How is mild ECU tenosynovitis and tendinosis treated?

Treatment of Mild ECU Tenosynovitis and Tendinosis

Initial conservative treatment with NSAIDs, rest, activity modification, and physical therapy should be the first-line approach for mild extensor carpi ulnaris (ECU) tenosynovitis and tendinosis. 1

Conservative Management Algorithm

First-Line Treatment

• Medications:

  • NSAIDs: Ibuprofen 400mg every 4-6 hours as needed for pain, not exceeding 3200mg daily 2
  • Take with meals or milk to reduce gastrointestinal side effects 2
  • Use the lowest effective dose for the shortest duration consistent with symptom control 2

• Initial Rest and Protection:

  • RICE protocol (Rest, Ice, Compression, Elevation) to manage pain and inflammation 3
  • Wrist splinting in neutral position to immobilize the ECU tendon and reduce irritation 1
  • Avoid activities that aggravate symptoms, particularly those involving repetitive wrist motion 1

Physical Therapy (4-8 weeks)

• Progressive Rehabilitation Program:

  • Begin with protected range of motion exercises (0-4 weeks) 3
  • Progress to eccentric strengthening exercises (4-8 weeks) 3, 4
  • Include proprioception training and coordination exercises 3
  • Gradually incorporate sport-specific or occupation-specific training (8-12 weeks) 3

• Specific Exercises:

  • Gentle wrist extension/flexion exercises
  • Progressive resistance training for wrist stabilizers
  • Forearm pronation/supination exercises
  • Grip strengthening activities

Second-Line Treatments

If symptoms persist after 4-6 weeks of conservative management:

• Corticosteroid Injections:

  • Limited to 2-3 injections with 4-6 weeks between injections 3
  • Note: May provide short-term relief but long-term effectiveness is questionable 4

• Alternative Therapies to Consider:

  • Sclerotherapy 4
  • Nitric oxide patches 4
  • Ultrasound-guided therapy (limited evidence) 3

Surgical Intervention

Consider surgical consultation if:

• Pain persists despite 3-6 months of well-managed conservative treatment 3
• Functional limitations significantly impact quality of life 3
• Evidence of progressive tendon degeneration on follow-up imaging 3

Surgical options may include:

• ECU subsheath release 5
• Tendon repair or reconstruction for severe cases 6
• Ultrasound-guided retinaculum release (newer technique with promising results) 5

Return to Activity Criteria

Return to full activity is permitted when the patient demonstrates:

• Complete resolution of pain during and after activity 3
• Full range of motion compared to uninjured side 3
• Strength symmetry >90% compared to uninjured side 3
• Successful completion of sport-specific functional tests 3

Important Considerations

• ECU tendinopathy is common in athletes who play racquet sports and golf due to repetitive wrist motion 1, 7
• Associated conditions like triangular fibrocartilage complex tears or lunotriquetral ligament tears may coexist and require evaluation 6
• Anatomical factors (flat ECU groove, anomalous tendon slips) may predispose to ECU problems 6
• Chronic cases may require more aggressive intervention, as demonstrated in a case report where a patient with 3 years of failed treatments benefited from ultrasound-guided retinaculum release 5

Monitoring and Follow-up

• Regular reassessment of pain levels, wrist function, and grip strength
• Modification of treatment plan if inadequate progress after 4-6 weeks
• Imaging (MRI or ultrasound) for persistent or worsening symptoms to evaluate for tendon tears or other complications