Snapping wrist – the extensor carpi ulnaris (ECU) tendon; the extensor pollicis brevis; and the distal radioulnar joint.

Ross Hauser, MD

Snapping. clicking or popping in the wrist, which is accompanied by pain or difficulties in rotational movement, are typically reported by people, like yourself, who play sports at a high level or have jobs that put great physical demand on your elbows and wrists. For many of you, there is probably a surgical recommendation or you already had a surgery that did not help as much as you would have helped, and now a second surgery is being recommended.

Like any injury, elbow pain, extensor tendon tear, arm pain can significantly impact quality of life. When people contact us, many of them have already become their own elbow pain expert, having read incredible amounts of research and material on the subject. They tell us about an elbow pain, diagnosed as extensor tendon tear that has progressively worsen. They tell us about pain when trying to grip anything. How difficult it can be to open a door or grip the steering wheel of a car.

While they have been able to do what they can to manage pain, the functional status of that arm is very restricted. They are not sure if the instability in that elbow was caused by damage to the elbow ligaments and tendons or if that damage caused the instability. They do not know which came first. All they know is that the range of motion in that elbow and subsequently that arm is worsening. To manage along they tell us about limited activity, the long periods of immobilization and rest and sleeping with slings and braces. Some tell us about both wrists popping and cracking a chronic subluxation due to their elbow and wrist instability.

For many people, especially teenage or younger athletes, there is a greater appeal to have surgery to fix this problem. For many of these people, the surgery can be very successful. However, these are the people we do not see in our center. We see the people who had the surgery with poor results or the people who cannot get or do not want surgery and are looking for alternative options.

Snapping ECU (extensor carpi ulnaris) tendon or wrist subluxation is a condition that causes the joint to “snap”, “pop”, or “click” with rotation. For many people, snapping or popping in their wrist is an inconvenience. They go about with their lives until such time as the popping and snapping start to be accompanied by greater amounts of pain and functional limitations in that hand.

What makes the snapping and popping sounds?

The wrist is held together by the ligaments of the wrist and when one of them becomes damaged, it affects the other. The interconnectedness of the wrist is its strength and weakness alike. When the tendon in the wrist that connects the joint to the bone is damaged, it begins to rub over the bone or muscles in its way (instead of moving fluidly) and causes the “snapping” or “popping” sensation. The tendon moves in this irregular way because its foundation, the ligaments, have also become damaged or lax. If these can be fixed or strengthened then the whole joint will be able to return to its normal function.

Let’s get a more technical explanation. This comes from the journal BioMed Central Musculoskeletal Disorders,(1) published April 2021. I will explain some of the points presented here:

“Extensor carpi ulnaris tendinopathy (ECU) can be one cause of ulnar side wrist pain and it is more prominent in pronation-supination movements against resistance. (When you make a movement rotating your wrist so that the palm is up or the palm is rotated down. Against resistance will obviously mean that you are engaged in a sports or work activity where wrist rotation is required).

In supination (palm rotated facing up), flexion (palm rotated facing down), and ulnar deviation within the ulnar groove (bending the wrist towards the pinky), the tendon is tense and becomes predisposed to subluxation or dislocation. Snapping occurs during this dislocation and relocation. As a result of this friction between the tendon sheath and ulnar groove, tendinopathy and pain occur. ECU tendon is an important structure that contributes to the dynamic stability of wrist, therefore, resulting degeneration contributes disruption of distal radioulnar joint and causes wrist instability.”

If you are reading this article because you are seeking treatment options, it has been, or it has been hopefully explained to you that the extensor carpi ulnaris ECU tendon is one of your major tendons in your arm that connects and allows muscle movement through various motions (rotation, extension, and flexion)  of the forearm to the wrist. This tendon is on your pinky side. Soft tissue or subsheath keeps the tendon in place at the wrist. A sudden forced rotation or hyperextension can cause this subsheath to tear and allow the ECU to move out of its natural groove. That is what creates the noise in your wrists, the tendon snapping in and out of its natural groove at the back of the wrist on the pinky side.

When the injury is acute and needs surgical intervention

Here is a case reported by the Department of Upper Limb and Hand Surgery and Microsurgery, KAT Hospital, in Athens, Greece. It was published in the journal Trauma Monthly. (2)

The doctors of this paper describe the problem: “dislocation/subluxation of the Extensor Carpi Ulnaris (ECU) tendon is a rare condition in the general population, but is a common problem among athletes that subject their wrists to forceful rotational movements. Pain and snapping sensation at the dorsoulnar aspect (back, pinky side) of the wrist especially during supination (your wrist rotates on impact during a fall for example, and something snaps) are the predominant symptoms that often necessitate surgical intervention.

In this case, the doctors describe a female “professional water-polo athlete with recurrent ECU tendon dislocation, in whom a combination of direct repair of the tendon’s subsheath and reinforcement with an extensor retinaculum graft led to definitive resolution of her symptoms and resulted in her uneventful (no problem) return to high-level sports activities 4 months postoperatively. . . The treatment of symptomatic ECU instability is still controversial, especially for acute dislocations. Depending on the type of injury many surgical techniques have been proposed. Combination of direct repair of the tendon’s subsheath and reinforcement with an extensor retinaculum graft is a reliable option.”

Not all similar injuries would require surgery. Below we will make the case for non-surgical regenerative injection treatments to repair the tendon sheath and prevent the tendon from subluxation or dislocating. The focus is on the tendon subsheath.

Is it a problem of distal radioulnar joint instability?

The tendon subsheath lives in the wrist as do many other structures. If a significant impact injury, such as a fall, did not tear the subsheath, then we have to look at the wear and tear as being caused by wrist instability. This video will examine the distal radioulnar joint of the wrist.

In this video Ross Hauser, MD. discusses the connection between snapping wrist and distal radioulnar joint instability. We are looking at the pinky side of the hand and wrist.

  • Many people have wrist pain with clicking, grinding, and popping.
  • The wrist is 8 bones in a sea of ligaments. Something within these 8 bones is causing clicking, grinding, and popping.
  • Somewhere this clicking, grinding, and popping may be coming from is the often overlooked distal radioulnar joint. Where the two bones of the forearms meet, the radius and ulna.
  • The radius bone of the wrist is supposed to rotate. But when you hold your hand straight up as in a “halt,” position and then move your hand back and forth, the radius and ulna should move together within a stable plane. When the radius and ulna do not move together and separate away from each other. This causes problems. This is demonstrated at the one-minute mark of this video. A still image is below.
  • The person in this digital motion image video has significant and severe distal radioulnar joint instability.
  • Our treatment, which is explained below, focused on the whole wrist joint and on the strong interosseous membrane of the forearm that connects the radius and ulna and the deep soft tissue structures that connect the ulna and radius.

In this still image from the video, Dr. Hauser demonstrates the abnormal separation of the ulna and radius bones caused by instability at the wrist's distal radioulnar joint. The hand is in "flexion," the fingers point towards the ground.

In this still image from the video, Dr. Hauser demonstrates the abnormal separation of the ulna and radius bones caused by instability at the wrist’s distal radioulnar joint. The hand is in “flexion,” the fingers point towards the ground.

What are we seeing in this image? A teenager with Ehlers Danlos Syndrome, a condition that causes joint instability, demonstrates the problem of weakened ligaments and obvious distal radioulnar instability in the right wrist.

Is it a problem of the multiple accessory tendons of the first extensor compartment?

Here is an interesting case presented in the International Journal of Surgery Case Reports. (3)

Explanatory note: The multiple accessory tendons of extensor pollicis brevis

  • The wrist extends – your fingers point up. In this position, you would be telling someone to “halt,” or “stop.”
  • The wrist flexes or moves in flexion, the fingers point downward.
  • The multiple accessory tendons of extensor pollicis brevis are one of the tendons in the back of the wrist which helps the muscles put your hand and wrist in the “halt,” position. Fingers pointed up.
  • The extensor carpi ulnaris tendon and the extensor pollicis brevis tendon both control muscle movement on the pinky side of the hand.

The doctors in this paper describe a 19-year-old male with catching sensation and occasional radial side (pinky side) wrist pain for 6 months. The patient had a normal MRI. An arthroscopic surgery revealed that it was the multiple accessory tendons of extensor pollicis brevis which is causing snapping.

Their solution to help this patient was a fibrous tunnel release (nerve release) with tenotomy (cutting away of the tendon tissue) of a few accessory tendons done.

The surgeons of this study concluded: “There are various causes for snapping wrist syndrome. Multiple accessory tendons can also cause snapping as shown in this case report. Moreover am presenting this case to highlight the diagnostic failure with the non-dynamic radiological investigation and to consider multiple accessory tendons as a differential diagnosis for snapping wrist syndrome.”

While this surgery offered success, below we will present a non-surgical alternative.

Is it a problem of the dorsal radiocarpal (radiolunotriquetral) ligament? Is snapping wrist really a problem of a snapping ligament?

Above we described the wrist as 8 bones floating in a sea of ligaments. It is often the bones and the tendon attachments that are blamed for the audible noises coming from the wrist. But for some, it can be a wrist ligament problem.

A case history reported in The Journal of Hand Surgery (4) discussed two cases of snapping wrists resulting from dorsal radiotriquetral ligament adhesions (ligament tears). The dorsal radiotriquetral ligament or radiocarpal ligament is a ligament in the back of the wrist. In these two cases, surgical debridement was used to repair the ligaments. Below we will offer a non-surgical option.

Ligaments are strong connective tissue that attaches bone to bone and keeps the bones in place. When the ligaments are weak or lax, the bones start floating around. The tendons, which attach the muscles to the bones to provide strength in movement, also become stretched and are prone to tearing. Let’s also keep in mind the converse or opposite reaction. If the tendons are stretched, that will put stress on the ligaments to hold the bones in place causing lesions or tearing.

What are we seeing in this image?

In this illustration, we can demonstrate that the wrist is held together by a “sea of ligaments,” in which the bones of the wrist from the base of the thumb to the base of the pinky float in. The symptoms of wrist ligament weakness are seen in instability, a popping and cracking noise from the wrist, loss of range of motion, muscle spasms in the arm and hand, loss of strength, especially grip strength, and numbness.

In this illustration, we can demonstrate that the wrist is held together by a "sea of ligaments," in which the bones of the wrist from the base of the thumb to the base of the pinky float in. The symptoms of wrist ligament weakness is seen in instability, a popping and cracking noise from the wrist, loss of range of motion, muscle spasms in the arm and hand, loss of strength, especially grip strength and numbness.

Water polo and tennis have a common problem with thumb side wrist pain

A 2018 paper (5) presented by radiologists from Columbia University Medical Center, Yale-New Haven Health at Bridgeport Hospital presented this summary of case history:

Problems of the extensor carpi ulnaris (ECU) tendon are often due to de Quervain’s tenosynovitis (a generative problem of the thumb tendon (please see the Caring Medical article: De Quervain’s Tenosynovitis treatment – should we look at the ligaments of the wrist and thumb?)

A common cause for tendinitis and tenosynovitis of the ECU tendon is its dislocation. This injury is more often seen in tennis players and golfers than in water polo athletes, as there are overall fewer water polo athletes when compared to tennis players and golfers.

So why bring water polo into this? Because the case is of a 14-year-old girl who used to be a tennis player and now participates in water polo. Here is what the radiologists observed:

“The patient was a 14-year-old active water polo player, who mainly played at offensive positions, mainly the center forward position. She had also been a very active tennis player four years ago, but she had switched to water polo due to her interest in the sport. She started complaining of ulnar-sided right wrist pain two years ago, especially after long water polo practice sessions and matches. She faintly remembered similar but less intense pain while playing tennis four years ago. Due to her ongoing ulnar pain, she underwent wrist radiographs, which were normal. Due to her intermittent ulnar-sided right wrist pain for the past three years, with weakness in the wrist and hand, there was a clinical concern of a triangular fibrocartilage complex (TFCC) tear. She underwent right wrist MRI which showed no triangular fibrocartilage tear or other internal derangements.”

In this patient, her doctors reported that the ECU tendon was subluxed out of the ulnar groove due to a subsheath tear but the patient responded to wrist immobilization in a cast in extension (fingers elevated above the wrist) and slight radial deviation (wrist tilted towards the thumb) for eight weeks. This position helps place the ECU tendon in the ulnar groove. The patient resumed water polo after 10 weeks and is currently doing well.

The problems of tennis

Here are the highlights of a review study that was published in the British Journal of Sports Medicine. (6) It examines the problems of sport-specific ECU injuries, in this case, we will explore tennis injuries.

  • ECU problems have been most frequently reported in tennis and golf, although injuries to the ECU stabilizing structures also occur in certain high-impact contact sports.

Tennis

  • The researchers cite a retrospective study of 50 professional tennis players over a 10-year period that described 28 individuals with ECU problems.
  • This was averaged out to a prevalence of 1 case per 18 players per year.
    • Men were more frequently affected with 42% of all patients having ECU instability, 50% had tenosynovitis or tendinopathy, and 8% presented with complete tendon rupture.
    • Acute injuries typically occur from a double-handed backhand stroke.
    • Tennis players presented with the sudden onset of ulnar-sided pain that prevented further play.
    • Symptoms usually resolved following a period of rest but recurred when attempting to play topspin shots with rapid forearm rotation.
  • The second group of tennis players described a more gradual onset of ulnar-sided wrist ache that did not interrupt play. This is likely to reflect tendinopathy since there were no acute signs of tendon subluxation.

The problems of the extensor carpi ulnaris, triangular fibrocartilage complex tear (TFCC), and distal radioulnar instability. A case of a hockey player

It was not until recently that doctors discovered the vast complexity and interaction between the distal radioulnar joint, the wrist’s outer joint where the ulnar and radius bones meet, and triangular fibrocartilage complex tears and extensor carpi ulnaris pathology. Please see our article: Non-Surgical Triangular fibrocartilage complex tear and distal radioulnar instability.

A case history of a 21-year-old hockey player was published in September 2020 (7) by doctors at the Department of Orthopedic Surgery, Nippon Medical School Musashi Kosugi Hospital in Japan. Here is a summary of the case and a discussion of the possible interactions of concurrent extensor carpi ulnaris and triangular fibrocartilage complex tear.

“Ulnar-sided wrist pain is common among athletes who subject their wrists to forceful rotational movements. Injury to the numerous complex structures in the ulnar wrist, including the extensor carpi ulnaris (ECU) tendon and triangular fibrocartilage complex (TFCC), can result in ulnar-sided wrist pain.  Although differentiating between ECU tendinitis and TFCC injury is necessary, ECU tendon disorders and TFCC injury occasionally occur concurrently. Subluxation or dislocation of the ECU tendon is rare but may cause symptoms in athletes subjecting their wrists to forceful rotational movements.”

The doctors then presented their case of a hockey player who suffered from the recurrent dislocation of the ECU tendon and ulnar-sided TFCC injury. The hockey player was a 21-year-old male university-league ice hockey player.

  • The hockey player initially underwent ECU stabilization (surgery); however, his ulnar wrist pain persisted, which adversely affected his athletic performance.
  • He underwent additional surgery to repair the TFCC, which led to the definitive resolution of his symptoms and resulted in his return to competitive performance 3 months postoperatively.
  • Treatment of symptomatic dislocation of the ECU remains controversial. In this hockey player, recurrent dislocation of the ECU tendon with concurrent ulnar-sided TFCC injury resulted in ulnar-sided wrist pain. Combined reconstruction of the tendon’s subsheath, using the extensor retinaculum, and repair of the TFCC injury were required for full recovery of his athletic performance.

Surgery for extensor carpi ulnaris and triangular fibrocartilage complex

Above we discuss the various surgical options. We also discusses simultaneous repairs necessitated during exploratory surgery. An April 2022 paper in the Journal of orthopaedic surgery (8) makes it a point to suggest that wrist arthroscopy should explore not only the ECU but also the TFCC and other damage and that repairs should be done on all to make for a successful surgery. Here are the paper’s summary learning points:

  • Seven patients with chronic ECU tendinopathy who were treated with diagnostic wrist arthroscopy and open surgical repair between 2010 and 2017.
  • Seven cases diagnosed with ECU tendinopathy had undergone open procedure for the ECU tendinopathy, as well as wrist arthroscopy in the same session.
  • Any pathology of the triangular fibrocartilage complex (TFCC) diagnosed by wrist arthroscopy were treated simultaneously with open procedure for the ECU tendinopathy.
  • Findings: “When treating patients with ECU tendinopathy, the possibility of TFCC combined injury should always be considered. If surgical treatment is planned, (the authors) suggest a wrist arthroscopy for more accurate diagnosis an intra-articular pathology, particularly for patients whose MRI findings suggest a degenerative tear or degeneration at the periphery of the TFCC. Additionally, if ECU and DRUJ stability is obtained by repair or reconstruction of the concurrent pathologies in the ECU subsheath, TFCC and other intra-articular structures, the results will be favorable.”

Non-Surgical treatment options

There are times when surgery may be necessary to repair complete ruptures and tears. For many of you reading this article, you may have had physical therapy as physical therapy is a very popular choice of treatment for this condition. This therapy aims to help strengthen and stretch the muscles of the joint. This may help with some of the pain associated with the condition and may revive some lost range of motion but does not fix the problem of damaged or otherwise loose ligaments and muscles.

Some physicians believe that corticosteroids or other anti-inflammatory medicines are a good way to treat this condition. These medications give a pain relief effect and reduce any inflammation if it is present. This method masks the problem of the snapping tendon and does not heal it. This simply causes the patient to treat the condition as if it is not hurt, further causing later-onset pain and joint degradation.

If serious enough, arthroscopic surgery may be warranted as discussed above.

Prolotherapy for Snapping ECU Tendon

In cases where there are partial tears or general chronic wrist instability Prolotherapy can be an alternative non-surgical procedure. Prolotherapy uses natural proliferants to aid the body to heal itself. Prolotherapy injections use dextrose solutions to induce the body’s natural immune response; inflammation. When this occurs, the body is sending immune and repair cells to the site of injury and attempts to heal it. If patients are in need of a stronger solution (depending on the severity of their case), then they can be injected with Platelet Rich Plasma (PRP) or stem cells from the tibia or iliac bone marrow as well. These injections help in retightening the ligaments, rebuilding cartilage, and just overall muscle and bone repair of the area.

Prolotherapy patients usually receive four to six treatments in order to obtain their desired results. This is a quick outpatient procedure that can naturally, quickly, and permanently cure someone of the symptoms of snapping the ECU tendon.

Prolotherapy treatment demonstrated and described

In the video below, Prolotherapy treatment is being demonstrated on a wrist. A summary of the video is below.

Summary:

As you can see the outer part, pinky-side, of the wrist is being treated.

  • The patient in the video is a personal fitness trainer. She is very physically fit. She does many exercises that put a lot of pressure on her wrists The pain in her wrist is making it very difficult for her to demonstrate the various exercises to her classes.
  • We are injecting both rows of the carpal bones. The wrist is comprised of 8 bones and 27 ligaments. It is easy to see why a treatment that focuses on strengthening and repairing the wrist ligaments would be so important to someone with significant wrist pain.
  • We see many people with wrist pain on the ulnar side (pinky side) where Snapping Wrist, extensor carpi ulnaris tendon, extensor pollicis brevis tendon, Triangular fibrocartilage complex injuries occur.
  • The video shows treatment around the navicular bone and the scaphoid lunate and surrounding ligaments. We see a lot of injuries there.
  • The average person requires 3 to 6 treatments.
  • Prolotherapy injections can be very effective for wrist instability. When we treat the wrist, we treat the entire wrist not only the ulnar side.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your wrist problems.  If you would like to get more information specific to your challenges of peroneal tendon injury and ankle instability, please email us: Get help and information from our Caring Medical staff

 

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References:

1 Erpala F, Ozturk T. “Snapping” of the extensor carpi ulnaris tendon in asymptomatic population. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-5. [Google Scholar]
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This article was updated July 12, 2021

 

 

 

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