What is the initial treatment for ulnar impingement?

Initial Treatment for Ulnar Impingement

The initial treatment for ulnar impingement syndrome should focus on conservative measures including rest, activity modification, NSAIDs, and splinting before considering surgical options. 1, 2

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Imaging studies:

   • Radiography is the appropriate initial imaging modality for acute elbow or forearm pain 3
   • Advanced imaging may be considered if radiographs are normal or nonspecific:
     • MRI without IV contrast or ultrasound for suspected soft tissue injuries 3
     • CT without IV contrast for suspected bony abnormalities 3

2. Clinical presentation:

   • Ulnar-sided wrist pain exacerbated by activity
   • Pain with ulnar deviation and axial loading
   • Limited range of motion
   • Symptoms that do not improve with rest 2

Conservative Management Algorithm

First-line Treatment (0-6 weeks)

1. Rest and activity modification:

   • Avoid activities that cause impaction (ulnar deviation with axial loading)
   • Relative rest rather than complete immobilization 4

2. Pain management:

   • NSAIDs at the lowest effective dose for the shortest duration possible 4
   • Ice application for 15-20 minutes several times daily 4

3. Splinting:

   • Night splinting to maintain neutral wrist position 4, 5
   • Functional bracing during activities 4

Second-line Treatment (6-12 weeks)

If symptoms persist after 6 weeks of first-line treatment:

1. Corticosteroid injection:

   • Consider local steroid injection using aseptic technique 4
   • Limit to 1-2 injections to avoid potential tissue damage 4
   • Diabetic patients should be informed about the risk of transient hyperglycemia (1-3 days) 4

2. Physical therapy:

   • Eccentric strengthening exercises for forearm muscles 4
   • Manual therapy combined with exercise therapy 4
   • Nerve gliding exercises may provide additional benefit 6

Surgical Considerations

If conservative measures fail after 3-6 months:

1. Surgical options include:

   • Arthroscopic triangular fibrocartilage complex debridement 2
   • Arthroscopic ulnar wafer resection 2
   • Ulnar shortening osteotomy 1

2. Advantages of arthroscopic approach:

   • Single-stage, minimally invasive approach
   • Similar efficacy with fewer complications than open procedures 2

Prevention and Rehabilitation

1. Technique modification for athletes and manual laborers to minimize repetitive stress 4
2. Equipment adjustments (larger grips, ergonomic tools) to reduce stress on the wrist 4
3. Strength and flexibility program focusing on forearm muscles 4

Important Considerations and Pitfalls

• Failure to recognize structural abnormalities (distal radioulnar joint incongruity, distal radius malunion) may lead to treatment failure 1
• Malunion of the distal radius resulting in ulnar impaction syndrome is best treated by corrective radial osteotomy rather than just addressing the ulnar impaction 1
• The presence of relative instability of the ulnar ligamentous complex may necessitate specific surgical approaches 1
• Avoid overuse of injected joints for 24 hours following intra-articular therapy 4

By following this structured approach to treatment, most patients with ulnar impingement syndrome can achieve significant symptom relief and improved function.