

Based on the patient’s clinical presentation, additional tests, including complete blood count, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. MRI of the wrist is indicated if joint instability is suspected and to confirm the diagnosis further. Ultrasound imaging is also useful in aiding in diagnosis. Radionuclide bone scanning is useful to identify stress fractures of the wrist not seen on plain radiographs.

How is this treated?

Treatment for this condition includes:

• Resting your arm.
• Wearing a splint on your wrist.
• Medicines to help with pain and swelling.
• Applying heat or ice to the area to ease pain.
• Physical therapy to strengthen and restore range of motion in your wrist.

Initial treatment of the pain and functional disability associated with extensor carpi ulnaris tendinitis should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy.

Local application of heat and cold also may be beneficial. Repetitive activities responsible for the evolution of the tendinitis should be avoided. For patients who do not respond to these treatment modalities, injection with local anesthetic and steroid may be a reasonable next step. The use of ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-induced complications.

Differential Diagnosis

Extensor carpi ulnaris tendinitis is generally easily identified on clinical grounds; however, coexistent bursitis may confuse the diagnosis. Fractures of the ulnar styloid and lunate and tears of the triangular fibrocartilage complex, ulnocarpal abutment syndrome, and Kienböck disease also may mimic extensor carpi ulnaris tendinitis.

Complications

Trauma to the extensor carpi ulnaris tendon from the injection itself is an ever-present possibility. Tendons that are highly inflamed or previously damaged are subject to rupture if they are directly injected.

This complication can be greatly decreased if the clinician uses gentle technique and stops injecting immediately if significant resistance to injection is encountered. Approximately 25% of patients report a transient increase in pain after this injection technique, and patients should be warned of this possibility.

Follow these instructions at home:

If you have a splint:

• Wear it as told by your health care provider. Remove it only as told by your health care provider.
• Loosen the splint if your fingers become numb and tingle, or if they turn cold and blue.
• Do not let your splint get wet if it is not waterproof.
• Keep the splint clean.

Bathing

• Do not take baths, swim, or use a hot tub until your health care provider approves. Ask your health care provider if you can take showers. You may only be allowed to take sponge baths for bathing.
• If your splint is not waterproof, cover it with a watertight plastic bag when you take a bath or a shower.

Managing pain, stiffness, and swelling

• If directed, apply ice to the injured area.
  • Put ice in a plastic bag.
  • Place a towel between your skin and the bag.
  • Leave the ice on for 20 minutes, 2–3 times a day.

Activity

• Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
• Avoid activities that put strain on your wrist for as long as told by your health care provider.
• Do not use your injured hand to support your body weight until your health care provider says that you can.
• Do exercises as told by your health care provider.

General instructions

• Do not use any tobacco products, including cigarettes, chewing tobacco, or e-cigarettes. Tobacco can delay bone healing. If you need help quitting, ask your health care provider.
• Take over-the-counter and prescription medicines only as told by your health care provider.
• Keep all follow-up visits as told by your health care provider. This is important.

How is this prevented?

• Warm up and stretch before being active.
• Cool down and stretch after being active.
• Give your body time to rest between periods of activity.
• Make sure to use equipment that fits you.
• If you play golf or racket sports, try to improve your technique or focus on proper form.
• Maintain physical fitness, including:
  • Strength.
  • Flexibility.
  • Endurance.

Contact a health care provider if:

• Your pain does not improve in 7-–10 days.
• Your pain gets worse.

Get help right away if:

• Your pain is severe.
• You cannot move your wrist.

Extensor Carpi Ulnaris Tendinitis Rehabilitation

Ask your health care provider which exercises are safe for you. Do exercises exactly as told by your health care provider and adjust them as directed. It is normal to feel mild stretching, pulling, tightness, or discomfort as you do these exercises, but you should stop right away if you feel sudden pain or your pain gets worse. Do notbegin these exercises until told by your health care provider.

Stretching and range of motion exercises

These exercises warm up your muscles and joints and improve the movement and flexibility of your forearm. These exercises also help to relieve pain, numbness, and tingling.

Exercise A: Extensor stretch

1. Extend your __________ arm in front of you, and point your fingers downward.
2. Gently pull the palm of your __________ hand toward you until you feel a gentle stretch on the top of your forearm and wrist.
3. Hold this position for __________ seconds.
4. Slowly return to the starting position.

Repeat __________ times with your elbow straight and __________ times with your elbow bent. Complete this exercises __________ times a day.

Exercise B: Wrist flexor stretch

1. Stand over a tabletop with your __________ hand resting on the tabletop and your fingers pointing away from your body. Your arm should be extended, and there should be a slight bend in your elbow.
2. Gently press the back of your hand down onto the table by straightening your elbow. You should feel a stretch in the top of your forearm.
3. Hold this position for __________ seconds.
4. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times a day.

Strengthening exercises

These exercises build strength and endurance in your forearm. Endurance is the ability to use your muscles for a long time, even after they get tired.

Exercise C: Wrist extension

1. Sit with your __________ forearm supported on a table and your hand resting palm-down over the edge of the table.
2. Hold a __________ weight in your __________ hand. Or, hold a rubber exercise band or tube in both hands. If you are holding a band or tube, take up any slack with your other hand so there is a slight tension in the exercise band or tube when you start.
3. Slowly move the back of your hand up toward your forearm.
4. Hold this position for __________ seconds.
5. Slowly lower your hand to the starting position.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise D: Ulnar deviation

1. Sit with your __________ forearm supported. Your thumb should be pointing upward, and your hand should be able to move down over the table edge.
2. Hold your __________ arm in front of you and hold a rubber exercise band or tube between your hands. There should be a slight tension in the exercise band or tube when you start.
3. Move your injured wrist so your pinkie travels toward the floor. Try to only move your hand and wrist and keep the rest of your arm still.
4. Hold this position for __________ seconds.
5. Slowly return your wrist to the starting position.

Repeat __________ times. Complete this exercise __________ times a day.

Exercise E: Ulnar deviation, eccentric

1. Sit with your __________ forearm supported. Your thumb should be pointing upward, and your hand should be able to move down over the table edge.
2. Hold your __________ arm in front of you and hold a rubber exercise band or tube between your hands. Do notput any tension on the exercise band or tube yet.
3. Move your __________ wrist so your pinkie travels toward the floor.
4. Add tension to the band or tube by pulling it with your __________ hand.
5. Hold this position for __________ seconds.
6. Slowly return to the starting position, controlling the speed with your __________ hand and wrist. Your hand will move toward the ceiling, thumb first. Try to move only your hand and wrist and keep the rest of your arm still.

Repeat __________ times. Complete this exercise __________ times a day.

Clinical Pearls

The extensor carpi ulnaris is a very strong tendon, but it is also very susceptible to rupture. Coexistent bursitis and arthritis also may contribute to wrist pain and may require additional treatment with a more localized injection of local anesthetic and methylprednisolone acetate.

Injection of the extensor carpi ulnaris tendon is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for elbow pain. Vigorous exercises should be avoided because they would exacerbate the patient’s symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique.