What causes volar wrist pain with a palpable cord-like structure on the ulnar side and how should it be evaluated and managed?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 26, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Volar Ulnar-Sided Wrist Pain with Palpable Cord

The palpable cord-like structure on the volar ulnar side of the wrist is most likely the flexor carpi ulnaris (FCU) tendon, and tenderness here suggests either FCU tendonitis or pisotriquetral pathology. 1

Differential Diagnosis

The volar ulnar location with a palpable cord narrows the differential to specific anatomic structures:

  • Flexor carpi ulnaris tendonitis is a common cause of volar ulnar wrist pain, with the FCU tendon being the palpable cord-like structure that runs along the ulnar volar aspect of the wrist. 1

  • Pisotriquetral arthritis presents with pain and tenderness on the palmar and ulnar aspects of the wrist in the area of the pisiform bone, which lies within the FCU tendon as a sesamoid bone. 2 This is the second most common degenerative arthritis in the wrist after scaphotrapezial osteoarthritis. 2

  • Ulnotriquetral ligament injury can produce volar ulnar pain, though this typically presents with the "ulnar fovea sign" (tenderness between the ulnar styloid and FCU tendon, just distal to the ulnar head). 3 The ulnar fovea sign has 95.2% sensitivity and 86.5% specificity for detecting foveal disruptions and ulnotriquetral ligament tears. 3

Physical Examination Findings

Key examination maneuvers to differentiate these conditions:

  • Direct palpation of the FCU tendon along its course will reproduce pain in FCU tendonitis. 1

  • Pisiform compression and grind test will elicit pain specifically in pisotriquetral arthritis. 1

  • Ulnar fovea sign (pressing distally into the interval between the ulnar styloid and FCU tendon, between the volar ulnar head and pisiform) that replicates the patient's exact pain suggests ulnotriquetral ligament injury or foveal disruption. 3

  • Assess DRUJ stability to differentiate between isolated ulnotriquetral ligament tears (stable DRUJ) versus foveal disruptions (unstable DRUJ). 3

Diagnostic Imaging Algorithm

Obtain three-view wrist radiographs immediately (posteroanterior, lateral, and 45-degree semipronated oblique) to exclude fractures and assess for pisotriquetral arthritis or ulnar variance. 4, 5

If radiographs are normal or equivocal but clinical suspicion remains high:

  • Proceed with 3.0T MRI without contrast as the next appropriate imaging study, which accurately depicts the TFCC, intrinsic and extrinsic ligaments, DRUJ stability, and tendon pathology including FCU tendonitis. 4

  • 3.0T MRI provides greater accuracy than 1.5T systems for detecting ulnocarpal pathology and TFCC lesions. 5

  • Do not routinely use intravenous contrast for mechanical conditions like FCU tendonitis or pisotriquetral arthritis; reserve contrast-enhanced MRI for suspected inflammatory arthritis or infection. 5

  • Ultrasound by an experienced operator can directly visualize FCU tendon pathology and provide a bedside diagnostic alternative. 4

Initial Conservative Management

Immobilization Phase (Weeks 0-4)

Immobilize the wrist in a custom-fitted splint maintaining neutral wrist alignment and neutral forearm rotation for at least 4 weeks. 4, 5 Continuous splint wear is critical for successful conservative management. 5

Mobilization Phase (Weeks 4-8)

Begin gentle active wrist motion only after completing the 4-week immobilization period. 4, 5 Premature mobilization is a predictor of poor outcomes and leads to persistent symptoms. 5

Strengthening Phase (Weeks 8-12)

Introduce strengthening exercises between weeks 8 and 12 to support recovery of wrist function. 4, 5

Return to Activity

Resume heavy tasks and sports no sooner than 3 months from treatment initiation, provided all phases are completed without persistent symptoms. 5

Surgical Considerations

For pisotriquetral arthritis refractory to conservative treatment:

  • Subperiosteal excision of the pisiform is the standard surgical approach after unsuccessful non-operative treatment. 2 However, the pisiform mechanically contributes to ulnar column stability by holding the triquetrum in correct position and acting as a fulcrum for transducing forearm forces to the hand. 2

For ulnotriquetral ligament tears or foveal disruptions:

  • Arthroscopy remains the gold standard for definitive diagnosis and can provide both diagnosis and treatment in the same procedure. 4

  • Arthroscopic foveal repair with suture anchor for peripheral TFCC tears with foveal detachment restores anatomic attachment critical for DRUJ stability. 4

Common Pitfalls

  • Do not dismiss volar ulnar pain as simple tendonitis without excluding pisotriquetral arthritis or ulnotriquetral ligament injury through proper examination and imaging. 1, 3

  • Failure to complete the full 4-week immobilization period is associated with treatment failure. 5

  • Do not rely on two-view radiography alone, as three views are essential for adequate wrist evaluation. 4

References

2
Research

Mechanical strain at the pisotriquetral joint.

Clinical anatomy (New York, N.Y.), 1998

4
Guideline

Confirming TFCC Injury

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Guideline

Imaging and Initial Conservative Management of Ulnocarpal Abutment Syndrome

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Related Questions

What are the possible causes and diagnostic approaches for finger swelling at the ulnar side, considering conditions like rheumatoid arthritis or gout?
What is the next best step for a patient with a Fall On Outstretched Hand (FOOSH) injury resulting in ulnar-sided wrist pain, particularly at the base of the 5th metacarpal bone dorsally, with limited wrist range of motion (ROM) and a normal X-ray?
What is the best course of management for a patient with sudden onset pisiform area pain, no history of trauma, that worsens with splint use and immobilization?
What condition causes ulnar‑side wrist pain with limited supination of the hand?
What is the diagnosis and treatment for medial wrist pain?
How should I manage a 7‑month‑old infant with suspected onychomycosis of the toenail?
What laboratory studies and evaluations are recommended for low serum albumin, and how should it be managed?
What does a pleural friction rub that intensifies with deep inspiration indicate, and how should it be evaluated and managed?
Does Coumadin (warfarin) come in a 1.25 mg tablet, and for an 81‑year‑old man with prior cerebrovascular accident (CVA), atrial fibrillation (AF), and remote deep‑vein thrombosis (DVT) who is taking 1 mg daily with an INR that fell from 2.9 to 1.9, how should the dose be adjusted?
How should metabolic acidosis be evaluated and managed?
As a healthy adult experiencing nighttime ear popping with decreased hearing, what is the likely cause and recommended management?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question