What is the best treatment approach for ulnar wrist pain in a polo player?

Treatment of Ulnar Wrist Pain in a Polo Horse Player

The optimal treatment for ulnar wrist pain in a polo player should begin with conservative management including immobilization, followed by appropriate imaging if symptoms persist, with surgical intervention reserved for specific cases of instability or persistent symptoms despite conservative measures. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Initial Imaging:

   • Start with plain radiographs of the wrist to evaluate for fractures, alignment issues, or arthritis 2, 1
   • Consider specialized views: posteroanterior in ulnar deviation, pronated oblique views, and comparison with contralateral wrist if needed 1

2. Advanced Imaging (if symptoms persist):

   • MRI is the preferred next study for ulnar-sided wrist pain, particularly for triangular fibrocartilage complex (TFCC) lesions 2, 1
   • 3.0T MRI provides better accuracy than 1.5T systems for TFCC lesions 2
   • MR arthrography may be considered for better visualization of peripheral TFCC attachments or if regular MRI is inconclusive 2, 1
   • CT arthrography is an alternative when MRI is contraindicated or metallic implants would cause significant artifact 2, 1

Treatment Algorithm

Phase 1: Conservative Management (4-6 weeks)

• Rest and Activity Modification:

  • Temporary cessation of polo playing
  • Immobilization with a wrist splint or brace, particularly during sleep and activities 1
  • Avoid gripping and rotational movements that exacerbate symptoms

• Anti-inflammatory Measures:

  • NSAIDs for pain and inflammation control
  • Corticosteroid injections (ultrasound-guided) for persistent inflammatory conditions 1
  • Ice application after activities

• Physical Therapy:

  • Gentle range of motion exercises once acute pain subsides
  • Progressive strengthening of wrist stabilizers
  • Focus on extensor carpi ulnaris (ECU) stabilization exercises

Phase 2: Advanced Interventions (if conservative treatment fails)

• Targeted Injections:

  • Ultrasound-guided corticosteroid injections for specific structures (TFCC, ECU tendon sheath)
  • Consider platelet-rich plasma injections for tendinopathy

• Surgical Intervention (for specific indications):

  • Arthroscopic debridement or repair of TFCC tears
  • Repair of ligamentous injuries
  • Stabilization of the distal radioulnar joint
  • Surgical exploration for suspected erosion of the sixth dorsal compartment floor 3

Return to Polo Playing

• Gradual Return Protocol:

  • Modified grip techniques on polo mallet
  • Protective taping or bracing during play
  • Equipment modifications (grip size, material)
  • Progressive increase in duration and intensity of play 1

• Maintenance Program:

  • Ongoing wrist strengthening exercises
  • Proper warm-up before play
  • Technique modifications to reduce ulnar-sided stress

Special Considerations for Polo Players

Polo players are particularly susceptible to ulnar-sided wrist pain due to:

1. Biomechanical Factors:

   • Repetitive pronosupination during mallet swinging 4
   • Forceful gripping during play
   • Impact forces transmitted through the wrist during ball striking

2. Common Pathologies:

   • TFCC tears from rotational forces
   • ECU tendinitis or subluxation
   • Lunotriquetral ligament injuries
   • Distal radioulnar joint instability

Pitfalls and Caveats

• Avoid Premature Return to Play: Returning to polo before adequate healing can lead to chronic instability and persistent pain
• Don't Overlook Extensor Carpi Ulnaris Subluxation: This is a common cause of ulnar wrist pain in athletes that requires specific treatment 4
• Consider Erosion of Sixth Dorsal Compartment: This uncommon but significant cause of ulnar wrist pain should be suspected when severe pain persists despite usual treatment methods 3
• Avoid Unnecessary Repeat Imaging: Additional imaging should only be performed if it will change management 1
• Don't Neglect Grip Modification: Changing grip technique and equipment can be as important as medical interventions for long-term success

By following this structured approach to diagnosis and treatment, most polo players with ulnar wrist pain can achieve pain relief and return to their sport at pre-injury levels.