TFCC Tear Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for Triangular Fibrocartilage Complex (TFCC) tears of the wrist. It is designed to guide the physical therapist in providing appropriate and progressive treatment based on the patient's individual presentation, healing timeline, and functional goals. Progression through phases is based on clinical criteria, not solely on time. Physician clearance is required before beginning any rehabilitation program, and throughout the stages as needed.

Pathophysiology

The Triangular Fibrocartilage Complex (TFCC) is the primary stabilizer of the distal radioulnar joint (DRUJ) and cushions the ulnocarpal articulation. It is composed of the articular disc, dorsal and volar radioulnar ligaments, the ulnocarpal ligaments, and the sheath of the extensor carpi ulnaris tendon. TFCC tears can occur due to acute trauma (e.g., a fall onto an outstretched hand with the forearm pronated) or chronic overuse, often involving repetitive wrist rotation and ulnar deviation. The severity of the tear dictates the appropriate treatment and rehabilitation.

Symptoms of a TFCC tear include pain on the ulnar side of the wrist, especially with forearm rotation and grip activities, clicking or popping sensations, weakness, and instability of the DRUJ. Diagnosis is typically confirmed through clinical examination, imaging (MRI or arthrogram), and arthroscopy.

Phase I: Protection (0-4 Weeks Post-Injury/Surgery)

Goals: Protect the healing tissues, reduce pain and inflammation, maintain range of motion (ROM) in uninvolved joints, and prevent muscle atrophy.

• Immobilization: Initially, the wrist is immobilized in a long arm cast or splint with the forearm in neutral rotation. The duration of immobilization depends on the severity and type of TFCC tear and the surgical procedure performed (if any). Typically around 4 weeks.
• Edema Control: Elevation of the hand above the heart, ice packs (20 minutes on, 20 minutes off, several times a day), and gentle active range of motion of the fingers and elbow are implemented to minimize swelling.
• Pain Management: Pain is managed through rest, ice, elevation, and, as prescribed by the physician, pain medication. TENS may also be considered.
• AROM of Uninvolved Joints: Active range of motion exercises for the fingers, elbow, and shoulder are performed multiple times daily to maintain mobility and prevent stiffness.
• Gentle Grip Strengthening (Non-affected hand): Isometrics.

Progression Criteria:

• Minimal pain at rest.
• Decreased edema.
• Physician approval to progress.

Phase II: Loading (4-8 Weeks Post-Injury/Surgery)

Goals: Gradually increase wrist ROM and strength, improve DRUJ stability, and begin functional activities.

• Splint/Brace: Removal of the long arm cast or splint, transitioning to a removable wrist brace (e.g., wrist cock-up splint or DRUJ brace). The brace is worn full-time, except during exercises and hygiene, initially. Gradual weaning from the brace occurs as symptoms subside and stability improves.
• Range of Motion Exercises:
  • Active and active-assisted ROM exercises are initiated for wrist flexion, extension, radial and ulnar deviation, forearm pronation, and supination.
  • Gentle stretching exercises are performed to improve ROM, holding each stretch for 30 seconds.
  • Joint mobilizations may be performed by the therapist to address any joint restrictions.
• Strengthening Exercises:
  • Isometric exercises are performed for wrist flexion, extension, radial and ulnar deviation, and forearm pronation and supination.
  • Progress to isotonic exercises (using light resistance bands or weights) as tolerated, focusing on controlled movements.
  • Begin grip strengthening exercises with a soft ball or putty.
• Proprioceptive Exercises:
  • Initiate proprioceptive exercises to improve wrist awareness and stability, such as wrist circles, wobble board exercises, and weight shifting.
• Scar Mobilization: If surgery was performed, begin scar mobilization techniques to prevent adhesions and improve tissue mobility.

Progression Criteria:

• Pain-free ROM within functional limits.
• Improved strength (at least 50% of the non-affected side).
• Stable DRUJ with functional activities.
• Physician approval to progress.

Phase III: Return to Function (8+ Weeks Post-Injury/Surgery)

Goals: Restore full wrist ROM, strength, and endurance, improve functional performance, and return to sport or work activities.

• Advanced Strengthening Exercises:
  • Progress to heavier weights or resistance bands for strengthening exercises.
  • Implement functional strengthening exercises that mimic activities of daily living, work, or sport.
  • Incorporate plyometric exercises (e.g., medicine ball throws) to improve power and agility.
• Endurance Training:
  • Increase the duration and intensity of activities to improve wrist and forearm endurance.
• Sport-Specific/Work-Specific Training:
  • Gradually introduce sport-specific or work-specific activities, focusing on proper technique and biomechanics.
  • Simulate activities to ensure the patient can perform them safely and effectively.
• Bracing (As Needed): Continue to use a wrist brace during high-risk activities or sports to provide additional support and protection.

Return to Sport/Work Criteria:

• Full, pain-free ROM.
• Strength equal to at least 80% of the non-affected side.
• Successful completion of sport-specific or work-specific training without pain or instability.
• Physician clearance for return to activity.

Common Special Tests

The following special tests are commonly used to assess for TFCC tears:

• Ulnar Fovea Sign: Palpate the ulnar fovea (between the ulnar styloid and the flexor carpi ulnaris tendon). Pain with palpation is indicative of a TFCC tear.
• Piano Key Test: Assess DRUJ stability by applying dorsal and volar pressure to the distal ulna while stabilizing the radius. Excessive movement or pain suggests DRUJ instability.
• TFCC Load Test (Grind Test): Apply axial compression and rotation to the wrist in ulnar deviation. Pain or clicking suggests a TFCC tear.
• Supination Lift Test: Patient attempts to lift a table while seated, palms up. Pain or weakness suggests a TFCC tear.
• DRUJ Ballotment Test: Stabilize the radius and translate the ulna anteriorly and posteriorly. Excessive movement or pain suggests DRUJ instability related to TFCC injury.

Disclaimer: This protocol is a general guideline and should be adapted to each patient's individual needs and progress. Close communication between the physical therapist, physician, and patient is essential for a successful outcome.