Understanding and Treating Wrist Instability: A Comprehensive Guide

What is Wrist Instability?

Wrist instability is a condition where the wrist experiences abnormal movement, often resulting from an injury to specific ligaments that leads to the misalignment of bones. The primary ligaments typically involved are the scapholunate (SL) ligament and the triangular fibrocartilage complex (TFCC). When these ligaments are damaged, they disrupt the standard mechanics of the wrist, impacting regular hand functions.

Symptoms of Wrist Instability

Common symptoms of wrist instability may include:

• An inability to lift things
• A sensation of the wrist ‘giving way’ or producing clicks/clunks
• Pain when placing weight through the wrist or at the end range of rotation
• Difficulty in twisting objects, such as when driving or opening a door
• Pain upon palpation over the dorsum of the wrist

Over time, these symptoms may escalate, leading to more severe pain and reduced wrist functionality. Left untreated, complete rupture of the wrist ligaments could result in wrist arthritis.

Understanding Wrist Anatomy

There are eight carpal bones in your wrist, accompanied by the scapholunate ligament and the triangular fibrocartilage complex. These components are essential for maintaining wrist stability, enabling you to lift and use your hand for a multitude of tasks.

The Scapholunate Wrist Ligament

The scapholunate wrist ligament, a crucial component of the wrist anatomy, is characterised by its relative thickness and continuity, running the full length of the wrist from anterior to posterior. Occupying a central position between the scaphoid and lunate bones, it is of vital importance due to the scaphoid’s central role as the fulcrum, the point around which wrist movement occurs.

By directing the movement of the other wrist bones, this ligament facilitates a variety of tasks that the wrist is capable of performing. A key function of the scapholunate wrist ligament is to allow rotation of the scaphoid, which in turn allows the wrist to reach full extension.

However, injury or disruption of the scapholunate ligament interferes with this important function. Such damage prevents the wrist from reaching full extension and causes severe pain when pressure is applied through an extended wrist, as is often the case when using the hands to push up from a sitting position.

As well as facilitating movement, the scapholunate wrist ligament plays an important role in providing stability to the wrist, particularly when lifting heavy objects. It maintains the stability of the wrist by facilitating the transmission of forces from the large radial bone through the wrist, thereby contributing significantly to the radial stabilisation of the wrist.

The Triangular Fibrocartilage Complex (TFCC)

Located on the side of the wrist closest to the ulna, the Triangular Fibrocartilage Complex (TFCC) is particularly influential when performing rotational movements. This could include turning a steering wheel or opening a door, actions where the presence of the TFCC is clearly felt.

The TFCC is a multi-component structure consisting of the meniscus homologue, the palmar and dorsal radioulnar ligaments, the ulnar capsule, the subcutaneous sheath of the extensor carpi ulnaris (ECU) tendon, the distal radioulnar joint (DRUJ) and the ulnocarpal joint.

The TFCC is primarily susceptible to injury from twisting movements and often coincides with incidents involving high mechanical forces. If the TFCC is damaged, symptoms may include a feeling of instability in the wrist, as if it’s going to give way, or pain on rotation. As a key contributor to the stability of the ulna within the wrist, any damage to this complex can have a significant impact on the overall functionality and stability of the wrist.

Identifying Wrist Ligament Injuries

Wrist ligament injuries can occur due to strong forces, chronic loading, or repetitive forceful gripping. Damage to these ligaments can cause wrist instability and proprioception loss – the ability to perceive the position and movement of the body.

Experiencing an Injured Ligament

Symptoms of a damaged wrist ligament might include the wrist ‘giving way,’ difficulty in lifting objects, pain over the dorsum of the wrist, and discomfort with weight-bearing or rotational activities.

How to Diagnose a TFCC Ligament Injury

Diagnosing a TFCC injury involves considering the injury mechanism, pinpointing pain over the Fovea of the ulna, inability to put weight through an extended wrist or twist the wrist, and a positive TFCC stress and approximation test. Strength testing is also necessary, with a significant reduction in strength in the supinated position indicating a possible injury.

Handling Wrist Instabilities

Wrist instabilities are complex, and their rehabilitation requires a comprehensive approach. Initially, a hand therapist may splint or tape your wrist, incorporating measures into your therapy program to address pain, swelling, instability, and proprioception loss. For the best results, it’s crucial to adhere to a home exercise program.

Supporting the TFCC

Several options can support the structures of the TFCC, including the use of the following:

• Tape
• Tape and splinting
• Specific wrist supports like the Warrior or Widget

Outline of Our Therapy Program

The therapy program at The Hands Physio is designed around several key elements intended to help with recovery and rehabilitation. Here’s an overview of the program’s components:

1. Bracing:This is an integral part of our program. It includes practical exercises that mimic everyday activities such as opening a door, turning a key, or operating a steering wheel.
2. Isometric Exercises: These exercises form another part of the regimen. They consist of two sets of 30-second repetitions that incorporate rotation movements.
3. Isometric Exercises with Weight: To enhance muscle strength, we introduce isometric exercises with weights, with a safe limit of up to 3 kilograms.
4. ADM and Lumbricals Putty: ADM and lumbricals putty exercises are included for increased flexibility and strength in the wrist and hand.
5. Hammer Exercises: We guide patients through four levels of hammer exercises, each stage gradually increasing in intensity, with the aim of each level to be performed for 60 seconds.
6. Theraband (TB) Exercises: TB exercises are included for ulnar deviation (UD) and pronation, intended to improve wrist mobility and strength.
7. Tbar Exercises: Graded Tbar exercises are part of the program, tailored to match each patient’s capacity.
8. Proprioception Wrist Exercises: Our program includes two levels of proprioception wrist exercises and Gyroball exercises to enhance wrist stability and movement perception.
9. Slosh Pipes Exercises: Four levels of Slosh Pipes exercises aim to improve balance and coordination. The goal is for patients to complete 60-second exercises with their eyes closed.

Returning to Sport and Other Activities

Recovering from a TFCC injury can take a significant amount of time. If there is no healing progress after three weeks, further investigations such as an MRI and referral to a hand surgeon may be necessary. Generally, a return to sport is recommended around six weeks, with modifications to activities at the gym to reduce force through the wrist.

At The Hands Physio, we’ve achieved very successful results treating wrist instability. Our focus is on restoring wrist stability and proprioception, enabling your hand to function normally again.