How should I manage a patient with extensor carpi ulnaris (ECU) tendon subluxation and a small tear of the ECU tendon plus a small tear of the scapholunate ligament?

Treatment of ECU Tendon Subluxation with Small Tears and Scapholunate Ligament Injury

Begin with 3-6 months of conservative management including activity modification, eccentric strengthening exercises, and NSAIDs for pain control, as approximately 80% of overuse tendinopathies recover fully with this approach. 1, 2

Initial Conservative Treatment Protocol

Activity Modification and Relative Rest

• Reduce or eliminate activities that provoke wrist pain while maintaining activities that don't worsen symptoms to prevent ongoing tendon damage 1, 2
• Avoid complete immobilization, as prolonged immobilization (beyond 1 week) compromises up-regulation of repair genes and hampers the healing process 3
• Continue non-provocative activities to prevent muscle atrophy and deconditioning 2, 4

Eccentric Strengthening Exercises

• Implement eccentric strengthening exercises as the cornerstone of treatment, which stimulate collagen production and guide normal alignment of newly formed collagen fibers 1, 2
• These exercises are the gold standard for tendinopathy treatment and can reverse degenerative changes 2, 4
• Begin exercises after the first week to avoid the detrimental effects of prolonged immobilization 3

Pain Management

• Use NSAIDs (oral or topical) for short-term pain relief only, recognizing they provide acute symptom control but do not affect long-term healing outcomes 1, 2, 4
• Topical NSAIDs have fewer systemic side effects compared to oral formulations 2
• Apply cryotherapy (ice through a wet towel for 10-minute periods) for acute pain relief, which reduces tissue metabolism and may blunt inflammatory response 1, 2, 5

Wrist Support and Positioning

• Consider wrist splinting or bracing to reduce tension on the ECU tendon during the healing process 5
• Use open-backed or modified wrist supports that reduce pressure on the affected area 2

Critical Treatment Pitfalls to Avoid

Corticosteroid Injections

• Never inject corticosteroids directly into the tendon substance, as this inhibits healing, reduces tensile strength, and may predispose to spontaneous tendon rupture 1, 2, 4
• If corticosteroid injection is considered for pain relief, peritendinous injections are preferred over intratendinous injections, and should be used with extreme caution 5

Immobilization Duration

• Avoid immobilization beyond 1 week, as prolonged immobilization compromises up-regulation of repair genes (BDNF, bFGF, COX 1, HIF-1alpha) and hampers the healing process 3
• Studies demonstrate that mobilized tendons show significantly increased mRNA levels for repair molecules by day 17, while immobilized tendons show decreased levels 3

Premature Surgical Intervention

• Do not proceed to surgery without an adequate 3-6 month trial of well-managed conservative treatment 2, 5, 4
• Surgery should only be considered after documented failure of comprehensive conservative management 2, 5

Expected Recovery Timeline

• Most patients achieve full recovery within 3-6 months with appropriate conservative treatment, with approximately 80% recovering in this timeframe 1, 2, 4
• Continue conservative treatments until symptoms resolve if improvement is occurring 2
• Consider referral to a hand specialist if no improvement occurs after 6-8 weeks of conservative treatment 2

Surgical Considerations

Reserve surgical repair for patients who fail 3-6 months of comprehensive conservative treatment, as this represents the evidence-based threshold for considering operative intervention 2, 5, 4

• Surgical options may include ECU subsheath reconstruction for persistent subluxation and repair of the scapholunate ligament if instability is documented
• Early surgical repair after acute injury may be considered in high-demand patients, though the evidence for this approach in wrist tendon injuries is limited 1

Important Clinical Considerations

• Label this condition as "tendinopathy" or "tendinosis" rather than "tendonitis" to reflect its chronic degenerative nature, which underscores that anti-inflammatory medications offer only temporary symptom relief 1, 2
• The scapholunate ligament tear requires assessment for carpal instability, though small tears may heal with conservative management similar to the tendon injury 1
• Assess for biomechanical factors contributing to ECU pathology, including wrist positioning during activities and repetitive loading patterns 2