after Carpal Ligament Injury

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W8 Rehabilitation after Carpal Ligament Injury

Terri M. Skirven, OTR/L, CHT, Lauren M. DeTullio, MS, OTR/L

The rehabilitation program for the wrist after carpal ligament injury is based on consideration of the specific injury; the stage of healing; the nature of any surgical procedures, whether reparative or salvage; and any resultant alteration in the biomechanics or load-bearing capacity or both of the wrist. Added to these considerations are the patient’s functional requirements, including work, self-care, leisure, and family and household responsibilities.

The goal of rehabilitation for the injured wrist is the return of motion and strength adequate for function with a relative absence of symptoms. In some, but not all, cases, this may mean that the wrist range of motion (ROM) and grip strength after rehabilitation may not reach the preinjury level. It can be ill-advised to set as a goal the achievement of arbitrary measurements of wrist ROM and grip readings at the expense of comfort and without regard for what the patient needs for function. The goal should be a symptom-free, stable wrist that is capable of withstanding the forces involved in the activities that the patient needs to perform for work, leisure, and other activities of daily living (ADL).

Relevant to this approach are the studies of functional ROM that were published in the 1980s, which illustrate that the wrist ROM required to perform most ADL tasks is less than what is considered normal ROM. Palmer and colleagues,¹ in a study evaluating wrist motion used by normal subjects in the performance of standardized tasks, found that functional wrist ROM is between 5 degrees of flexion and 30 degrees of extension, 10 degrees of radial deviation, and 15 degrees of ulnar deviation. In this study, Palmer and colleagues¹ described a “dart thrower’s motion” pattern (i.e., extension/radial deviation to flexion/ulnar deviation) that was used to perform many of the tasks. Ryu and associates² found that 40 degrees of wrist extension, 40 degrees of wrist flexion, and a total of 40 degrees of radial and ulnar deviation are needed to perform most ADL.

Throughout the rehabilitation program, the therapist must closely monitor and use the patient’s symptom response to therapy as an indicator of the capacity of the wrist to handle load. The “no pain, no gain” philosophy has no place in the rehabilitation program. Aggressive and repetitive wrist mobilization and isotonic strengthening may trigger persistent symptoms and potentially undermine the stability of the wrist and either should be used with caution or should be avoided altogether, depending on the diagnosis and the patient’s functional requirements. General goals of rehabilitation after wrist injury include the following:

• Control of edema and pain

• Maintenance of the ROM of uninvolved joints

• Achievement of functional motion of the wrist when healing permits

• Preservation of wrist stability

• Avoidance of activity and exercise that adversely load the wrist and undermine recovery of function and healing

• Return to previous level of function when healing permits

Wrist Evaluation Procedures

The foundation for a wrist rehabilitation program is a thorough assessment. The components of the wrist assessment include a detailed history; visual inspection; objective measurements of ROM, strength, and sensibility; palpation and provocative testing; a functional assessment; and administration of an outcome measure appropriate for the wrist, such as MacDermid’s patient-rated wrist evaluation.³ If the patient has been referred to therapy from a nonspecialized practitioner with a vague diagnosis such as wrist pain or sprain, the clinical examination takes on even greater importance. In this instance, undiagnosed pathology may exist, therapy may not be indicated, and the patient may need to be referred to a hand surgeon for definitive diagnosis.

The history includes details pertaining to the onset of the problem, such as when the problem started, and whether the condition occurred as a result of a single traumatic event, or whether it started gradually and worsened over time. It is important to determine what treatment has been provided, including surgical and nonsurgical management, and the efficacy of the treatment provided. This information helps in the treatment planning process by avoiding approaches that have proved not to be helpful.

A careful exploration of the patient’s symptoms is included—when symptoms occur, whether in response to a specific activity or related to use in general; whether symptoms occur at rest; what relieves the symptoms; and what makes the symptoms worse. In some cases, it may be helpful to use a numeric pain rating or other type of pain measurement that establishes a baseline for later comparison when evaluating the patient’s response to therapy. The impact of the patient’s symptoms and condition on ADL and work and leisure activities is important to determine the degree of disability caused by the wrist problem. An ADL checklist or questionnaire can be used to document a baseline of functional performance and to identify problem areas.

Visual inspection of the wrist and hand with comparison to the uninvolved side can give clues about the nature and extent of the problem. Spontaneous use, wrist posture and alignment, nail and skin color and condition, signs of use or disuse, and muscle bulk or atrophy all are important to note.

A baseline of the patient’s status and function is established with specific measurements of active ROM and passive ROM of all planes of wrist motion and of supination and pronation. Care must be taken when measuring passive ROM to stay within the patient’s comfort range and to avoid forceful end range overpressure. In some cases, passive ROM measurements may be deferred at the initial evaluation depending on the patient’s pain level and healing status. A goniometer is used to insure accuracy of measurement. The most reliable method for measuring wrist flexion and extension is with the goniometer placed on the dorsum of the wrist for flexion and on the volar aspect of the wrist for extension.⁴ Wrist ROM varies in the normal wrist; measurements of the uninvolved side should be taken for comparison.

The size of the wrist can be documented with circumference and volumetric measurements. For more acute conditions, the size of the wrist compared with the uninvolved side may be larger reflecting the presence of swelling, and with more chronic conditions, it may be smaller reflecting disuse and loss of muscle bulk. van Velze and colleagues ⁵ found that the left nondominant side was 3.3% smaller than the dominant side with volume measurement in a study of 263 male laborers. The volumeter has been found to be reliable to within 1% of the total volume when one examiner performs the measurement.⁶

Grip strength measurement is performed with the use of a dynamometer. In some instances, measurement of grip strength may be deferred. In the case of a patient with an incompletely healed condition, referred after cast removal for early phase rehabilitation, grip testing would not be relevant and if attempted could potentially overstress the healing wrist. Guidelines for the recommended method of measurement have been published by the American Society of Hand Therapists.⁷ Regular calibration and maintenance of grip gauges is important to ensure accuracy and comparability of repeated measurements.

A sensibility screen is performed to help detect the presence of nerve compressions. The median, ulnar, and dorsal radial sensory nerve can be compressed or irritated with a wrist injury, and the cutaneous distribution of these nerves is examined. Semmes-Weinstein light touch threshold testing has been found to be the most sensitive clinical test for detecting nerve compression.⁸

In cases with a nonspecific diagnosis, such as “wrist pain or strain,” referred from a nonspecialized practitioner, a physical examination with palpation and provocative testing should be performed to identify the symptomatic regions and structures, and to determine if the patient should be referred to a hand surgeon for definitive diagnosis. Important for the performance of a physical examination is a thorough knowledge of surface anatomy and an understanding of the biomechanics and pathomechanics of the wrist and of the common conditions that may occur as a result of injury. Piecing together details from the history of the mechanism or onset of the injury or condition, and correlating this information with the physical findings can help in the process of determining what structures may be involved. The provocative clinical tests are used to identify the clicks, clunks, snaps, and pops of the various instability patterns and conditions that can occur. Examples of provocative tests include the scaphoid shift test, also referred to as the Watson test or radial stress test, used to assess scaphoid stability.⁹ The midcarpal shift test is performed to detect midcarpal instability,¹⁰ and the lunotriquetral ballottement test is used to detect lunotriquetral instability.¹¹ These are only a few of a plethora of clinical provocative maneuvers that have been described and are helpful in the evaluation of a painful wrist.¹² The importance of an accurate diagnosis cannot be overstated. If the therapist has any suspicion that more than a minor soft tissue strain has occurred, or the patient fails to improve after an initial brief trial of therapy, the patient should be referred to a specialist for further evaluation.

Selected Conditions and Guidelines for Rehabilitation

Scapholunate Instability

Scapholunate instability is an example of carpal instability dissociative, and is the most frequent form of carpal instability.¹³ Carpal instability dissociative refers to instability between carpal bones of the same carpal row.¹⁴ This instability is caused by partial or complete disruption of the intrinsic interosseous ligaments. Scapholunate instability refers to a spectrum of conditions, including subtle instability without overt anatomical disruption, but with insufficient load-bearing capacity; dynamic instability that occurs only under load; static instability with full dislocation/rotary subluxation of the scaphoid; and scapholunate advanced collapse.¹⁵ Rehabilitation for scapholunate ligament injuries depends on whether the injury is acute or chronic, the presence and degree of instability, and whether the therapy is to be provided preoperatively or postoperatively. A clinical provocative test for scapholunate instability is the scaphoid shift test, also known as the Watson test and the radial stress test.⁹ The scaphoid shift test is performed by the application of pressure over the volar prominence of the scaphoid as the wrist is moved from ulnar to radial deviation with slight flexion. A positive test reproduces the patient’s symptoms, usually a painful clunk.¹⁶

Nonoperative Management

Acute scapholunate ligament injuries treated nonoperatively are typically immobilized for up to 8 weeks with either a short arm cast or a thermoplastic splint. During this initial period of immobilization, the patient performs finger ROM exercises and digital tendon gliding exercises. After the immobilization phase and during the early phases of rehabilitation from 2 to 4 weeks, the wrist is protected intermittently with a removable splint to protect against inadvertent stresses to the wrist from ADL. Active ROM exercises are begun to resolve stiffness and promote recovery of motion lost secondary to cast immobilization.

ROM exercises in the “dart thrower’s”¹⁷ pattern may be better tolerated initially because during this pattern of motion there is minimal scaphoid and lunate motion and minimal scapholunate interosseous ligament elongation.^18,¹⁹ This pattern involves the combined motions of wrist extension and radial deviation to wrist flexion and ulnar deviation. The dart thrower’s path of wrist motion allows a degree of radiocarpal stability; this direction, rather than the anatomical directions of flexion/extension and radial/ulnar deviation, may be the primary functional direction of the radiocarpal joint (Fig. W8-1).²⁰ As the patient exhibits tolerance for this pattern of motion, standard wrist ROM exercises can be introduced.

FIGURE W8-1 A and B, Dart throw motion. The combined motion of wrist extension and radial deviation (A) to wrist flexion and ulnar deviation (B).

Modalities such as hot packs and ultrasound are helpful in reducing symptoms, increasing tissue extensibility, and improving functional ROM. Overaggressive techniques should be avoided to prevent overstress to the injured and healing ligaments. Gradual resumption of ADL and progressive strengthening begins typically 2 to 4 weeks after the initial phase of therapy and as symptoms permit. The goal is to prepare the wrist to handle the demands of ADL, work, and leisure unique to each patient. Isometric strengthening exercise is generally better tolerated than isotonic strengthening.

With mild scapholunate instability, strengthening of the flexor carpi radialis has been suggested.¹⁵ The flexor carpi radialis passes over the scaphoid tuberosity on its path toward its distal insertion at the base of the second metacarpal; contraction of the flexor carpi radialis provides a volar restraint for the unstable scaphoid and an extension moment as long as the dorsal scapholunate ligaments are intact. Strengthening of the flexor carpi radialis without intact dorsal scapholunate ligaments could induce a dorsal translation of the proximal pole of the scaphoid with subluxation of the proximal pole.¹⁵ In this case, isometric radial deviation exercise involving the simultaneous contraction of the flexor carpi radialis and the extensor carpi radialis longus may be helpful in reinforcing scaphoid stability.

Throughout the rehabilitation program, continuous monitoring of symptoms is stressed with care to avoid triggering persistent wrist pain or discomfort. If the patient is unable to progress to preinjury activity levels despite a carefully applied and monitored program, consultation with and re-evaluation by the referring physician is indicated.

The focus of therapy for a patient with a chronic scapholunate ligament injury who is not a candidate for surgery is placed on symptom management and joint protection through the use of splints and supports and modalities of heat and cold. Job modification and retraining is addressed to limit further stress to the wrist from work, sports, and other ADL and inappropriate exercises. The goal is to discourage the progression of instability and secondary changes in a patient who is not a candidate for surgery. Limited ROM and isometric exercise to maintain functional wrist mobility and strength are included in the therapy program, but caution must be observed. Repetitive ROM exercises under load are likely to exacerbate symptoms and may undermine the condition of the wrist further. Symptom response should be used routinely as an indicator of the tolerance of the wrist to applied stresses.

Postoperative Therapy

Generally, goals for therapy after surgery for scapholunate ligament injuries must parallel the surgical goals. The load-bearing capacity of the healing ligament repair/reconstruction needs to be considered when introducing strengthening exercises. Wrist kinematics, if altered by the surgical procedure, must be factored into the goal-setting process and treatment. Finally, the patient’s activity requirements must be considered and restricted or modified as needed.

After scapholunate ligament repair or reconstruction, the wrist is immobilized in a thumb spica splint or cast for 8 weeks. After this initial period of immobilization, a removable thermoplastic thumb spica splint may be used for intermittent protection and support during the early phase of rehabilitation. Active ROM exercises for the wrist are initiated at this time. The “dart thrower’s” pattern of wrist ROM can be incorporated initially to minimize stress on the healing ligaments. Incision or portal scar massage and desensitization are begun. Light isometric strengthening can begin at 12 weeks; loading, power grip, weight bearing, and lifting all are avoided for 6 months.²¹

After a ligament augmentation procedure such as a dorsal capsulodesis, patients are immobilized in a thumb spica splint or cast for 8 weeks. At 8 weeks after pin removal, active ROM exercises for the wrist are initiated. A removable thermoplastic thumb spica splint is used for intermittent protection and support. Scar massage and desensitization are begun at this time. At 12 weeks, light strengthening with isometric exercises can begin; patients are progressed slowly with continuous monitoring of symptoms. No stress loading is permitted for 6 months, and wrist flexion is limited by 15 to 20 degrees.²² If by 12 weeks after surgery, wrist ROM is significantly limited, gentle static progressive splinting may be used to help increase wrist ROM.

After a limited intercarpal fusion, such as the scapholunate advanced collapse wrist procedure, the wrist is immobilized with a cast or splint up to 12 weeks until bony consolidation occurs. With more rigid internal fixation, motion may begin earlier. During the phase of immobilization, digital motion and edema control measures are included in a home program. Active ROM exercises are begun for the wrist when sufficient healing of the fusion has occurred as determined by the surgeon. ROM of the wrist is limited depending on the specific fusion performed and should not be stressed. Strengthening can begin when there is radiographic confirmation that bony union is achieved.²³

After bone-ligament-bone graft reconstruction for scapholunate ligament injuries, the most important consideration for rehabilitation is the status of consolidation of the graft and the avoidance of premature loading of the wrist from aggressive exercise or work or leisure activities that could delay or disrupt healing. During the early healing phase, a wrist splint is worn, and finger ROM and tendon gliding exercises are performed with edema control if needed. After pin removal, typically at 8 weeks, gentle active wrist ROM exercises are started and are performed within a comfort range and without load. At all other times, a wrist splint is used for protection. Generally, by 4 to 6 months, strengthening exercises and return to usual activities of self-care, work, and leisure are permitted with specific timing based on healing of the bone graft as determined by the surgeon on successive follow-up visits. Without question, ongoing communication between the surgeon, therapist, and patient is crucial to promote an optimal outcome.

Lunotriquetral Instability

Lunotriquetral instability is the second most frequent form of carpal instability and is an example of carpal instability dissociative.¹³ Lunotriquetral instability results from disruption of the lunotriquetral supporting ligaments from either a traumatic or a degenerative etiology. Volar rotation of the scaphoid and lunate with extension of the triquetrum can be seen with lunotriquetral instability. This pattern is termed volar intercalated segment instability. The rehabilitation program for a lunotriquetral injury must take into consideration whether the injury is acute or chronic, whether the condition resulted from an isolated tear or is part of a degenerative wear pattern seen with ulnocarpal abutment, and whether the plan is for operative versus nonoperative management.

Examples of clinical tests used in the detection of lunotriquetral instability include the ballottement test, the shear test, and the ulnar snuffbox test. The ballottement test is performed by stabilizing the lunate and attempting to displace the triquetrum volarly and dorsally with the other hand. A positive test elicits pain, clicking, or laxity.¹¹

The shear test was described by Kleinman.¹³ The examiner’s fingers are placed dorsal to the lunate, and the thumb is placed on the pisotriquetral complex. With the lunate supported, the pisotriquetral complex is loaded in the anteroposterior plane, creating a shear force across the lunotriquetral joint. The wrist is ulnarly and radially deviated. The test is positive if pain or clicking is produced.

The ulnar snuffbox test involves lateral pressure on the triquetrum in the space distal to the ulnar head formed by the extensor carpi ulnaris and the flexor carpi ulnaris tendons. A positive test reproduces the patient’s pain.²⁴

Nonoperative Management

Acute lunotriquetral ligament injuries treated nonoperatively are immobilized for 3 to 8 weeks with a short arm cast, an above-elbow cast or thermoplastic splint. The rationale for including the elbow is to eliminate the motion at the lunotriquetral joint that occurs during forearm rotation.¹⁵ A pad beneath the pisiform and over the dorsal distal radius may be used to maintain optimal alignment.¹⁵ During this initial period of immobilization, the patient performs finger ROM exercises and digital tendon gliding exercises. After the immobilization phase and during the early phases of rehabilitation from 2 to 4 weeks, the wrist is protected intermittently with a removable splint to protect against inadvertent stresses to the wrist from ADL. Active ROM exercises are begun to resolve stiffness and promote recovery of motion lost secondary to cast immobilization. Gradual resumption of ADL and progressive strengthening begins typically 2 to 4 weeks after the initial phase of therapy and as symptoms permit. The goal of the rehabilitation program is to prepare the wrist to handle the specific demands of ADL and work and leisure activities. Isometric exercises are generally better tolerated than isotonic exercises. Continuous monitoring of symptoms is stressed. Persistence of tenderness and swelling over the lunotriquetral interval with inability to progress to preinjury activity levels most likely indicates the need for re-evaluation by the referring hand surgeon.

In the case of a chronic lunotriquetral ligament injury in a patient who is not a candidate for surgery, symptom management and joint protection are the focus of rehabilitation, accomplished through the use of splints and supports and modalities of heat and cold. Job modification and retraining may be required to limit further stress to the wrist from work, sports, and other ADL and inappropriate exercises. The goal is to discourage exacerbation of pain and the progression of instability and secondary changes.

A home program of limited ROM and isometric exercise to maintain functional wrist mobility and strength is appropriate. It is important to observe caution with exercise; one should avoid repetitive ROM exercises under load, which would likely exacerbate symptoms and undermine further the condition of the wrist. Symptom response should routinely be used as an indicator of the tolerance of the wrist to applied stresses.

When the lunotriquetral ligament injury or instability occurs as part of a degenerative wear pattern in cases of ulnocarpal abutment, it is important to be aware of and avoid activities and exercises that increase abutment. Activities that involve forearm pronation and grip increase ulnar variance and would be expected to exacerbate symptoms of ulnocarpal abutment.

Postoperative Management

After lunotriquetral repair and reconstruction with pinning, a short arm cast or splint is used for 8 weeks; digital motion and edema control are addressed during this phase of initial immobilization. After removal of pins usually at 8 weeks, a volar splint for the wrist is used for protection for an additional 4 weeks and is removed for ROM exercises and bathing. Active ROM exercises for the wrist begin at 8 weeks after pin removal. Desensitization, scar massage, and edema management are incorporated as needed. Light strengthening can begin at 12 weeks. Impact loading and forceful rotational motions should be avoided for 4 to 6 months.²¹

After lunotriquetral arthrodesis, a short arm cast or splint is used for 8 weeks; digital motion and edema control techniques are stressed during the phase of continuous immobilization. Active ROM exercises for the wrist begin at 8 weeks, and a removable volar wrist splint is used for protection until healing is complete. Desensitization, scar massage, and edema management are incorporated as needed. Light strengthening can begin at 12 weeks if healing of the arthrodesis is complete.²⁵ Close communication with the referring surgeon is essential for the progression of the therapy program to increasing levels of load and resistance.

Midcarpal Instability

Midcarpal instability is an example of the Mayo Clinic’s category of carpal instability nondissociative and refers to instability between the proximal and distal carpal rows.¹⁴ Lichtman’s classification¹⁰ includes three categories of midcarpal instability. The first two are palmar and dorsal midcarpal instability depending on the direction of the instability. The third category is extrinsic midcarpal instability, which refers to instability that occurs as a result of an extrinsic cause, such as a distal radius fracture malunion. Palmar midcarpal instability is the more frequently encountered form of midcarpal instability and is characterized by a volar sag on the ulnar side of the wrist, a clunk that occurs at the end of the range of ulnar deviation with forearm pronation, tenderness over the triquetral-hamate and capitolunate intervals, and weakness of grip. A lateral radiograph of the wrist in neutral deviation often shows a volar intercalated segment instability pattern with slight palmar translation of the distal carpal row.²⁶

The metacarpal shift test has been described by Lichtman and colleagues ¹⁰ and is used to detect midcarpal instability. The test is performed by applying a volar load across the midcarpal joint and then ulnarly deviating the wrist with simultaneous axial load. A positive test is one that causes a painful clunk and reproduces the patient’s symptoms. Feinstein and associates²⁶ described a grading system for the midcarpal shift test based on the degree of volar translation possible and on the presence of a clunk that occurs at the end range of ulnar deviation (Table W8-1). As with any of the wrist examination procedures, it is important to test the contralateral side. Often a painless clunk may be present on the uninvolved side, indicating laxity rather than pathology.

TABLE W8-1 Grading for the Midcarpal Shift Test

Grade	Palmar Translation	Clunk
1	None	None
2	Minimal	Minimal
3	Moderate	Moderate
4	Maximal	Significant
5	Self-induced	Self-induced

Alexander CE, Lichtman DM: Triquetrolunate instability. In Lichtman DM, Alexander AH, eds: The Wrist and Its Disorders. 2nd ed. Philadelphia: WB Saunders, 1997.

Nonoperative Management

Nonoperative management for midcarpal instability includes the use of wrist splints and supports, symptom-relieving measures and modalities, activity analysis and modifications as needed, and strengthening exercises for stabilization of the midcarpal joint. A midcarpal stabilization splint has been developed for palmar midcarpal instability (Fig. W8-2).²⁷

FIGURE W8-2 Midcarpal stabilization splint reduces the ulnar volar sag of the wrist and achieves a more neutral carpal alignment.

The splint provides dorsally directed pressure on the pisiform with counterpressure over the head of the distal ulna to reduce the ulnar volar sag of the carpus and to achieve a more neutral carpal alignment. In many cases, the wrist symptoms and the clunk are partially or fully eliminated while the splint is worn. The splint allows nearly full extension and radial and ulnar deviation and limits flexion and can be worn for a variety of activities. The midcarpal stabilization splint is initially worn most of the day during activities and removed at night. If the patient reports pain at night, the splint can be worn at night.

Splint use is continued for 3 to 6 weeks, and as symptoms lessen, the patient can wean from the splint. The splint is used in all cases in combination with the stabilization exercises and with activity modifications as needed. If the patient routinely engages in a sport or other activity that adversely loads the wrist and provokes symptoms, it is recommended that the patient avoid the activity if possible during the initial period of splint use. Alternatively, the splint may be worn during the offending activity. As symptoms lessen, modification of the activity and continued use of the splint during performance of the activity are appropriate prevention strategies.

Further study is needed to refine the exercise approach for midcarpal instability. Some general guidelines can be observed, however, based on an understanding of the pathomechanics of midcarpal instability and on an appreciation of the loads generated on and across the wrist with various types of exercises. The pathomechanics of midcarpal instability are reproduced with wrist motion under load. Standard isotonic exercises that involve motion under load (wrist curls with free weights) may reproduce the pathomechanics of the wrist and can exacerbate symptoms. Exercises to avoid include repetitive wrist ROM exercises, isotonic wrist curls with free weights, and repetitive power grip strengthening.

Isometric exercises are emphasized particularly for the extensor carpi ulnaris and the flexor carpi ulnaris. The combined action of the extensor carpi ulnaris and flexor carpi ulnaris during isometric exercise for ulnar deviation provides a degree of stabilization for the ulnar wrist (Fig. W8-3). Exercises can be done in supination, which is a more stable position for the wrist.²⁸ Supination causes a decrease in ulnar variance with a tightening effect on the ulnar wrist ligaments. Exercises are progressed by altering the forearm position to perform the exercises in neutral and then in pronation. Grip strengthening exercises also can be done in supination. The patient’s symptom response must be monitored and used as a guide to the modification of and progression of the exercise program. Lichtman and colleagues¹⁰ described dynamic muscle compression achieved by activation of the extensor carpi ulnaris, flexor carpi ulnaris, and hypothenar muscles reproducing the normal joint contact forces in the absence of adequate ligament support.