What could be the cause of intense pain on the left wrist near the pinky side after twisting it during pickleball, given a history of a previous torn ligament or tendon in the same area?

Ulnar-Sided Wrist Pain After Pickleball Injury

Based on the symptoms described, this is most likely a triangular fibrocartilage complex (TFCC) tear or ulnar collateral ligament injury, and plain radiographs (X-rays) should be obtained first, followed by MRI if X-rays are normal but symptoms persist. 1

Likely Diagnosis

The pain on the ulnar (pinky) side of the wrist that worsens with rotational movements like "screwing in a light bulb" is highly characteristic of a TFCC injury. Given the patient's:

• History of previous ligament/tendon injury in the same area
• Mechanism of injury (twisting during pickleball)
• Location of pain (ulnar side of wrist)
• Pain with rotational movements

These findings strongly suggest a TFCC tear or injury to the ulnar collateral ligament complex.

Diagnostic Approach

1. Initial Imaging: Plain Radiographs (X-rays)

   • Standard 3-view wrist series (PA, lateral, and oblique views) 1
   • Purpose: Rule out fractures, assess for ulnar variance, and detect any bony abnormalities
   • Note: Normal X-rays do not rule out ligamentous injury 1

2. Secondary Imaging: MRI without contrast

   • Indicated if X-rays are normal but symptoms persist
   • High sensitivity for detecting TFCC tears and other soft tissue injuries 1
   • Can identify concomitant injuries that may be missed on other imaging modalities

3. Alternative: Ultrasound

   • Can be performed dynamically to assess instability
   • Moderate agreement with MRI for diagnosing tendon tears (sensitivity 64.52%, specificity 85.19%) 1
   • Advantage: Can be performed during provocative maneuvers

Initial Management

1. RICE Protocol

   • Rest: Avoid activities that cause pain, especially rotational movements
   • Ice: Apply for 15-20 minutes several times daily
   • Compression: Use a compressive wrap or brace
   • Elevation: Keep the wrist elevated when possible 1

2. Immobilization

   • Wrist splint or brace to prevent painful movements 1
   • Duration: Typically 3-4 weeks for partial tears

3. Pain Management

   • NSAIDs for short-term pain relief 1
   • Consider acetaminophen if NSAIDs are contraindicated

Follow-up Care

• Gradual introduction of gentle range of motion exercises after the acute phase 1
• Progressive strengthening exercises focusing on wrist extensors 1
• Sport-specific rehabilitation before returning to pickleball

When to Consider Surgical Referral

Refer to a hand specialist if:

• Symptoms persist despite 3-6 months of conservative management
• MRI shows complete TFCC tear with instability
• Patient has high functional demands (competitive athlete) 1

Important Considerations

• Previous injury increases the risk of re-injury and may complicate healing 1
• Avoid early aggressive activity which can worsen the injury
• Age-related factors may play a role (degenerative TFCC tears are more common in patients over 40) 1
• Proper technique modification for pickleball is essential to prevent recurrence 1