Wrist Pain in a Tennis Player

Abstract

HISTORY: A 19 year-old male Division I tennis player developed atraumatic left wrist pain, worsening over 2.5 weeks. His pain was located at the ulnar aspect of his wrist and radiated proximally along his forearm. The pain was exacerbated by ulnar deviation during his backhand swing. He initially denied mechanical symptoms, including clicking and snapping, as well denying any numbness and tingling. His pain did not improve with physical therapy over one month, at which time he presented with new onset of clicking at the ulnar aspect of his wrist during ulnar deviation. PHYSICAL EXAMINATION: Initial examination revealed no swelling or deformities. He had no tenderness to palpation. He exhibited full range of motion and strength, equal to the opposite side. Ulnar deviation reproduced pain at the ulnar aspect of the wrist. At his follow up visit, the patient exhibited focal tenderness along the extensor carpi ulnaris tendon and subluxation of the tendon was visualized and palpated during active supination of the forearm. DIFFERENTIAL DIAGNOSIS: 1. Extensor carpi ulnaris tendon subluxation 2. Extensor carpi ulnaris tendinopathy and/or tenosynovitis 3. Extensor carpi ulnaris tendon partial tear 4. Triangular fibrocartilage complex tear TEST AND RESULTS: Left wrist radiographs: - No evidence of fracture or dislocation Left wrist ultrasound (performed prior to development snapping): - Extensor carpi ulnaris tendon intact with normal morphologic appearance, overall normal wrist ultrasound Left wrist MRI (performed prior to development snapping): - Mild extensor carpi ulnaris tendinopathy and peritendonitis, no subluxation FINAL WORKING DIAGNOSIS: Extensor carpi ulnaris subluxation TREATMENT AND OUTCOMES: 1. Due to the development of new subluxation and failed improvement with conservative treatment, the patient elected for surgical intervention of the tendon subluxation following development of mechanical symptoms and considering that he was an in-season athlete. 2. The patient underwent successful surgical reconstruction of the extensor compartment. A sample of soft tissue confirmed chronic tenosynovitis. 3. The patient was casted for three weeks, followed by rehabilitation and return to play 3 months later.