![[Case Studies] TFCC injuries: From diagnosis to rehabilitation with Dr Ian Gatt](https://cdn-images-3.listennotes.com/podcasts/physio-network/case-studies-tfcc-injuries-6KQG_gN8yUq-ezPAnrBlK-X.1400x1400.jpg "[Case Studies] TFCC injuries: From diagnosis to rehabilitation with Dr Ian Gatt")
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Welcome to this episode of Case Studies by Physio Network.
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Today I'm joined by Dr.
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Ian Gatz to discuss a real case of a TFCC injury in a boxer.
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Ian is an experienced sports physiotherapist and upper limb specialist with extensive experience working in elite boxing and Olympic sport.
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His combination of clinical expertise and understanding of the demands placed on the hand and wrist in combat athletes make him an ideal guest to help us unpack this case.
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In today's episode, we explore the TFCC, the differential diagnosis that you may want to consider when assessing ulnocided wrist pain, and how Ian approached the clinical reasoning behind this case.
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We also discuss the framework he uses to link rehabilitation directly to function, helping treatment progress from early stage recovery towards the specific demands of your patients and their sports.
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More broadly, we explore how clinicians can make rehabilitation flow towards returning patients not only to sports but to achieve the activities they personally deem most important.
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And most importantly, Ian shares the key lessons from the case, including how to structure progression, make treatment meaningful, and use clear functional criteria to guide return to activity.
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Ian covers a lot in this case, and today you'll be able to gain lots of new ideas for your rehab and also a confidence in how to treat and assess TFCC injuries.
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I'm James Armstrong and this is Case Studies.
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Ian, thanks so much for joining us.
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It's great to have you back on the podcast today on the Case Studies episode.
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Thanks for having us, James.
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So today we're going to talk listeners through a case on TFCC, which we'll talk about in a second, particularly in a boxer.
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We're going to go through how they presented and the treatment from the assessment and some really good tips for listeners in how they can improve their treatment management of these injuries.
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Let's just cut straight to the TFCC.
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What are we talking about, first of all, Ian?
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Well, it's an interesting part because the the ulnar side of the wrist is usually called like the black box of the wrist because it's got so many different structures.
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And I think when people point to the honor side, it's very easy to think TFCC as being like one structure, one thing.
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First of all, if you're thinking what is TFCC, TFCC is triangular fibrocultilage complex.
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And the last C, the complex, means there are many things.
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You've got the dorsal volar, radioalno ligaments, the ulnolunate, onotrichletal ligaments, you've got the articular disc, the meniscoid, the ulnar cortical ligaments, and then the extensocarpial naris.
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So all together, you've got tendons, ligaments, cartilage, all of those can potentially produce pain.
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And then beyond that, you could have conditions which could be vascular, conditions which could be neurological, you could have fractures, for example, the hemoid fracture.
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In fact, I've posted many times about the differential diagnosis.
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So I think it's just that wariness for people to just go, oh, well, there's pain on the other side, that must be the FCC.
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It's not as simple as that.
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And listening to the history of the person, the type of trauma or non-traumatic, what sort of symptoms are coming, the location of the symptom also.
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Sometimes even when people are pointing, palpating, whether it's upper part, a bit middle, a bit lower part, over the ulnar side, again could be very different.
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In fact, where are we today?
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Posted very recently on social media with a bit like an algorithm of if you had ulnar sided pain, some of the things to do, some of the tests to do.
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And again, even with diagnosis, we know sometimes you could be wrong, but what you don't want to be wrong in is missing red flags, missing things which are require further investigations or even something even more like that, like surgical interventions.
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Brilliant, brilliant.
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So just from you you're talking there, you I can imagine that the TSCC is often probably an area that people are quite afraid of or certainly not that confident with.
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So hopefully we'll go through this case and it might give people a little bit more confidence in what they're looking for.
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And as you say, a complex area that needs some some careful consideration.
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So let's introduce the case in, if you don't mind, starting with the athletes and how they ended up presenting to yourself.
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This was a very interesting case.
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For the listeners, maybe they don't know, but I spent over two decades working in the UK in high-performance sports.
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And recently, let's say 10 months ago, I moved to India.
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And even before coming, this case was presented to me as a high priority athlete.
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And the problem that this athlete had, so this is a boxer, a 29-year-old female boxer, orthodox for those who know a bit distances and boxing.
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And what happened was that they had various knee surgeries.
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They had three surgeries on the same knee, on the left knee, and they were actually doing recovery for a recent meliscectomy on that left knee.
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And what happened was during the period of rehabilitation and trying to do various things, this wrist flared up.
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And through various investigations and various components, we found out that this was a TFCC injury.
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And one of the main two things that I always try and differentiate is between a central tear and a peripheral.
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Why?
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Because peripheral tears, many times what you'll end up doing is requiring repair because they've got a better circulatory location, whereas central tears, you do a debridment, which also means that peripheral tears might need more time.
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The problem came.
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So imagine I'm not even there yet, not yet in India.
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And having to give my advice on this wrist remotely, asking people to take objective measures, asking them how things are going, is this wrist really good or bad.
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We even ended up doing virtual consultations with the athlete.
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And the the thought process was where the knee is now, which was still lacking bits, and we're trying to get this knee back to full swing.
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We felt it would be the right idea to operate the roost now, because if we combine the two together, we've got a better chance of returning the athletes in a better stage earlier rather than later.
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So this actually ended up being like a combo approach of trying to manage holistically the athlete with consideration of not losing time at a later stage.
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One of the biggest components I probably brought to the table was not just only, okay, we go for surgery, happy days, but planning ahead how long it's going to take.
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So thinking about things that sometimes are forgotten in sports for people that are not very comfortable working with athletes, is making a plan of their return back to sport.
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So your macro planning, let's call it so, and then even looking at the stages of mesoplanning, which would be every week, what the athlete would be doing to be able to estimate when they would return.
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And so even before getting there, I'm telling them, listen, based on my calculations, the athlete should be ready by this date and then be able and available by this date.
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And again, I've not even started this role.
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I'm already giving consultations around the cirrhist injury, which nobody had a clue what we're going to do with.
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So when the patient presented you, what sort of assessments might you have done?
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Obviously, the subjective history being really key.
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Are there any other specific assessments that you found in your experience to be more sensitive or specific to allow you to then start looking at what further investigations might be needed?
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Subjectively, functionally, what are they doing?
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Rather than a lot of times we focus on what they can do, but what are they doing?
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Is there a percentage split?
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Is it actually they can do 90% of the activities and we're focusing on a small 10% and it doesn't sound too bad?
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Whereas they tell you, if I take the boxer, they say, Listen, just hitting a water bag, which is a very soft item in boxing, it's painful even with 20% impact.
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And I feel like nervy going down the hand, something like that, it tells you, listen, that's sounds like there's a lot going on there.
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Because of that, I always think, whether it's an athlete or an athlete, I always think about tissue tolerance and forces.
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So, what is the tissue tolerance of somebody to do something?
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And the first thing I try and estimate it by listening to somebody, somebody says, I can live a jug, I can live a big jug of water, two liters, and not have pain, versus somebody that goes, I lift a glass of 200 ml, and literally my wrist feels like I have no power, for example.
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So it's already telling you the difference subjectively that somebody can tolerate a little force, somebody can tolerate a lot of force.
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And then I try and quantify it.
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And the simplest thing to do is things like can use a hand grip dynameter, squeeze, what's the number that gives you, and is there any pain associated, and what's the difference between sides?
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And then because the TFCC, for example, or a lot of structures on the underside tend to be compressive in nature.
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So if you put, for example, a nice test I like to use is a weight-bearing scale test, the thing that we go on to check our weight, put it on a table, put their hand on that weight-bearing scale test, put the weight over it, risk goes into extension, and also there's a bit of pronation, which means you're really compressing those structures.
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And so, what's the number that comes out on the weight-bearing scale test?
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What are the symptoms?
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What's the difference?
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And literally with those two simple tests already, I'm trying to quantify forces.
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And then I'm with I start going a bit more into certain specificities.
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Is there something really somebody says whenever I lift a jug of water, it's painful?
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You can use dumbbells, for example, to quantify that.
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So if I grab a dumbbell and I get them to go from a flexed elbow to extended elbow, one kilo, they're fine, two, three, four, five.
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We get to six kilos on one side.
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On the affected side, one kilo is super painful.
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That's a big tolerance difference.
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Whereas if somebody can do six and six and there's sun pain, it's all right.
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Already selling you, well, you can tolerate quite a bit before it's painful.
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And I'm using all this information.
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One is to understand beyond the pathology, it's more the severity towards function.
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I'm doing a gap analysis using numerical values, and then I'm thinking, is this something I can comfortably manage using a conservative approach to close the gap?
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Or it doesn't look good.
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If somebody comes to us and I've had this for six months, and they're got a 90% difference with lots of pain, it doesn't look good at the moment, the prognosis.
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Whereas if somebody comes to you after six months and you know they've got a 10% difference, you go, all right, can you just run me a bit more through your daily activities, your daily sports to understand?
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Because from what I'm seeing, there's not a lot going on.
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But that's why I said the subjective feeds already, it's telling me already if I'm gonna test what's my sensitivity to what potential is going to be their tissue tolerance?
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Do I really think it's gonna be a very low threshold or it's a high threshold?
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And that really enables me beyond thinking that differential diagnosis, which is already playing in my head, by the way, all the different things it could be from the history, I'm thinking function.
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And you mentioned their differential diagnosis, sort of when when this athlete turns up or or when our listeners may have what they suspect from the subjective to be a TFCC involvement.
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What are some of your differentials around the area that you see sometimes people miss or or assume is a TFCC and actually it's something slightly different?
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It's a bit like the terminology we used for the knee, that patternophemoral syndrome and PFP, the old PFP, which is many things, or sometimes even shoulder times we say rotator cuff related shoulder pain, or actually it could be anything.
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It could be a tendon issue, it could be a bone issue, it could be a vascular issue, it could be a neurological issue, it could be the miniscoid cartilage.
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Um, so you have to think about it, could be numerical things.
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What I try and always consider is there anything, first of all, that is a red flag?
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And I mentioned this before.
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Red flag for me, is there any any pins and needles or any pains going down into the digits, particularly that you know that ring finger, that that little finger?
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Where is the pain location?
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Also, is it further up from the wrist?
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Is it more in the hand?
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Is the mechanism of injury and maybe the sport?
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If we think about the sport like racket sports, gymnastic golf, uh is it making me think more fracture of hook of hammit, for example, rather than a TFCC?
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There again, there are certain tests that you can use, X amount of specificity sensitivity as always, but at least you're thinking about those things as you're going along.
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And again, even when I say TFCC, that's why I said it could be the tendon, it could be the ligament, it could be DREJ.
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So just the radial on a joint, really important stabilizer for rotations.
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It could be the lunate with the triquetrium, the little carpal bones, there could be some instability.
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So it's always useful to understand.
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Is this traumatic or non-traumatic?
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If non-traumatic, tell me the history of it.
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If it's been traumatic, do you remember what happened?
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How did it was it an extension mechanism?
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Is it a flexion mechanism?
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And you're trying to at least get a bit of an idea.
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Now, we know that with rehab sometimes, there's no specific exercise to match a pathology.
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As much as I don't know why we keep trying to teach that you treat a pathology, you treat function, you load, and if the exercise sticks, it's really good.
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As long as you're not missing a red flag.
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If you start loading early and you've missed a fracture, especially like a hook of hammate, or maybe there isn't a fracture of the lunate, you don't want to miss that one because I've seen some horror stories where then people get avascular necrosis off there, and I've seen excisions in young athletes because it's been missed, thinking that it's just a wrist brain.
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Think about the the worst-case scenarios and back work backwards from it rather than go, yeah, everything is a TFCC or a wrist brain unless proven otherwise.
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I prefer going.
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Does this look a worst case scenario?
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Yeah, great.
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There's nothing there in my thing.
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It's a bit like if you have somebody that comes with, are you suspecting codacina of the spine?
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What are your cardinal symptoms?
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Is this one of those?
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No, great.
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At least we've already not missed that one.
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Is this a spondylasthesis?
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No, that's not that one.
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So I use the same analogy really when I'm looking at a hand and wrist injury.
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Is there anything else which is making me overthink?
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Or does it look a very simple representation?
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And that's why I go use function because if somebody has a bad injury, simple things like force protection and range of motion, you're gonna see significant differences.
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Yeah.
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And even if you've missed it and you tried a little trial treatment for a few days, maybe a week, you're not gonna see the improvements you want to.
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So stop, take a little breath and think, what might be going on here?
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Yeah, something worse could be going on that I might have missed as a clinician.
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So that then gives you hopefully the confidence to start moving forward, as you say, with our rehabilitation treatment around function, around their abilities, their or their the gaps, as you you nicely use the word, that gap analysis of where are they now, where do they need to be.
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So with this case, this athlete, what how did you approach this and what did your treatment end up looking like?
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I was remote.
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I wasn't there on sites, and as much as you want to do a lot remotely, what I didn't feel confident is because I think I was gonna have something like six weeks till I got to to India, I didn't want to thank the athlete for failure.
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And I thought because of the type of injury they had, they had a variety of things going in that wrist, which it's a bit like when you get an angry for for an ACL, which tells you you've got a full-tier ACL, and you're thinking, oh, do I go conservative or do I go operative?
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And also the fact I didn't know the athlete, you know, I just met them literally once online.
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I didn't know and because of the long history of this knee, they were not out for over a year with different knee problems, whatever.
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I thought, let's go down the surgical route, which then you know gives us an opportunity then to make sure that the area is stable and we can push from there.
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And I think here's the difference.
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Most uh TFCC repairs, most surgeons would go six weeks, do not move it, keep it stable.
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And again, I say this a lot even on social media.
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I think I love surgeons to bits.
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I think they're amazing in what they do surgically, but they don't have a clue about rehabilitation because they don't do rehabilitation.
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And for decades, for years, physios we have followed them like sheep.
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I don't think we should.
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There should be that free thinking that maybe in certain environments people feel vulnerable, and people have asked me, listen, I'm not sure what to do.
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I don't want to challenge the surgery.
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I said, Well, you're not trying to challenge him, you're trying to educate.
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And so I believe maybe it's because I've done it for many years, decades now in my career.
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I'll push the boundaries.
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What is the boundaries?
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You know, I you're not a cowboy.
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I'm not trying to force things, but you can start moving things earlier.
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There's lots of good evidence that moving earlier is better.
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Why moving things earlier will reduce fear of movement, we'll get that circulation in the area, we'll get the muscles going, means you don't have to start sticking all these complexes and electrodes on people and shocking them because you don't get that uh that atrophy that will hack them from disease.
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And so I start moving things earlier on, so that by six weeks, rather than starting range of motion, I've achieved full range of motion.
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But I've taken my time, I've built it, and so that's the first thing I do, and safely, and using different things, close kinetic chain.
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So, for example, you can use these.
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I don't know if you've ever used them, James, these discs that you can use for your press-ups.
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They rotate and you put them on the floor.
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Yeah, yeah.
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So I put them on a table and I'll get somebody to rotate using some body weight, and that can create some nice pronation supination, a close kinetic chain.
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Yeah, you can put them against a wall and put some weight on them and do the same.
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You can use these flexible, these rubbery ones, let's call them, and even bending them, you can create pronation supination.
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And so, even from a rotation point of view, you can do that.
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And there are various things you can do.
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You can do fingers on a wall, curate loathing.
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As I said earlier, you can use dumbbells, you can use cattle bells, you can use swiss balls, whatever there is.
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There's so many varieties and colors and your terra bands and whatever.
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But as long as I'm not just doing things generic, and let's see how it goes, it's a combination of thinking open chain, closed chain, various movements, combination of isometric to isotonic, short lever, long lever, so even with a hand and wrist closer to the body, further away from the body.
00:20:22.559 --> 00:20:26.079
And when you're doing all that, you're thinking, what sort of loading I'm doing?
00:20:26.240 --> 00:20:27.680
And the easiest thing you can do.
00:20:27.759 --> 00:20:31.359
So if you're a young practitioner and thinking, well, I'm afraid of loading.
00:20:31.599 --> 00:20:32.559
How can I load?
00:20:32.720 --> 00:20:35.359
Well, get that weight-bearing scale again.
00:20:35.519 --> 00:20:38.880
See how much load you can put on the one side, the unaffected.
00:20:39.039 --> 00:20:40.960
What is 100% on the other side?
00:20:41.039 --> 00:20:43.680
Let's just use an easy number, 100 kilos.
00:20:43.759 --> 00:20:46.079
It's probably too much, but let's say 100 kilos.
00:20:46.400 --> 00:20:51.599
You could say, you know what, let me start with 10% of that in the early few days.
00:20:51.759 --> 00:20:53.039
That's 10 kilos.
00:20:53.440 --> 00:20:55.200
Do they have any symptoms doing that?
00:20:55.440 --> 00:20:55.759
No.
00:20:56.240 --> 00:20:58.160
What's the worst you can do with TFCC?
00:20:58.240 --> 00:21:00.960
Or where's the most stress in extension and pronation?
00:21:01.119 --> 00:21:08.960
So put them in a neutral position, put them with the knuckles on the weight bearing scale test, use a cushion so it's a bit soft, also on the knuckles.
00:21:09.200 --> 00:21:15.599
That means that you've started some initial loathing 10% of what they can do out of the max.
00:21:16.000 --> 00:21:18.000
You have no reactions to that, great.
00:21:18.079 --> 00:21:24.960
You've got a baseline, and then you build 20, 30, 40, 50, 60, you keep on going till you get to 100.
00:21:25.200 --> 00:21:37.440
And so objectivity for me becomes really useful because you're it's not the number on its own, it's matching it to somebody's symptoms and bringing it to life as tissue tolerance.
00:21:37.599 --> 00:21:39.119
How much can you tolerate?
00:21:39.279 --> 00:21:48.000
How much forces can you tolerate rather than you just put somebody arbitrary and they go, oh, that's painful, and you don't have a clue how much they're loading.
00:21:48.160 --> 00:21:53.200
So there's lots of different varieties you can do, and that's why I go back to Close Kinetic.
00:21:53.279 --> 00:22:00.480
I like it because you can control things a bit better than swinging weights at the edge of a table, for example.
00:22:00.799 --> 00:22:03.839
Ian, the time has rushed past very quickly.
00:22:04.000 --> 00:22:04.960
Thank you so much.
00:22:05.119 --> 00:22:08.480
And I do recommend obviously, listeners do check out the case study.
00:22:08.559 --> 00:22:12.319
There's a lot more information than we've been able to capture today.
00:22:12.400 --> 00:22:17.680
So, listeners, head on down to the show notes and check out Ian's case study with Physio Network.
00:22:17.839 --> 00:22:18.880
Ian, thank you so much again.
00:22:18.960 --> 00:22:22.000
I'm sure we'll see you on the podcast at some point in the near future.
00:22:22.319 --> 00:22:23.599
Thank you very much, James.
00:22:23.839 --> 00:22:29.759
And guys, just jump on social media if you want, LinkedIn, Instagram, Twitter, the usual.
00:22:29.920 --> 00:22:32.559
You always find me posting things about the Oppulum.
00:22:32.880 --> 00:22:34.400
Absolutely, yep, I can second that.
00:22:34.480 --> 00:22:38.000
Ian puts out some great content, so do check him out on all the socials as well.
00:22:38.160 --> 00:22:39.359
Ian, take care of yourself.
00:22:39.440 --> 00:22:40.319
Have a good evening.
00:22:40.480 --> 00:22:41.359
Thank you.
00:00:02.799 --> 00:00:06.160
Welcome to this episode of Case Studies by Physio Network.
00:00:06.240 --> 00:00:07.519
Today I'm joined by Dr.
00:00:07.599 --> 00:00:12.400
Ian Gatz to discuss a real case of a TFCC injury in a boxer.
00:00:12.640 --> 00:00:20.160
Ian is an experienced sports physiotherapist and upper limb specialist with extensive experience working in elite boxing and Olympic sport.
00:00:20.399 --> 00:00:29.920
His combination of clinical expertise and understanding of the demands placed on the hand and wrist in combat athletes make him an ideal guest to help us unpack this case.
00:00:30.160 --> 00:00:42.159
In today's episode, we explore the TFCC, the differential diagnosis that you may want to consider when assessing ulnocided wrist pain, and how Ian approached the clinical reasoning behind this case.
00:00:42.399 --> 00:00:54.479
We also discuss the framework he uses to link rehabilitation directly to function, helping treatment progress from early stage recovery towards the specific demands of your patients and their sports.
00:00:54.719 --> 00:01:04.879
More broadly, we explore how clinicians can make rehabilitation flow towards returning patients not only to sports but to achieve the activities they personally deem most important.
00:01:05.120 --> 00:01:16.879
And most importantly, Ian shares the key lessons from the case, including how to structure progression, make treatment meaningful, and use clear functional criteria to guide return to activity.
00:01:17.280 --> 00:01:30.239
Ian covers a lot in this case, and today you'll be able to gain lots of new ideas for your rehab and also a confidence in how to treat and assess TFCC injuries.
00:01:30.400 --> 00:01:33.680
I'm James Armstrong and this is Case Studies.
00:01:34.000 --> 00:01:35.760
Ian, thanks so much for joining us.
00:01:35.840 --> 00:01:40.159
It's great to have you back on the podcast today on the Case Studies episode.
00:01:40.560 --> 00:01:42.159
Thanks for having us, James.
00:01:42.480 --> 00:01:50.239
So today we're going to talk listeners through a case on TFCC, which we'll talk about in a second, particularly in a boxer.
00:01:50.400 --> 00:02:01.439
We're going to go through how they presented and the treatment from the assessment and some really good tips for listeners in how they can improve their treatment management of these injuries.
00:02:01.680 --> 00:02:04.560
Let's just cut straight to the TFCC.
00:02:04.799 --> 00:02:06.719
What are we talking about, first of all, Ian?
00:02:08.560 --> 00:02:19.199
Well, it's an interesting part because the the ulnar side of the wrist is usually called like the black box of the wrist because it's got so many different structures.
00:02:19.439 --> 00:02:28.080
And I think when people point to the honor side, it's very easy to think TFCC as being like one structure, one thing.
00:02:28.400 --> 00:02:36.560
First of all, if you're thinking what is TFCC, TFCC is triangular fibrocultilage complex.
00:02:36.719 --> 00:02:39.840
And the last C, the complex, means there are many things.
00:02:40.000 --> 00:02:53.360
You've got the dorsal volar, radioalno ligaments, the ulnolunate, onotrichletal ligaments, you've got the articular disc, the meniscoid, the ulnar cortical ligaments, and then the extensocarpial naris.
00:02:53.520 --> 00:03:00.639
So all together, you've got tendons, ligaments, cartilage, all of those can potentially produce pain.
00:03:00.719 --> 00:03:10.159
And then beyond that, you could have conditions which could be vascular, conditions which could be neurological, you could have fractures, for example, the hemoid fracture.
00:03:10.319 --> 00:03:13.759
In fact, I've posted many times about the differential diagnosis.
00:03:13.840 --> 00:03:21.039
So I think it's just that wariness for people to just go, oh, well, there's pain on the other side, that must be the FCC.
00:03:21.199 --> 00:03:22.639
It's not as simple as that.
00:03:22.800 --> 00:03:33.120
And listening to the history of the person, the type of trauma or non-traumatic, what sort of symptoms are coming, the location of the symptom also.
00:03:33.280 --> 00:03:42.639
Sometimes even when people are pointing, palpating, whether it's upper part, a bit middle, a bit lower part, over the ulnar side, again could be very different.
00:03:42.800 --> 00:03:44.000
In fact, where are we today?
00:03:45.439 --> 00:03:55.520
Posted very recently on social media with a bit like an algorithm of if you had ulnar sided pain, some of the things to do, some of the tests to do.
00:03:55.680 --> 00:04:10.960
And again, even with diagnosis, we know sometimes you could be wrong, but what you don't want to be wrong in is missing red flags, missing things which are require further investigations or even something even more like that, like surgical interventions.
00:04:11.360 --> 00:04:12.479
Brilliant, brilliant.
00:04:12.719 --> 00:04:21.519
So just from you you're talking there, you I can imagine that the TSCC is often probably an area that people are quite afraid of or certainly not that confident with.
00:04:21.600 --> 00:04:26.480
So hopefully we'll go through this case and it might give people a little bit more confidence in what they're looking for.
00:04:26.560 --> 00:04:31.279
And as you say, a complex area that needs some some careful consideration.
00:04:31.519 --> 00:04:39.519
So let's introduce the case in, if you don't mind, starting with the athletes and how they ended up presenting to yourself.
00:04:39.920 --> 00:04:41.519
This was a very interesting case.
00:04:41.680 --> 00:04:48.079
For the listeners, maybe they don't know, but I spent over two decades working in the UK in high-performance sports.
00:04:48.319 --> 00:04:52.079
And recently, let's say 10 months ago, I moved to India.
00:04:52.160 --> 00:04:57.759
And even before coming, this case was presented to me as a high priority athlete.
00:04:58.000 --> 00:05:06.800
And the problem that this athlete had, so this is a boxer, a 29-year-old female boxer, orthodox for those who know a bit distances and boxing.
00:05:06.959 --> 00:05:12.240
And what happened was that they had various knee surgeries.
00:05:12.399 --> 00:05:22.399
They had three surgeries on the same knee, on the left knee, and they were actually doing recovery for a recent meliscectomy on that left knee.
00:05:22.560 --> 00:05:31.439
And what happened was during the period of rehabilitation and trying to do various things, this wrist flared up.
00:05:31.759 --> 00:05:39.839
And through various investigations and various components, we found out that this was a TFCC injury.
00:05:40.000 --> 00:05:46.480
And one of the main two things that I always try and differentiate is between a central tear and a peripheral.
00:05:46.639 --> 00:05:46.800
Why?
00:05:46.879 --> 00:06:00.399
Because peripheral tears, many times what you'll end up doing is requiring repair because they've got a better circulatory location, whereas central tears, you do a debridment, which also means that peripheral tears might need more time.
00:06:00.639 --> 00:06:01.439
The problem came.
00:06:01.519 --> 00:06:04.959
So imagine I'm not even there yet, not yet in India.
00:06:05.279 --> 00:06:16.720
And having to give my advice on this wrist remotely, asking people to take objective measures, asking them how things are going, is this wrist really good or bad.
00:06:16.879 --> 00:06:20.560
We even ended up doing virtual consultations with the athlete.
00:06:21.120 --> 00:06:30.720
And the the thought process was where the knee is now, which was still lacking bits, and we're trying to get this knee back to full swing.
00:06:30.879 --> 00:06:43.600
We felt it would be the right idea to operate the roost now, because if we combine the two together, we've got a better chance of returning the athletes in a better stage earlier rather than later.
00:06:43.839 --> 00:06:53.680
So this actually ended up being like a combo approach of trying to manage holistically the athlete with consideration of not losing time at a later stage.
00:06:53.839 --> 00:07:06.079
One of the biggest components I probably brought to the table was not just only, okay, we go for surgery, happy days, but planning ahead how long it's going to take.
00:07:06.319 --> 00:07:18.399
So thinking about things that sometimes are forgotten in sports for people that are not very comfortable working with athletes, is making a plan of their return back to sport.
00:07:18.560 --> 00:07:32.079
So your macro planning, let's call it so, and then even looking at the stages of mesoplanning, which would be every week, what the athlete would be doing to be able to estimate when they would return.
00:07:32.240 --> 00:07:43.439
And so even before getting there, I'm telling them, listen, based on my calculations, the athlete should be ready by this date and then be able and available by this date.
00:07:43.519 --> 00:07:45.439
And again, I've not even started this role.
00:07:45.519 --> 00:07:51.600
I'm already giving consultations around the cirrhist injury, which nobody had a clue what we're going to do with.
00:07:51.839 --> 00:07:55.439
So when the patient presented you, what sort of assessments might you have done?
00:07:55.600 --> 00:07:58.079
Obviously, the subjective history being really key.
00:07:58.319 --> 00:08:08.399
Are there any other specific assessments that you found in your experience to be more sensitive or specific to allow you to then start looking at what further investigations might be needed?
00:08:08.879 --> 00:08:11.439
Subjectively, functionally, what are they doing?
00:08:11.680 --> 00:08:15.680
Rather than a lot of times we focus on what they can do, but what are they doing?
00:08:15.839 --> 00:08:17.279
Is there a percentage split?
00:08:17.439 --> 00:08:24.319
Is it actually they can do 90% of the activities and we're focusing on a small 10% and it doesn't sound too bad?
00:08:24.480 --> 00:08:35.679
Whereas they tell you, if I take the boxer, they say, Listen, just hitting a water bag, which is a very soft item in boxing, it's painful even with 20% impact.
00:08:35.919 --> 00:08:43.360
And I feel like nervy going down the hand, something like that, it tells you, listen, that's sounds like there's a lot going on there.
00:08:43.600 --> 00:08:51.360
Because of that, I always think, whether it's an athlete or an athlete, I always think about tissue tolerance and forces.
00:08:51.759 --> 00:08:55.679
So, what is the tissue tolerance of somebody to do something?
00:08:55.919 --> 00:09:15.679
And the first thing I try and estimate it by listening to somebody, somebody says, I can live a jug, I can live a big jug of water, two liters, and not have pain, versus somebody that goes, I lift a glass of 200 ml, and literally my wrist feels like I have no power, for example.
00:09:15.840 --> 00:09:22.639
So it's already telling you the difference subjectively that somebody can tolerate a little force, somebody can tolerate a lot of force.
00:09:22.799 --> 00:09:24.399
And then I try and quantify it.
00:09:24.480 --> 00:09:35.840
And the simplest thing to do is things like can use a hand grip dynameter, squeeze, what's the number that gives you, and is there any pain associated, and what's the difference between sides?
00:09:36.000 --> 00:09:43.919
And then because the TFCC, for example, or a lot of structures on the underside tend to be compressive in nature.
00:09:44.159 --> 00:10:04.080
So if you put, for example, a nice test I like to use is a weight-bearing scale test, the thing that we go on to check our weight, put it on a table, put their hand on that weight-bearing scale test, put the weight over it, risk goes into extension, and also there's a bit of pronation, which means you're really compressing those structures.
00:10:04.320 --> 00:10:09.200
And so, what's the number that comes out on the weight-bearing scale test?
00:10:09.360 --> 00:10:10.320
What are the symptoms?
00:10:10.480 --> 00:10:11.279
What's the difference?
00:10:11.440 --> 00:10:16.399
And literally with those two simple tests already, I'm trying to quantify forces.
00:10:16.480 --> 00:10:19.840
And then I'm with I start going a bit more into certain specificities.
00:10:20.000 --> 00:10:24.320
Is there something really somebody says whenever I lift a jug of water, it's painful?
00:10:24.480 --> 00:10:27.279
You can use dumbbells, for example, to quantify that.
00:10:27.360 --> 00:10:35.679
So if I grab a dumbbell and I get them to go from a flexed elbow to extended elbow, one kilo, they're fine, two, three, four, five.
00:10:35.840 --> 00:10:37.759
We get to six kilos on one side.
00:10:37.919 --> 00:10:41.120
On the affected side, one kilo is super painful.
00:10:41.279 --> 00:10:42.799
That's a big tolerance difference.
00:10:42.960 --> 00:10:47.759
Whereas if somebody can do six and six and there's sun pain, it's all right.
00:10:48.000 --> 00:10:51.600
Already selling you, well, you can tolerate quite a bit before it's painful.
00:10:52.000 --> 00:10:53.919
And I'm using all this information.
00:10:54.639 --> 00:11:00.399
One is to understand beyond the pathology, it's more the severity towards function.
00:11:00.559 --> 00:11:10.399
I'm doing a gap analysis using numerical values, and then I'm thinking, is this something I can comfortably manage using a conservative approach to close the gap?
00:11:10.639 --> 00:11:11.919
Or it doesn't look good.
00:11:12.000 --> 00:11:21.840
If somebody comes to us and I've had this for six months, and they're got a 90% difference with lots of pain, it doesn't look good at the moment, the prognosis.
00:11:22.000 --> 00:11:34.080
Whereas if somebody comes to you after six months and you know they've got a 10% difference, you go, all right, can you just run me a bit more through your daily activities, your daily sports to understand?
00:11:34.159 --> 00:11:36.480
Because from what I'm seeing, there's not a lot going on.
00:11:36.720 --> 00:11:46.240
But that's why I said the subjective feeds already, it's telling me already if I'm gonna test what's my sensitivity to what potential is going to be their tissue tolerance?
00:11:46.320 --> 00:11:51.200
Do I really think it's gonna be a very low threshold or it's a high threshold?
00:11:51.519 --> 00:12:02.480
And that really enables me beyond thinking that differential diagnosis, which is already playing in my head, by the way, all the different things it could be from the history, I'm thinking function.
00:12:02.960 --> 00:12:06.720
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00:12:06.960 --> 00:12:19.200
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00:12:19.440 --> 00:12:24.159
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00:12:24.480 --> 00:12:27.840
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00:12:28.159 --> 00:12:38.799
And you mentioned their differential diagnosis, sort of when when this athlete turns up or or when our listeners may have what they suspect from the subjective to be a TFCC involvement.
00:12:39.039 --> 00:12:47.039
What are some of your differentials around the area that you see sometimes people miss or or assume is a TFCC and actually it's something slightly different?
00:12:47.360 --> 00:13:02.799
It's a bit like the terminology we used for the knee, that patternophemoral syndrome and PFP, the old PFP, which is many things, or sometimes even shoulder times we say rotator cuff related shoulder pain, or actually it could be anything.
00:13:03.120 --> 00:13:11.600
It could be a tendon issue, it could be a bone issue, it could be a vascular issue, it could be a neurological issue, it could be the miniscoid cartilage.
00:13:11.759 --> 00:13:15.759
Um, so you have to think about it, could be numerical things.
00:13:16.000 --> 00:13:21.519
What I try and always consider is there anything, first of all, that is a red flag?
00:13:21.679 --> 00:13:22.639
And I mentioned this before.
00:13:22.879 --> 00:13:32.480
Red flag for me, is there any any pins and needles or any pains going down into the digits, particularly that you know that ring finger, that that little finger?
00:13:32.720 --> 00:13:34.080
Where is the pain location?
00:13:34.159 --> 00:13:36.559
Also, is it further up from the wrist?
00:13:36.639 --> 00:13:37.759
Is it more in the hand?
00:13:38.000 --> 00:13:40.320
Is the mechanism of injury and maybe the sport?
00:13:40.399 --> 00:13:49.440
If we think about the sport like racket sports, gymnastic golf, uh is it making me think more fracture of hook of hammit, for example, rather than a TFCC?
00:13:49.679 --> 00:13:59.200
There again, there are certain tests that you can use, X amount of specificity sensitivity as always, but at least you're thinking about those things as you're going along.
00:13:59.360 --> 00:14:04.639
And again, even when I say TFCC, that's why I said it could be the tendon, it could be the ligament, it could be DREJ.
00:14:04.879 --> 00:14:09.840
So just the radial on a joint, really important stabilizer for rotations.
00:14:10.000 --> 00:14:16.159
It could be the lunate with the triquetrium, the little carpal bones, there could be some instability.
00:14:16.559 --> 00:14:19.039
So it's always useful to understand.
00:14:19.200 --> 00:14:20.879
Is this traumatic or non-traumatic?
00:14:21.039 --> 00:14:23.679
If non-traumatic, tell me the history of it.
00:14:23.840 --> 00:14:26.559
If it's been traumatic, do you remember what happened?
00:14:26.720 --> 00:14:28.639
How did it was it an extension mechanism?
00:14:28.799 --> 00:14:30.320
Is it a flexion mechanism?
00:14:30.559 --> 00:14:33.360
And you're trying to at least get a bit of an idea.
00:14:33.679 --> 00:14:39.679
Now, we know that with rehab sometimes, there's no specific exercise to match a pathology.
00:14:40.000 --> 00:14:49.600
As much as I don't know why we keep trying to teach that you treat a pathology, you treat function, you load, and if the exercise sticks, it's really good.
00:14:50.000 --> 00:14:52.320
As long as you're not missing a red flag.
00:14:52.480 --> 00:15:12.000
If you start loading early and you've missed a fracture, especially like a hook of hammate, or maybe there isn't a fracture of the lunate, you don't want to miss that one because I've seen some horror stories where then people get avascular necrosis off there, and I've seen excisions in young athletes because it's been missed, thinking that it's just a wrist brain.
00:15:12.159 --> 00:15:21.600
Think about the the worst-case scenarios and back work backwards from it rather than go, yeah, everything is a TFCC or a wrist brain unless proven otherwise.
00:15:21.759 --> 00:15:22.720
I prefer going.
00:15:23.120 --> 00:15:25.120
Does this look a worst case scenario?
00:15:25.360 --> 00:15:26.320
Yeah, great.
00:15:26.480 --> 00:15:28.799
There's nothing there in my thing.
00:15:28.879 --> 00:15:34.720
It's a bit like if you have somebody that comes with, are you suspecting codacina of the spine?
00:15:34.879 --> 00:15:36.720
What are your cardinal symptoms?
00:15:36.879 --> 00:15:37.919
Is this one of those?
00:15:38.080 --> 00:15:38.879
No, great.
00:15:39.039 --> 00:15:42.000
At least we've already not missed that one.
00:15:42.159 --> 00:15:44.080
Is this a spondylasthesis?
00:15:44.399 --> 00:15:45.759
No, that's not that one.
00:15:45.840 --> 00:15:49.919
So I use the same analogy really when I'm looking at a hand and wrist injury.
00:15:50.159 --> 00:15:53.360
Is there anything else which is making me overthink?
00:15:53.519 --> 00:15:56.000
Or does it look a very simple representation?
00:15:56.159 --> 00:16:06.240
And that's why I go use function because if somebody has a bad injury, simple things like force protection and range of motion, you're gonna see significant differences.
00:16:06.559 --> 00:16:06.799
Yeah.
00:16:07.039 --> 00:16:15.600
And even if you've missed it and you tried a little trial treatment for a few days, maybe a week, you're not gonna see the improvements you want to.
00:16:15.840 --> 00:16:21.120
So stop, take a little breath and think, what might be going on here?
00:16:21.200 --> 00:16:25.360
Yeah, something worse could be going on that I might have missed as a clinician.
00:16:25.600 --> 00:16:39.360
So that then gives you hopefully the confidence to start moving forward, as you say, with our rehabilitation treatment around function, around their abilities, their or their the gaps, as you you nicely use the word, that gap analysis of where are they now, where do they need to be.
00:16:39.600 --> 00:16:44.960
So with this case, this athlete, what how did you approach this and what did your treatment end up looking like?
00:16:45.200 --> 00:16:46.080
I was remote.
00:16:46.240 --> 00:17:01.039
I wasn't there on sites, and as much as you want to do a lot remotely, what I didn't feel confident is because I think I was gonna have something like six weeks till I got to to India, I didn't want to thank the athlete for failure.
00:17:01.360 --> 00:17:16.960
And I thought because of the type of injury they had, they had a variety of things going in that wrist, which it's a bit like when you get an angry for for an ACL, which tells you you've got a full-tier ACL, and you're thinking, oh, do I go conservative or do I go operative?
00:17:17.200 --> 00:17:22.000
And also the fact I didn't know the athlete, you know, I just met them literally once online.
00:17:22.240 --> 00:17:29.200
I didn't know and because of the long history of this knee, they were not out for over a year with different knee problems, whatever.
00:17:29.359 --> 00:17:39.440
I thought, let's go down the surgical route, which then you know gives us an opportunity then to make sure that the area is stable and we can push from there.
00:17:39.680 --> 00:17:41.359
And I think here's the difference.
00:17:41.599 --> 00:17:48.640
Most uh TFCC repairs, most surgeons would go six weeks, do not move it, keep it stable.
00:17:49.839 --> 00:17:54.000
And again, I say this a lot even on social media.
00:17:54.079 --> 00:17:56.079
I think I love surgeons to bits.
00:17:56.240 --> 00:18:03.119
I think they're amazing in what they do surgically, but they don't have a clue about rehabilitation because they don't do rehabilitation.
00:18:03.279 --> 00:18:07.759
And for decades, for years, physios we have followed them like sheep.
00:18:08.160 --> 00:18:09.519
I don't think we should.
00:18:09.680 --> 00:18:16.559
There should be that free thinking that maybe in certain environments people feel vulnerable, and people have asked me, listen, I'm not sure what to do.
00:18:16.640 --> 00:18:17.839
I don't want to challenge the surgery.
00:18:18.000 --> 00:18:21.279
I said, Well, you're not trying to challenge him, you're trying to educate.
00:18:21.440 --> 00:18:26.880
And so I believe maybe it's because I've done it for many years, decades now in my career.
00:18:27.039 --> 00:18:28.079
I'll push the boundaries.
00:18:28.319 --> 00:18:29.200
What is the boundaries?
00:18:29.519 --> 00:18:31.119
You know, I you're not a cowboy.
00:18:31.279 --> 00:18:35.680
I'm not trying to force things, but you can start moving things earlier.
00:18:35.759 --> 00:18:39.279
There's lots of good evidence that moving earlier is better.
00:18:39.440 --> 00:18:55.759
Why moving things earlier will reduce fear of movement, we'll get that circulation in the area, we'll get the muscles going, means you don't have to start sticking all these complexes and electrodes on people and shocking them because you don't get that uh that atrophy that will hack them from disease.
00:18:56.160 --> 00:19:04.160
And so I start moving things earlier on, so that by six weeks, rather than starting range of motion, I've achieved full range of motion.
00:19:04.240 --> 00:19:12.079
But I've taken my time, I've built it, and so that's the first thing I do, and safely, and using different things, close kinetic chain.
00:19:12.240 --> 00:19:14.000
So, for example, you can use these.
00:19:14.160 --> 00:19:19.359
I don't know if you've ever used them, James, these discs that you can use for your press-ups.
00:19:19.519 --> 00:19:21.200
They rotate and you put them on the floor.
00:19:21.279 --> 00:19:21.599
Yeah, yeah.
00:19:21.839 --> 00:19:31.759
So I put them on a table and I'll get somebody to rotate using some body weight, and that can create some nice pronation supination, a close kinetic chain.
00:19:31.839 --> 00:19:35.599
Yeah, you can put them against a wall and put some weight on them and do the same.
00:19:35.839 --> 00:19:43.519
You can use these flexible, these rubbery ones, let's call them, and even bending them, you can create pronation supination.
00:19:43.759 --> 00:19:46.720
And so, even from a rotation point of view, you can do that.
00:19:46.880 --> 00:19:48.559
And there are various things you can do.
00:19:48.720 --> 00:19:51.680
You can do fingers on a wall, curate loathing.
00:19:51.839 --> 00:19:58.240
As I said earlier, you can use dumbbells, you can use cattle bells, you can use swiss balls, whatever there is.
00:19:58.319 --> 00:20:02.400
There's so many varieties and colors and your terra bands and whatever.
00:20:02.640 --> 00:20:22.400
But as long as I'm not just doing things generic, and let's see how it goes, it's a combination of thinking open chain, closed chain, various movements, combination of isometric to isotonic, short lever, long lever, so even with a hand and wrist closer to the body, further away from the body.
00:20:22.559 --> 00:20:26.079
And when you're doing all that, you're thinking, what sort of loading I'm doing?
00:20:26.240 --> 00:20:27.680
And the easiest thing you can do.
00:20:27.759 --> 00:20:31.359
So if you're a young practitioner and thinking, well, I'm afraid of loading.
00:20:31.599 --> 00:20:32.559
How can I load?
00:20:32.720 --> 00:20:35.359
Well, get that weight-bearing scale again.
00:20:35.519 --> 00:20:38.880
See how much load you can put on the one side, the unaffected.
00:20:39.039 --> 00:20:40.960
What is 100% on the other side?
00:20:41.039 --> 00:20:43.680
Let's just use an easy number, 100 kilos.
00:20:43.759 --> 00:20:46.079
It's probably too much, but let's say 100 kilos.
00:20:46.400 --> 00:20:51.599
You could say, you know what, let me start with 10% of that in the early few days.
00:20:51.759 --> 00:20:53.039
That's 10 kilos.
00:20:53.440 --> 00:20:55.200
Do they have any symptoms doing that?
00:20:55.440 --> 00:20:55.759
No.
00:20:56.240 --> 00:20:58.160
What's the worst you can do with TFCC?
00:20:58.240 --> 00:21:00.960
Or where's the most stress in extension and pronation?
00:21:01.119 --> 00:21:08.960
So put them in a neutral position, put them with the knuckles on the weight bearing scale test, use a cushion so it's a bit soft, also on the knuckles.
00:21:09.200 --> 00:21:15.599
That means that you've started some initial loathing 10% of what they can do out of the max.
00:21:16.000 --> 00:21:18.000
You have no reactions to that, great.
00:21:18.079 --> 00:21:24.960
You've got a baseline, and then you build 20, 30, 40, 50, 60, you keep on going till you get to 100.
00:21:25.200 --> 00:21:37.440
And so objectivity for me becomes really useful because you're it's not the number on its own, it's matching it to somebody's symptoms and bringing it to life as tissue tolerance.
00:21:37.599 --> 00:21:39.119
How much can you tolerate?
00:21:39.279 --> 00:21:48.000
How much forces can you tolerate rather than you just put somebody arbitrary and they go, oh, that's painful, and you don't have a clue how much they're loading.
00:21:48.160 --> 00:21:53.200
So there's lots of different varieties you can do, and that's why I go back to Close Kinetic.
00:21:53.279 --> 00:22:00.480
I like it because you can control things a bit better than swinging weights at the edge of a table, for example.
00:22:00.799 --> 00:22:03.839
Ian, the time has rushed past very quickly.
00:22:04.000 --> 00:22:04.960
Thank you so much.
00:22:05.119 --> 00:22:08.480
And I do recommend obviously, listeners do check out the case study.
00:22:08.559 --> 00:22:12.319
There's a lot more information than we've been able to capture today.
00:22:12.400 --> 00:22:17.680
So, listeners, head on down to the show notes and check out Ian's case study with Physio Network.
00:22:17.839 --> 00:22:18.880
Ian, thank you so much again.
00:22:18.960 --> 00:22:22.000
I'm sure we'll see you on the podcast at some point in the near future.
00:22:22.319 --> 00:22:23.599
Thank you very much, James.
00:22:23.839 --> 00:22:29.759
And guys, just jump on social media if you want, LinkedIn, Instagram, Twitter, the usual.
00:22:29.920 --> 00:22:32.559
You always find me posting things about the Oppulum.
00:22:32.880 --> 00:22:34.400
Absolutely, yep, I can second that.
00:22:34.480 --> 00:22:38.000
Ian puts out some great content, so do check him out on all the socials as well.
00:22:38.160 --> 00:22:39.359
Ian, take care of yourself.
00:22:39.440 --> 00:22:40.319
Have a good evening.
00:22:40.480 --> 00:22:41.359
Thank you.
