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

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 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.

For many people, especially teenage or younger athletes, there is a great appeal to have the 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 less than hoped results or the people who cannot get or do not want a surgery and are looking for 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, the snapping or popping in their wrist is an inconvenience. They go about with their lives until such time as the popping and snapping starts 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 effects 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.

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.(1)

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 sport 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 being 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 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 are causing the  clicking, grinding, and popping.
  • Somewhere this clicking, grinding, and popping maybe 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 suppose to rotate. But when you hold you 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.

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

Here is an interesting case presented in the International journal of surgery case reports.(2)

Explanatory note: The multiple accessory tendon 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 tendon of extensor pollicis brevis is 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 tendon of extensor pollicis brevis which is causing snapping.

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

The surgeons of this study concluded: “There are various causes for snapping wrist syndrome. Multiple accessory tendon can also cause snapping as shown in this case report. Moreover am presenting this case to highlight the diagnostic failure with non dynamic radiological investigation and to consider multiple accessory tendon as 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 (3) 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 debridgement 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.

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.

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.

Non-Surgical treatment options

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 corticosteroid 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

Prolotherapy is an alternative non-surgical procedure that uses natural proliferants to aid the body to heal itself. Prolotherapy injections use dextrose solutions to induce the bodies 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 severity of their case), then they can be injected with Platelet Rich Plasma (PRP) or stem cells from 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 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.

1 Stathopoulos IP, Raptis K, Ballas EG, Spyridonos SP. Recurrent dislocation of the extensor carpi ulnaris tendon in a water-polo athlete. Trauma monthly. 2016 Feb;21(1). [Google Scholar]
2 Subramaniyam SD, Purushothaman R, Zacharia B. Snapping wrist due to multiple accessory tendon of first extensor compartment. International journal of surgery case reports. 2018 Jan 1;42:182-6. [Google Scholar]
3 Swann RP, Noureldin M, Kakar S. Dorsal Radiotriquetral Ligament Snapping Wrist Syndrome–A Novel Presentation and Review of Literature: Case Report. The Journal of hand surgery. 2016 Mar 1;41(3):344-7. [Google Scholar]

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