What is the treatment for ulnar tendonitis?

Treatment of Ulnar Tendonitis

Begin with 3-6 months of conservative management including relative rest, NSAIDs, cryotherapy, and eccentric strengthening exercises before considering any invasive interventions. 1

Initial Conservative Treatment (First-Line for 3-6 Months)

Relative Rest and Activity Modification

• Reduce repetitive strain on the damaged tendon while maintaining some activity to prevent muscle atrophy 1
• Avoid complete immobilization as it leads to muscular atrophy and deconditioning 1, 2
• For athletes in stick and racquet sports (common causes of extensor carpi ulnaris tendinopathy), modify technique to minimize repetitive wrist motion and axial loading 3

Pain Management

• NSAIDs (oral or topical) are recommended for short-term pain relief, though they do not affect long-term outcomes 1, 4
• Topical NSAIDs are preferable due to fewer systemic side effects, particularly elimination of gastrointestinal hemorrhage risk 1, 4
• Cryotherapy through a wet towel for 10-minute periods provides effective acute pain relief 1, 4

Rehabilitation

• Eccentric strengthening exercises are the cornerstone of treatment and can reverse degenerative changes in the tendon 1, 5
• Physical or occupational therapy should include therapeutic exercise, splinting, manual therapy, and modalities 3
• Deep friction massage may provide additional benefit 6

Secondary Treatment Options (If Initial Measures Insufficient)

Corticosteroid Injections

• May be more effective than oral NSAIDs for pain relief in the acute phase, but do not improve long-term outcomes 6, 1
• Critical pitfall: Avoid direct injection into the tendon substance as this inhibits healing, reduces tensile strength, and may predispose to rupture 1, 2, 4
• Consider for short-term relief only, not as definitive treatment 5

Advanced Conservative Options

• Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathies, though costly 1, 4
• Ultrasonotherapy may decrease pain and increase collagen synthesis, though evidence is limited 1
• Splinting combined with steroid injection has been used successfully in extensor carpi ulnaris tenosynovitis 7

Surgical Management

Indications

• Surgery is justified only if pain persists despite 3-6 months of well-managed conservative treatment 1, 2
• Early surgical intervention may be warranted if preoperative imaging reveals bone involvement or partial tendon rupture 7

Surgical Techniques

• Excision of abnormal tendinous tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
• For extensor carpi ulnaris with subsheath damage, reconstruction using extensor retinaculum may be necessary 8
• If concurrent triangular fibrocartilage complex (TFCC) injury is present (common in athletes with forceful wrist rotation), combined repair may be required 8

Expected Outcomes and Prognosis

• Approximately 80% of patients with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment 1
• In one series of extensor carpi ulnaris tenosynovitis, 7 of 15 patients (47%) required surgical release after conservative treatment failure 7
• Athletes can successfully return to play with combined medical management and rehabilitation 3

Critical Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance 1, 2
• Avoid multiple corticosteroid injections as they may weaken tendon structure despite short-term symptom relief 2
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1, 2
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 4
• Early intervention may prevent tendon damage in some patients with extensor carpi ulnaris involvement 7