Physical Therapy Following Arthroscopic Repair of
the Triangular Fibrocartilage Complex (TFCC) of the
Wrist
Calley Keithler, SPT | Dec. 12, 2019
Case Description
32-year-old female with a history of falling on an outstretched hand (FOOSH). Patient had prolonged
period of wrist immobilization prior to proper diagnosis of radial sided TFCC tear. Arthroscopic surgery
was performed, and patient began PT after removal of cast (7 weeks post-op).
Relevant Anatomy
TFCC runs from the ulnar styloid process to the ulnar of side of the radius. It also has distal attachments
to the triquetrum, hamate, and base of fifth metacarpal. 1,2,3,4
Components of the TFCC include: a triangular fibrocartilage, an articular disk, dorsal and volar
radioulnar ligaments, sheath of the extensor carpi ulnaris tendon, and a meniscus. 1,2,3,4,5
The TFCC has a rich peripheral blood supply to the outermost portion (outer 10-40% depending on the
individual), while the innermost portion is primarily avascular. 1,3
Function and Purpose
The primary purpose of the TFCC is to provide stability to the radioulnar joint. 4 In a neutral wrist
position: the TFCC accepts 18-20% of the axial load 1 and it will help to transfer compression forces
from wrist to forearm.1,2 Additionally, the TFCC extends the gliding surface of the radius. 2
TFCC Injuries
The primary mechanism of injury is through axial loads to the wrist combined with ulnar deviation.
Injury may also occur from wrist distraction pulling ulnarly.2,3,6
Patients typically present with: ulnar side wrist pain, possible wrist clicking with pronation and
supination, possible history of a FOOSH injury, limited ROM, pain with ADLs and with weightbearing. 1,2
Difficult wrist motions: wrist extension, ulnar deviation, and supination/pronation. 1,3,6
Risk factors: age (more common in older individuals), chronic inflammation (ex. RA) 2, and participating
in certain sports.7 Additionally, TFCC tears tend to occur on the dominant wrist. 2
80% of individuals with distal radius fracture also tear the TFCC. 8
Differential Diagnosis
Distal causes of ulnar sided wrist pain: lunotriquetral instability, midcarpal instability, extensor carpi
ulnaris tendonitis/subluxation, flexor carpi ulnaris tendonitis, arthritis of the distal radioulnar joint,
arthritis in the pisotriqueral joint, fracture of the hook of hamate, fracture of the pisiform, or
hypothenar hammer syndrome (aka: ulnar artery thrombosis). 1,3 *(Note this list is not exhaustive)*
Possible proximal causes of ulnar sided wrist pain: cervical radiculopathy, Essex Lopresti lesion. 1
Special tests: best to identify are the TFCC stress test and press. 1 Can also utilize piano key test for
instability.3
Palpation: the TFCC is between the extensor carpi ulnaris and the flexor carpi ulnaris - distal to the
styloid process and proximal to the pisiform (aka the fovea). 2,3
TFCC tears can be identified with an MRI.1,2,3,6
Treatment of TFCC Injuries
Initial treatment: conservative management – i.e. immobilization. 2,3,7
Arthroscopic surgery: recovery time is typically 6-12 weeks, but it can depend on the patient history. 2,3
Example Post-Surgical TFCC Rehab Protocols9
Week Suggested Rehab Indications to progress to next “phase”
1-3 PROM and isometric wrist exercises. Encourage full Healed incision, controlled pain, minimal
elbow and shoulder ROM. effusion
3-6 Can begin wrist AROM (but avoid radial and ulnar Full passive wrist flexion and extension. No
deviation at this phase). Start to introduce effusion
prolonged low-load stretching. Pain free joint
mobilizations.
6-10 Progress to ulnar and radial deviation ROM. Can No pain. At least 4/5 wrist flexion and
begin strengthening wrist in sagittal, coronal, and extension strength. Painless, full ROM of
transverse planes as tolerated. radial and ulnar deviation
10-14 Strengthen wrist in all planes. Introduce multi- Full ROM and painless in all planes. Normal
planar exercises and functional diagonal patterns. and symmetrical wrist strength.
14+ “Return to sport” Add sport specific training N/A
including throwing progression and weight-bearing
through bilateral wrists.
References:
1. Ahn Ak, Chang D, Plate AM. Triangular fibrocartilage comples tears: a review. Bull NYU Hosp Jt Dis. 2006:64(3-4):114-118.
http://hjdbulletin.org/files/archive/pdfs/584.pdf. Accessed November 7, 2019.
2. Barlow SJ. A non-surgical intervention for triangular fibrocartilage complex tears. Physiother Res Int. 2016;21(4):271-276. doi:
10.1002/pri.1672.
3. Sachar K. Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction
syndrome, and lunotriquetral ligament tears. J HandI Surg Br. 2012;37(7):1489-1500. doi: 10.1016/j.jhsa.2012.04.036.
4. Zimmerman RM & Jupiter JB. Instability of the distal radioulnar joint. J Hand Surg Eur Vol. 2014;39(7):727-738. doi:
10.1177/1753193414527052.
5. Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of
function what we have learned in 25 years. J Hand Surg Br. 2007;32(7):1086-1106. doi: 10.1016.j.jhsa.2007.06.014.
6. Abdelmegeed, M. Physical therapy after triangular fibrocartilage injuries and ulnar wrist pain [dissertation]. Loma Linda: Loma
Linda University; 2015.
7. McAdams TR, Swan J, Yao J. Arthroscopic treatment of triangular fibrocartilage wrist injuries in the athlete. Am J Sports Med.
2009;37(2):291-297. doi: 10.1177/0363546508325921.
8. Bombaci H, Polat A, Deniz G, et al. The value of plain x-ray in predicting TFCC injury after distal radius fractures. J Hand Surg.
2008;33(3):322-326.
9. Elite Sports Medicine. Triangular fibrocartilage complex (TFCC) repair rehabilitation protocol. Connecticut Children’s Medical
Center website. https://www.connecticutchildrens.org/wp-content/uploads/2017/02/TFCC_Repair_Protocol.pdf . October,
2014. Accessed December 9, 2019.
