Wendy Medeiros, OTR, CHT (retired) Non surgical Management of TFCC tears BAHT Nov. 2017
Wendy Medeiros, OTR, CHT (retired) Non surgical Management of TFCC tears BAHT Nov. 2017

It’s a pleasure to be here. My name is Wendy and I’m going to speak to you about what I’ve learned over the past 11 years studying just TFCC tears. We have a lot to learn about the dynamics and treatment of the wrist. And there hasn’t been significant change in the treatment of TFCC tears since I started 25 years ago I’ve learned quite a bit from the large populations of those with TFCC tears I took a sample of 190,000 cases in this picture of those who have come to WristWidget.com Since 2006 we have seen 500,000 cases of people with TFCC come to our little island (right there) in Hawaii And it’s from this data that I’ve learned quite about the dynamics of the TFCC We know that it’s equally spread amongst men and women the age … The age group is surprisingly in the 25-34 year range And have been surprised to see over the 11 years the population least affected is over 65. We know this happens among weightlifters, golfers, surfers … The higher incidence is found in the dominant wrist, of course The rural laborers are often missed … an ignored population We don’t see a lot of people who have indications for diabetes, heart disease, but we do see a lot of people with auto-immune disorders Interestingly, We have discovered too, is that there is a high instance of people who develop a TFCC tear after doing a high whey protein load. I’ve consulted with physicians, acupuncturists, naturopathic doctors, and obviously therapists around the world to gather some really interesting insightMost of the cases that we’ve seen around, 40,000 cases, were dissected, looked at closely Most of them don’t take medications there is a small group of people that do, but it is too small to mention here Most of them say that the anti-inflammatories that they take didn’t work. Current understanding of the TFCC is limited by the challenge of identifying it early MRIs have a very high false negative, and a false positive. This is really important There is a big difference between a test at 1.5 MRI and a test at 3.0 And even with a great MRI they are often misdiagnosed TFCC tears More often than not, they are underestimated. There is no standard protocol for treatment around the world The treatments that are provided in India are quite different than the treatments provided in the US. And I hear about them all. I hear it. I look at X-rays, I look at MRIs, I look at case studies, I look at everything these patients have experienced and I can come to conclusions with great confidence. There is also a growing concern about the access to medicine We know there is a shortage of hand therapists, MDs and radiologists that can read the MRIs Access to hand surgeons, world wide are decreasing as the population rises. We know that the access to medicine is decreasing in most countries. simply because of a population increase. I have defined a weight-bearing test which uses a non-digital scale And so far, non-digital scales are easy to find anywhere in the world. I’ve gathered in the past 12 years, weight-bearing data which has really great uses for the understanding of the progression of this injury And how it changes over a long life. I am here to express to you the Weight Bearing Test and hopefully this will be part of your assessment process. For this test you will need a non-digital scale, and sports tape, or a WristWidget. You will use your uninjured wrist as a control Place the hand in a relaxed position. Keeping your elbow straight, lean over your wrist so your body weight moves through your wrist. Here we see a tolerance of around 70 pounds. Do the exact same with your injured wrist, but go slowly. Press through your straight elbow until you feel discomfort. Here we see a tolerance of around 45# Do not exceed your pain tolerance. Next, you will need two 1/2 inch wide strips of tape cut to around 13 inches long. Start the tape at the base of the hand and wrap loosely around the wrist. Then on the second wrap, pull it tight. Leaving space for the ulna bone, wrap the second piece of tape in the same manner. You will now repeat the tolerance test on the scale, exactly as you did before. Here we see the patient’s tolerance has risen to match their uninjured wrist. You can carry out the same test with the WristWidget. Put on the WristWidget as shown Again, make sure you leave room for the ulna bone. Pull both straps tight and attach the velcro. Carry out the same test to ensure the tolerance is even across both wrists. So. In TFCC tears, 100% of the time, if you see a significant improvement there is a TFCC tear and you tape it … you use non-elastic tape, 1/2 inch wide, or 9 mm It’s long enough to go around the wrist 3 times proximally and distally keeping the ulna head free using non-elastic tape If you apply this tape on a wrist that has a TFCC tear 100% of the time, that weight bearing tolerance will increase. And not just a little bit, but significantly. In central tears, what happens is the weight bearing … if you have a complete tear of the central portion of the TFCC the weight bearing tolerance will go to 20 lbs … 10 kilo. And when you put the tape on it will go immediately to normal, and that’s significant. So it becomes almost a little bit of a diagnostic assistant. In peripheral tears it’s a little slower And in complete tears of the peripheral portion of the TFCC what you see is the is the weight bearing will go up progressively on a weekly basis People that have ECU tendon injuries only and no involvement with the TFCC You will see normal pain-free, weight bearing. Your uninjured wrist is your control So you have a nice control to identify when you’re at 100% Undiagnosed fractures are also interesting.
What will happen in most cases is the weight bearing tolerance will not change when you tape the wrist. So if your weight-bearing doesn’t change If there is a significant loss of weight bearing tolerance that does not change with tape it’s NOT the TFCC. look at fractures and undiagnosed fractures. There are important landmarks 45 pounds… 20 kilograms is functional meaning you need 20 kilograms of weight bearing tolerance to get through light tasks … getting dressed, eating, showering … You need 45 kg to load it. If you don’t have 45 kg of weight bearing tolerance, you shouldn’t be working or playing playing tennis, until you’re back to load 9kg is a red flag for, a great concern for a predictable cascading events in the wrist. The lower the weight bearing tolerance, the higher the incidence of extensor carpi ulnaris, tendonitis or subluxation Are you guys following me? The longer the presentation of the symptoms the more predictable the cascade of events are, particularly the scaphoid-lunate injuries The longer you have an unstable under 45 or 20 kgs of stability in the wrist the deterioration is rapid. I did a case study with Susan Barlow We gathered thirty cases. We chose one. We chose this particular one because it was an early diagnosis It was a fantastic work done by a physician at Stanford It was a really straightforward case. This gentleman had a MRI confirmed TFCC tear He started with the WristWidget. And measured grip strength as the gentleman had no weight bearing tolerance (10 kg) We had him wear the WristWidget continuously. And then we retested every week for stability. Over the course of 12 weeks we followed him and then did a follow-up at one year I just did a final follow-up. I love case studies. He had a fantastic outcome. Alright. So, a mild tear, one that has 45 kg or above The healing time is 4 weeks. Once they have 45kg of stability you can start on a stretching and strengthening program. And this makes a difference. All TFCC tears are instructed not to do bicep curls or pushups for the entire time of healing until they get to 100% weight bearing tolerance is when they can start doing bicep curls. They can start doing stretching
and strengthening of the wrist at 45kg of stability. In moderate tears, we define these as people with 25-45kg 8 week recovery time. They are not allowed to do anything heavier than 5# or 2 kg They are functional and can get through the day but shouldn’t be loading it. They need to continue to wear the WristWidget 24/7 A significant tear is everything under 20kg. These require 12 weeks And they must have protective splinting in the beginning until they get to that functional place of 20kg And the splinting should be protective but there should be nothing on the ulna head and a lot of nighttime splints push down on the ulna head and it harms … it slows the progress… it is painful to them there should be no compression to the ulna head. And during the day they should be protective as well These people have lost 80% of the stability in their wrist If you don’t protect them and get them into that functional window They’ll see that progressive deterioration more quickly. They’ll see the ECU start to sublux They’ll see something else Scaphoid Lunate problems, they’ll see the ulnar nerve start to have problems So they need to be watched closely until they get to that functional range. TFCC tears don’t have swelling. They just don’t. I did a volumetric tests. They don’t swell. Sometimes they say they swell, just a little bit, most people say, nah, it doesn’t swell. They do not have pain at night. If the ECU is present, they will have pain at night. they will have a general ache in the morning and a general ache at night. The TFCC tears generally do not hurt at night or in the morning. Clicking is something that is not consistent. Clicking is important to note. If they have or don’t have clicking there is no consistency in their weight bearing numbers Except that the lower they are the more cascaded events, the higher the clicking. But in general the moderate and the mild TFCC tears don’t always present with clicking They also don’t have a delayed onset of pain. If the TFCC is hurt, it hurts when they use it. It’s not something that aches … just achey … It doesn’t sit there achey during the day. Somebody says they have an achey wrist you know ECU’s involved and there is something else going on. Strengthening usually makes things worse until a certain point. And I didn’t define that, I was told that over and over and over and over and over and over and over and over and over again that …. strengthening made it worse. Of course I can’t control the type of strengthening that people do But I know that normal strengthening is in pronation and supination I also know that that leads to ECU involvement, so while it can make sense, because of that I don’t recommend any strengthening until the patient has 65 lb or 45 Kg of stability 65kg of stability I do know though, that strengthening is really important at a certain point. And I’m so happy to be here … because, I am excited to learn from others studying it. I do see a predictable bio-mechanics in the shoulder and elbow I see a tight pronator tight interior capsule of the shoulder tight sub-scapularus or weak sub- scapularus so I do see patterns of motion that are worth attention. An unexpected group of people I just want to talk about really quickly This group of people wake up in the morning and their wrists are non-functional They didn’t fall, they didn’t hurt it, they don’t know why they hurt their wrist, but their wrists are now non-functional. When I was speaking with acupuncturists around the world they all said that this is related to the gut. And I …. I decided to do a study and I had twenty very kind people follow me through this and I had them all go get stool tests and bloodwork and surprisingly, 18 out of the 20 had significant pathology in their gut, and when treated, their wrist pain went away. There is definitely a correlation between the stomach and the TFCC People who have complete tears of the TFCC also say that they feel sick and nauseous. I don’t really know when that’s going to go But that’s something that’s worth talking about with patients. Also, acupuncture is probably one alternative treatments that we can offer them Acupuncture is probably the best. And cortisone most people say it doesn’t help. Ultrasound …. they say it doesn’t help estim, iontophoresis, ROM exercises, I don’t get alot of reports on success. The survey …. I started collecting surveys from all the people that came to the website, and I asked them to do their weight bearing test, and and gather some information I would really love it if you guys could contribute to this body of knowledge. There’s a website where you can just put in your data Just watch the video and enter the data Right now I have quite a bit of data But I don’t have anything from the UK yet. I’ve tested people in Asian, Australian, and American market The biggest question that is hard … difficult to answer It took me a very long time, to articulate, was, was, “When can I go back to work?” “When can I start playing tennis again?” “When can I get back to normal?” I can answer that now. And that is: once you have 45 kg of stability in the wrist. It’s loadable. It took a long time to get that. And this is really actually kind of good knowledge because it probably applies with distal radius fractures and with a lot of other injuries of the wrist that affect stability. I certainly know that this number affects There is certainly something interesting about these numbers. Dynamic stability of the shoulder is essential and it is diagonal stability. Diagonal strength is really important. particularly in tennis players and golfers The lats and external rotators of the shoulders, the rhomboids and the triceps all neutral on pronation or supination is really important There’s a high incidence of the pronator tightness, and we have a stretch: Once you get to 45kg of stability you do this on the ground you take your arm and fully supinate it place it at midline and then Place under your hips and lift your legs up. and that really stretches the pronator and the bicep and that one is really effective. So, I’m hoping to publish the normal weight bearing tolerance in the adult human wrist between ages 18 and 65, next year and the more data I have the more we will be able to see trends I would like to use this data to define post op TFCC repair protocols. So if somebody who has had to have surgery on it it would be really nice to grade their progression through their repair I have a theory that Ulnar variance is a by-product of the spreading of the distal radius and the ulna and so when the TFCC is disrupted, there is a spreading and that creates the “illusion” of ulnar variance I would really like to know the effects of tape on ulna variance to support that theory that there is rather a longer ulnar bone that some people are born with that appears out of nowhere and that it’s actually just a byproduct of the injury that it caused spreading of the radius and ulna. There definitely needs to be some discussion about the TFCC and the scapolunate Dynamic … the dynamic influence of one if you develop a scapolunate problem Typically the TFCC comes next If you develop a TFCC problem, typically the ECU and then the scapoid after that I don’t see this with other structures. I don’t see other things/ you just see this pattern and if untreated it develops into ulnar abutment. Definitely want to understand the relationship between the stomach and the TFCC There are more, more anatomical variations in the distal ulna than we know now There are some really interesting anatomic variations of the wrist that I have seen. … construct, taking pictures, and Xrays and looking at them in certain ways we can define this group of people that haven’t been defined I also want to understand the weight bearing tolerance and how different diseases and different medications affect it There are some medications that have popped up on the radar screen and have a bilateral influence on weight bearing tolerance You’ll probably see this if you start asking questions PRP is a really exciting new treatment available to the wrist It’s got a long ways to go I’ve had two people out of 40,000 Two, two people who said it significanlty affected their outcome Everybody else, it doesn’t and I don’t want to discount it because I think it has value I really would like to find somebody who can standardize their treatment protocol using the weight bearing knowledge and define protocols for productive and successful treatments using PRP. I have a small group of people I am using it on for ankles and they’re using it for high ankle sprains, I need to mention this because I looked at the ankle, I don’t work on ankles and it looks exactly like the wrist and so I think that if you have people … high ankle sprains are very difficult to treat … it would be nice to have a simple solution and I did a very large study on distal radius fractures and we were looking at fracture healing time and I think that having weight bearing numbers to define fracture healing time is really valuable. I look forward to hearing from all of you I hope you walk away today knowing that TFCC tears heal Thank you

3 thoughts on “Wendy Medeiros, OTR, CHT (retired) Non surgical Management of TFCC tears BAHT Nov. 2017”

  1. Alfredo Florimonte says:

    What about pushups on fists to stabilize the joint? Instead of normal pushups of course…

  2. peak kite says:

    I don't have a tfcc tear since I have full weight bearing tolerance but my tfcc is constantly feeling inflammed I had an MRI done and it appeared that I did not have a tear but that the tissue was just damaged by repetetive lifting. My question is is it possible that the wrist widget will help this sort of injury since it's not a tear but just a terrible ache(btw my ecu appeared to be ok on the mri so I don't think the pain comes from that) and exactly how does it heal because I was always thaught during biology that cartilage doesn't regrow or heal.

  3. YangYi Chen says:

    I'm recovering and using the Wrist Widget now. I have a Significant tear. On the slide titled, Protocol for 100% Recovery (@12:00), do I understand right that you say to remove the Wrist Widget at night until 65lbs/45 Kg? That seems contradictory to the instruction for Moderate tear, 24/7 wear. Please clarify, thank you. EDIT: Nevermind, I see you have a protocol listed on your website, says 24/7 wear. Please confirm this is correct, for the sake of clarity. Thanks! https://www.wristwidget.com/pages/tfcc-treatment-protocol-weight-bearing-test-results-45-20kg

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