Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis

What is Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis

Flexor carpi ulnaris (FCU) and the flexor carpi radialis (FCR) are tendons in your forearm. Tendons connect muscles to bones. The Flexor carpi ulnaris is located on the pinkie side of your forearm, and the flexor carpi radialis is located on the thumb side of your forearm.

Flexor Carpi Ulnaris tendinitis is inflammation of the Flexor Carpi Ulnaris, and Flexor Carpi Radialis tendinitis is inflammation of the Flexor Carpi Radialis. These conditions cause wrist pain.

What are the activities which cause Flexor carpi radialis tendinitis?

Flexor carpi radialis tendinitis rarely occurs in isolation, but can be caused by the following activities

• Repetitive wrist flexion or overstretching, as with sports such as golf, racquet sports, volleyball or water polo, or
• with occupations involving repeated wrist flexion. 
• Overuse injury may be exacerbated by constriction in the Flexor carpi radialis tunnel, although most often the underlying mechanism of injury is irritation from STT osteophytes

What are the causes of Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis?

Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis may be caused by:

• Repetitive motions or overuse (common).
• Wear and tear. (common).
• An injury.
• Excessive exercise or strain.
• Certain antibiotic medicines.

In few cases, the cause may be unknown.

What increases the risk of Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis?

Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis are more likely to develop in:

• People who play sports that involve constantly flexing or stretching the wrist and forearm, such as volleyball and water polo.
• Older adults.
• People with have a job that involves flexing the wrist over and over, such as people who work as typists, butchers, and cashiers.
• People with certain health conditions, such as:
  • Rheumatoid arthritis.
  • Gout.
  • Diabetes.

What is the anatomy of flexor carpi radialis?

The flexor carpi radialis (FCR) is one of the muscles of the volar superficial layer of the forearm.

With its action, it flexes, abducts, and pronates the wrist.

Because of its biarticular function, the FCR also collaborates, even if minimally, in the flexion of the elbow.

The FCR originates on the anterior aspect of the medial epicondyle (epitrochlea) of the humerus, on the superficial fascia of the forearm (antebrachial fascia), and from the surrounding intermuscular septa.

Its fibers insert at the base of the second metacarpal bone (77%) or at the base of the third metacarpal (23%)

In the terminal part, the FCR tendon runs superficial to the carpal tunnel and through its own osteofibrous canal

What are the symptoms of Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis?

Symptoms of Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis may develop gradually.

Here are the most common Symptoms:

• Pain or tenderness in the wrist.
• Pain when flexing or stretching the wrist.
• Pain when gripping or lifting with the palm of the hand.
• Swelling of the affected area.

What research says about Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis

A study reviewed the incidence and treatment of flexor carpi radialis tendinitis in who had trapeziectomy and abductor pollicis longus suspensionplasty for thumb carpometacarpal joint arthritis.

This study was conducted in 77 patients (81 thumbs)

Among the 77 patients, Eighteen patients, 20 wrists (25%) had flexor carpi radialis tendinitis.

The onset was 2-10 months (mean 4.7) after surgery.

Two cases had preceding trauma.

Eight cases (40%) responded to splinting and steroid injection.

Ten patients, 12 wrists (60%) underwent surgery after failing non-operative treatment.

Eleven wrists had frayed or partially torn flexor carpi radialis tendon and one had a complete tendon rupture with pseudotendon formation.

Flexor carpi radialis tenotomy and pseudotendon excision were performed. All operated patients obtained good pain relief initially post-operatively.

However, the pain recurred in two patients after 8 months. One required a local steroid injection for localized tenderness at the site of the proximal tendon stump. The other patient required a revision operation for scaphotrapezoid impingement.

Both obtained complete pain relief.

This study has shown a high incidence of flexor carpi radialis tendinitis following trapeziectomy and abductor pollicis longus suspensionplasty.

Patients should be warned about this potential complication.

Pathogenesis of Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis

Another study conducted on five patients described the pathology of flexor carpi ulnaris (FCU) tendinopathy.

Five patients (1 bilateral) who failed nonsurgical management of FCU tendinopathy had FCU tendon debridement.

The diagnosis of FCU tendinopathy was made when patients complained of pain localized to the distal FCU tendon. This pain was characteristically activity related. Physical examination in all patients revealed tenderness of the FCU tendon approximately 3 cm proximal to its insertion on the pisiform as well as pain localized to the FCU tendon with resisted flexion and ulnar deviation of the wrist. Similar to disorders of the pisotriquetral joint, pain with resisted flexion and ulnar deviation of

The excised tendon was examined histologically and 4 patients (1 bilateral) were followed-up for at least 12 months.

The results of this study – The pathology was degenerative tendinosis (angiofibroblastic hyperplasia) in all specimens, identical to that observed in tennis elbow and the rotator cuff.

Surgical excision of the pathologic degeneration gave excellent pain relief in all cases.

The pathology of Flexor Carpi Ulnaris tendinopathy (also known as degenerative tendinosis) is almost similar to that of other extrasynovial tendons. 

How is Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis diagnosed?

Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis may be diagnosed based on:

• Your symptoms.
• Your medical history.
• A physical exam.

During the physical exam, you may be asked to move your hand, wrist, and arm in certain ways. In order to rule out another condition, your health care provider may order one or more of the following tests:

• MRI to get detailed images of the body’s soft tissues and detect tendon tears and inflammation.
• Ultrasound to detect soft-tissue injuries, such as tears and inflammation of the ligaments or tendons.

How is Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis treated?

Treatment for Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis may include:

• Rest. You should limit activities that cause your symptoms to get worse or flare up.
• Heat and ice treatment. Both heat and cold can help to ease pain and may be applied to the wrist or forearm as needed to reduce pain and inflammation.
• Splint. You may need to wear a splint to keep your wrist and forearm from moving (keep them immobilized) until your symptoms improve.
• Medicine. Your health care provider may prescribe steroids or other anti-inflammatory medicines, like ibuprofen, to temporarily ease your pain and other symptoms.
• Physical therapy. Your health care provider may ask you to do exercises to maintain mobility and range of motion in your wrist.

Is surgery required for Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis?

• Surgical debridement of the pathologic tendinosis tissue is effective treatment for patients who fail nonsurgical management.
• As per one study, Surgical excision of the pathologic degeneration gave excellent pain relief in all cases.

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 tingle, become numb, or turn cold and blue.
• Do not let your splint get wet if it is not waterproof.
• Keep the splint clean.

Managing pain, stiffness, and swelling

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

Raise (elevate) the injured area above the level of your heart while you are sitting or lying down.

Activity

• Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
• 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 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 Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis prevented?

Here are the care instructions to prevent Flexor Carpi Ulnaris and Flexor Carpi Radialis Tendinitis

• 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.
• Be safe and responsible while being active to avoid falls.
• Do at least 150 minutes of moderate-intensity exercise each week, such as brisk walking or water aerobics.
• Maintain physical fitness, including:
  • Strength.
  • Flexibility.
  • Cardiovascular fitness.
  • Endurance.

Contact a health care provider if:

• Your pain does not improve.
• Your pain gets worse.

Get help right away if:

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

Flexor Carpi Ulnaris and Flexor Carpi Radialis 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 not begin these exercises until told by your health care provider.

Stretching

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. These exercises are done using your healthy forearm to help stretch the muscles in your injured forearm.

Exercise A: Wrist flexion, passive

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

Exercise B: Wrist extension, passive

1. Extend your right arm in front of you and turn your palm upward.
2. Gently pull your palm and fingertips back so your fingers point downward. You should feel a gentle stretch on the palm-side of your forearm.
3. Hold this position for a few seconds.
4. Slowly return to the starting position.

Exercise C: Forearm rotation, palm up, passive

1. Sit with your right elbow bent to an “L” shape (90 degrees) with your forearm resting on a table.
2. Keeping your upper body and shoulder still, use your other hand to rotate your forearm palm up until you feel a gentle to moderate stretch.
3. Hold this position for a few seconds.
4. Slowly release the stretch, and return to the starting position.

Exercise D: Forearm rotation, palm down, passive

1. Sit with your right elbow bent to an “L” shape (90 degrees) with your forearm resting on a table.
2. Keeping your upper body and shoulder still, use your other hand to rotate your forearm palm down until you feel a gentle to moderate stretch.
3. Hold this position for a few seconds.
4. Slowly release the stretch, and return to the starting position.

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. These exercises are done using the muscles in your injured forearm.

Exercise E: Wrist flexion, active

1. With your fingers relaxed, bend your wrist forward as far as you can.
2. Hold this position for a few seconds.
3. Slowly return to the starting position.

Exercise F: Wrist extension, active

1. With your fingers relaxed, bend your wrist backward as far as you can.
2. Hold this position for a few seconds.
3. Slowly return to the starting position.

Exercise G: Supination, active

1. Stand or sit with your arms at your sides.
2. Bend your right elbow to an “L” shape (90 degrees).
3. Turn your palm upward until you feel a gentle stretch on the inside of your forearm.
4. Hold this position for a few seconds.
5. Slowly return your palm to the starting position.

Exercise H: Pronation, active

1. Stand or sit with your arms at your sides.
2. Bend your right elbow to an “L” shape (90 degrees).
3. Turn your palm downward until you feel a gentle stretch on the top of your forearm.
4. Hold this position for a few seconds.
5. Slowly return your palm to the starting position.

Strengthening exercises

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

Exercise I: Wrist flexors

1. Sit with your right forearm supported on a table and your hand resting palm-up over the edge of the table. Your elbow should be below the level of your shoulder.
2. Hold a suitable weight in your right or left hand. Or, hold a rubber exercise band or tube in both hands, keeping your hands at the same level and hip distance apart. There should be a slight tension in the exercise band or tube.
3. Slowly curl your hand up toward your forearm.
4. Hold this position for a few seconds.
5. Slowly lower your hand back to the starting position.

Exercise J: Wrist extensors

1. Sit with your right forearm supported on a table and your hand resting palm-down over the edge of the table. Your elbow should be below the level of your shoulder.
2. Hold a suitable weight in your right or left hand. Or, hold a rubber exercise band or tube in both hands, keeping your hands at the same level and hip distance apart. There should be a slight tension in the exercise band or tube.
3. Slowly curl your hand up toward your forearm.
4. Hold this position for a few seconds.
5. Slowly lower your hand back to the starting position.

Exercise K: Ulnar deviators

1. Stand with a suitable weight in your right or left hand. Or, sit with your healthy hand supported, and hold onto a rubber exercises band or tube. There should be a slight tension in the exercise band or tube.
2. Move your right or left wrist so your pinkie travels toward your forearm and your thumb moves away from your forearm.
3. Hold this position for a few seconds.
4. Slowly lower your wrist to the starting position.

Exercise L: Radial deviators

1. Stand with a suitable weight in your right or left hand. Or, sit and hold onto a rubber exercise band or tube while your right or left arm is supported on a table and the other arm is below the table. There should be a slight tension in the exercise band or tube.
   • If you are holding a weight, raise your right or left hand so your thumb moves toward your forearm at a comfortable height. You will not need to raise your hand very far.
   • If you are holding an exercise band or tube, pull on it.
2. Hold this position for a few seconds.
3. Slowly lower your wrist to the starting position.

Exercise M: Forearm rotation, palm up

1. Sit with your right or left forearm supported on a table and your hand resting palm-down. Your elbow should be at your side, below the level of your shoulder, and bent to an “L” shape (about 90 degrees). Keep your wrist stable. Do not allow it to move backward or forward during the exercise.
2. Gently hold a lightweight hammer with your right or left hand.
3. Without moving your elbow or wrist, slowly rotate your palm upward to a thumbs-up position.
4. Hold this position for a few seconds.
5. Slowly return your forearm to the starting position.

Exercise N: Forearm rotation, palm down

1. Sit with your right forearm supported on a table and your hand resting palm-up. Your elbow should be at your side, below the level of your shoulder, and bent to an “L” shape (about 90 degrees). Keep your wrist stable. Do not allow it to move backward or forward during the exercise.
2. Gently hold a lightweight hammer with your right or left hand.
3. Without moving your elbow or wrist, slowly rotate your palm and hand upward to a thumbs-up position.
4. Hold this position for a few seconds.
5. Slowly return your forearm to the starting position.

Exercise O: Grip

1. Hold one of these items in your right or left hand: modelling clay, therapy putty, a dense sponge, a stress ball, or a large, rolled sock.
2. Squeeze as hard as you can without increasing any pain.
3. Hold this position for a few seconds.
4. Slowly release your grip.

The flexor carpi radialis (FCR) muscle functions to flex and radially deviate the wrist. 

Flexor carpi radialis tendinitis is a relatively frequent cause of volar radial wrist pain, but is often unrecognized since it is usually overshadowed by pain from adjacent osteoarthritis with which it is commonly associated. 

Sources

Flexor carpi ulnaris tendinopathy