Experiencing ongoing wrist pain, especially on the pinky-finger side when pressing down, and aggravated by turning a key? This could be a sign of a Triangular Fibrocartilage Complex (TFCC) issue. The TFCC is vital for wrist stability, holding bones in place during gripping and distributing force between your forearm and hand when lifting or pushing.  Understanding what the TFCC is, how it gets injured, and the treatments available is crucial for finding lasting relief. Here at Hand Therapy, we use the latest research-backed programs to help heal TFCC tears, aiming to eliminate that constant ache and those sharp stings you’ve been feeling.

Imagine your wrist’s pinky-finger side. That’s where your Triangular Fibrocartilage Complex (TFCC) lives. It’s not just one thing; it’s a complex network of ligaments and cartilage that plays a crucial role in your wrist’s health and function.

Think of it this way:

The Triangular Fibrocartilage Disc: This is like a tiny, specialised shock absorber in your wrist, cushioning impacts and distributing pressure.

Crucial Ligaments: These are strong, fibrous bands that connect your forearm bones (radius and ulna) to your wrist bones, providing essential stability.

A Meniscal Homolog and ECU Tendon Sheath: These components work together to provide dynamic stability, meaning they help keep your wrist stable even when it’s moving.

Here’s a crucial detail about the TFCC’s structure that impacts healing: its blood supply. The central part of the disc has a very limited blood supply. This means if you tear it here, it struggles to heal on its own. However, the outer parts of the TFCC are richly supplied with blood vessels, meaning they have a much better chance of healing. This is why it is important to establish which part of the TFCC is torn.

The TFCC isn’t just sitting there; it’s actively performing several critical functions that are essential for healthy wrist movement and stability:

Stabilises Your Forearm Bones: At your wrist, your two forearm bones, the radius and ulna, meet at a joint called the Distal Radioulnar Joint (DRUJ). The TFCC is the primary stabiliser of this joint, ensuring your forearm turns smoothly up or down.

Cushions Your Wrist: It acts like a shock absorber, cushioning the impact between your ulna and the small bones in your wrist (carpus). 18% of forces transmitted through your wrist is absorbed by the TFCC!

Supports Wrist Movements: The TFCC helps you perform all sorts of complex wrist movements, including turning your forearm in and out and generating strong grip strength. It also keeps the Extensor Carpi Ulnaris (ECU) tendon in place, which is key for wrist stability.

An injured TFCC leads to pain, a feeling of instability, hesitation and avoidance to use your wrist. The question is, to what extent is the TFCC torn?

TFCC injuries commonly occur due to a combination of wrist extension and rotational forces magnified by compression simultaneously during movements. The most frequent ways you can injure your TFCC include:

• Falling onto an Outstretched Hand is a very common cause, where the impact transmits substantial axial (straight-on) and rotational forces through your wrist.
• Forceful Wrist Movements like activities that put a lot of compressive load on the TFCC while your wrist is bent towards your pinky finger (ulnar deviation) cause injury. Think about sports like when the ball impacts a bat or racket like in tennis, golf, baseball,
• Repetitive gymnastic motions, which involve forceful swinging and impact, slowly frays the TFCC. This is unique as the rotation originates proximally, meaning the elbow and forearm is the start of the movement rather than the hand.
• When a power drill binds up and twists your wrist instead of the bit, it causes a forceful rotation that leads to a TFCC tear.
• Regularly turning your wrist and hand upwards (supination) while holding a heavy object as when holding a loaded tray, or frequent weight-bearing like during a push-up position, leads to an overuse injury of the TFCC.

TFCC injuries are generally categorised into two main types based on how they happen:
Type 1 – Tears caused by a sudden trauma, like a fall or a sports-related incident.
Type 2 – Tears result from the gradual breakdown and unraveling of the TFCC over time, this is called degeneration. This often happens due to age or repetitive stress. Degenerative changes in the TFCC can start in your thirties, due to a loss of elasticity and eventual thinning of or punctures in the central part of the disc.

Try these screening tests which might suggest a TFCC injury

Several factors can make you more susceptible to a TFCC injury like ulnar length, associated fractures, and repetitive motions.

• A positive ulnar variance is an anatomical variation where your ulna, the forearm bone on the pinky side, is slightly longer than your radius, the forearm bone on the thumb side. This directly increases the load on the TFCC.
• Even if there is no difference in length between the two forearm bones, chronic repetitive stress with repetitive axial loading puts you at high risk for a TFCC injury, for example in athletes and manual workers.
• An ulnar styloid fracture strongly suggests a possible TFCC injury.

Pain is a good indication of how bad your TFCC injury is. Pain only after intense activity is less severe, however when your pain spreads and becomes persistent and long-lasting even at rest, your TFCC injury is more severe.
The ability of the TFCC to cushion force going through your wrist is another indicator of severity. Being unable to lift a heavy travel bag but able to lift a kettle, means that the extent of tissue damage is less. If you are unable to even lift a coffee cup, your TFCC tear is severe.
Age is a big component at determining severity. As we age, the TFCC becomes more rigid with higher risk of compromised blood supply. The risk rises from 27% after age 30 to 49% from age 70.
If you are able to press at least 17% of your body weight onto one hand, your TFCC tear is less severe. Your TFCC tear will be more severe, the less weight you can put through your wrist.

A specialised hand therapist is the best to assess and diagnose the extent of your wrist injury. The specialist will follow a structured guideline with different assessment methods and specialised tools to determine and classify your injury.
Clinical Examination: Your therapist will thoroughly assess your symptoms and medical history. They’ll also perform specific physical tests, like checking for tenderness over the ulnar fovea, performing special tests that test the integrity of your TFCC with regards to its stability and load-absorption ability, including quantifying your grip strength.

X-ray:

X-rays don’t show the TFCC directly, they can reveal associated issues like ulnar styloid fractures or differences in forearm bone length (ulnar variance). It is not the primary diagnostic test for a TFCC tear.

MRI:

MRI is a highly sensitive and specific tool for identifying TFCC tears. In more complex cases, an MRI might be prescribed by an orthopaedic hand surgeon for a clearer picture and better understanding. In severe cases, especially when imaging isn’t clear or for therapeutic or surgical planning, wrist arthroscopy is a minimally invasive surgical procedure that allows the surgeon to directly visualise the TFCC.

Sonar (Diagnostic Ultrasound)

A diagnostic sonar is the most cost-effective and detailed way to visualise the TFCC and its tears.

Persistent pain from a TFCC injury can be incredibly frustrating. Several factors contribute to why your pain might not resolve on its own or with initial treatments:

• Poor Blood Supply to the Central Disc: As we mentioned, the central part of the TFCC has a very limited blood supply. Tears in this area are unlikely to heal spontaneously because they just don’t get the blood flow needed for repair.
• Chronic Instability: If the TFCC injury leads to ongoing instability of your forearm joint (DRUJ), this can cause chronic pain and further wear on the joint cartilage, potentially leading to degenerative osteoarthritis over time.
• Uncorrected Ulnar Variance: If you have positive ulnar variance, the increased load on your TFCC can hinder healing and contribute to your ongoing symptoms.
• Continued Wear and Tear without proper management or compensatory methods to protect the TFCC structure, existing injuries can continue to worsen.

Medical professionals often prescribe insufficient diagnoses and treatments to alleviate symptoms, necessitating further intervention. This is due to a lack of complete understanding of the TFCC’s intricate nature and specific recovery requirements. This diagnostic challenge emphasises the need for a thorough clinical evaluation by a medical professional who understands wrist injuries. It’s vital to correlate imaging findings with your specific symptoms and physical examination to ensure that treatment is directed at the actual source of your pain. This is where a specialised Hand Therapist is invaluable!

Common secondary problems associated with a TFCC and its prolonged recovery period may include joint stiffness, muscle weakness, grip strength deficits, wrist instability, arthritis and ulnar nerve problems. The wrist bones become stiff due to a lack of mobility during the immobilisation phase. Your fingers become tight and weak due to immobilisation and decreased use of the muscles that originate in the forearm, pass through the wrist and move the fingers. Due to the injury of the TFCC, decreased use of the wrist as a whole and all the muscles involved, your wrist becomes weak and unstable. Arthritis develops due to prolonged malfunction and maladaptations of movements on the wrist bones. The ulnar nerve becomes compressed by excessive swelling and causes tingling, numbness, weakness and pain in the arm, wrist and hand.

Hand therapists offer cost-effective, accurate, and swift diagnosis of the source of your wrist pain. We will advise you on how to modify your activity participation and to what extent it must be limited. We fabricate splints to use as immobilisation techniques such as wearing a wrist splint or cast for a period, to restrict movement and allow the TFCC to heal. Custom splints are designed to specifically conform to the contours of your wrist, ensuring optimal healing. We will attend to the remaining structures to minimise healing time, while simultaneously controlling problems that are expected to develop from a TFCC injury. Restoring dexterity, speed, power and maximum functionality and performance of the wrist and forearm. This is done through targeted and graded loading and impact training to regain full and pain-free movement in your wrist. We’ll use targeted exercises to rebuild strength in your wrist, forearm, and hand. We specifically focus on muscles like the extensor carpi ulnaris (ECU) and pronator quadrates (PQ), which are crucial for wrist stability. A hand therapist will facilitate return to delicate motor patterns to enhance the finesse of precise manoeuvring of the wrist, hand and fingers. We look beyond just your wrist at your entire upper extremity. Optimal force generation for wrist function depends on the coordinated action of your entire limb. We limit secondary problems with accurate diagnosing and treating of the main problem.

Rehabilitation for TFCC injuries often follows a structured, clearly defined program with gradual progression and measurable goals with research-backed guidelines. We use a four-stage protocol called the Wrist Sensorimotor Rehabilitation Program (WSRP):

Stage 1: Pain Control (week 0-2)
Goal: Reduce your pain and inflammation and ensure an optimal healing environment.
Techniques: We start with isometric grip strengthening to about 30% of the norm and graded ECU eccentric training, which forms part of the TFCC. We’ll include active pain free exercises and incorporate interval splinting to protect your wrist. As part of stage one, we will advise on pain management, safety during participation and restrictions necessary.
Progression: You’ll move to Stage 2 when you have less pain than 5/10 with isometric exercises and a pain free arc of at least 10 degrees active range of movement.

Stage 2: Joint stability (week 2-4)
Goal: Enhance your wrist’s dynamic stability and control. Improve muscle control, speed and power in various ranges (especially ECU and PQ) and paying particular attention to your wrist’s position during load bearing.
Techniques: We’ll continue AROM exercises and achieve at least 50% of normal grip strength, in particularly isometric and isotonic ECU & PQ strength, while continuing the use of splints for up to 8 hours per day.
Progression: You’ll advance when your pain is less than 2/10 with isometric exercises, you can complete specific repetitions of targeted movements, and maintain wrist control throughout the range of motion. We expect a gradual weekly increase in grip strength of at least 10% of your normal values.

Stage 3: Neuromuscular Rehabilitation (week 4-6)
Goal: To regain the cushioning properties of the TFCC to allow for at least 70% of normal load bearing capacity.
Techniques: We’ll progress your isometric and isotonic exercises, introduce reactive muscle activations (quick, controlled movements), graded weight-bearing, and coordination training (like using free weights with specific patterns) to allow for pushing, pressing and lifting without hesitation.
Progression: You’ll move forward when your pain is less than 2/10 with weight-bearing and you show good coordination across multiple joints.

Stage 4: Movement Normalisation and Function, full participation and performance (week 6+)
Goal: Get you back to your pre-injury level of upper extremity function, whether that’s for daily activities, work, or sports. You will have normal stability, normal ability to bear weight and lift heavy objects while exhibiting normal force transmission with good endurance.
Techniques: We’ll continue with advanced reactive muscle activations, advanced weight-bearing, and resistive coordination training.
Progression: You’ve achieved this stage when you can fully return to your pre-injury activities.

The recovery timeline for a TFCC injury varies depending on whether it’s treated with or without surgery, which is mainly dependent on the ability of the TFCC to provide stability to the joint and its ability to cushion forces across the wrist.

Non-surgical management: For type 1 and 2 TFCC tears, recovery typically takes about 6 weeks. Full recovery is generally considered when you have normal weight-bearing tolerance, no pain with functional loads, and no clicking for at least two consecutive weeks.

When a dorsally subluxated DRUJ and complete foveal TFCC tear is present, surgery will offer better outcomes. Should your wrist only be able to bear 15% or less of your usual load, it qualifies as a surgical indicator. However, recovery after surgery is generally longer. You will be in a cast or splint for up to 6 weeks followed by a strict and extensive rehabilitation program that can extend for about 6 months. Full participation in high impact activities like professional sports can take up to 12 months to achieve.

For arthroscopic debridement offers a shorter immobilization period with faster recovery. This minimally invasive procedure is the preferred treatment for central or radial tears, especially since the central portion of the TFCC has limited blood supply and is unlikely to heal with direct repair. Debridement involves removing damaged tissue and can also induce bleeding to stimulate a healing response.

Ulnar Unloading Procedures are procedures like ulnar shortening osteotomy (USO) or the Wafer procedure are used to reduce the load on the wrist joint. These are often indicated for TFCC injuries associated with degenerative changes or positive ulnar variance.

While surgery can be beneficial for stubborn cases, it’s important to know that persistent pain after surgery is reported in some patients (around 1 in 8). Recurrence of the tear or instability can also occur, though less frequently (around 1 in 60 athletes re-tore the TFCC in sport).

Beyond rest and immobilisation, several medical treatments can help manage TFCC pain and promote healing:

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen are commonly prescribed to reduce pain and inflammation, however it is not recommended in the acute phase as it may slow tissue recovery.
• Cortisone Injections: These injections deliver anti-inflammatory medication directly into the TFCC complex to provide localized pain relief. Used with extreme caution and an understanding of the long term implications.
• PRP Therapy can be reserved for more complex cases, it involves injecting concentrated growth factors from your own blood to promote healing and tissue repair. Only used under specific circumstances.
• Prolotherapy: Involves injecting a dextrose solution to stimulate a controlled inflammatory response, encouraging tissue regeneration and strengthening ligaments. These are often guided by ultrasound for precise delivery. This is not always effective, and can actually cause more damage by increasing pressure on the injured tissues in a confined space like the wrist.
• Chiropractic therapy and biokineticist input is not recommended in the acute phase of TFCC recovery, but can assist with a full return to participation in the end stage.

• Wrist sprain
• Wrist ligament tear
• Pinky sided wrist pain
• Ulna side wrist pain

• Ulna styloid fractures: Typically present with more bruising.
• ECU tendonitis: Characterised by pain during very specific movements, not necessarily during weight-bearing.
• Ulnar nerve neuritis: Originating from the elbow or wrist, accompanied by tingling, deep pain, and numbness.
• Arthritis: Pain is provoked with specific testing and is diffuse, felt throughout the wrist rather than only on the ulnar side.

While we’ve focused on the TFCC here, it’s important to know that other issues can mimic TFCC pain. There are many different diagnoses that can lead to ulnar-sided wrist pain. A comprehensive hand and wrist evaluation is essential to accurately identify the source of your pain and ensure you receive the most appropriate treatment. If you’re experiencing ongoing wrist pain, especially on the pinky-finger side, we encourage you to schedule an evaluation with us at Hand Therapy. We’re here to help you understand your unique situation and guide you on the path to lasting relief.