A Pictorial Review Of Wrist Injuries In The Elite Golfer (End)
Radial Sided Injury
De Quervain’s Tendonitis
De Quervain’s tendonitis has been reported as the leading cause of radial sided pain in the leading wrist in elite golfers, the severity of symptoms tend not to be as severe as ECU tendonitis . Finkelstein’s test is pathognomonic in making the diagnosis: the patient flexes the thumb into the palm while the examiner ulnarly deviates the wrist producing the patient’s symptoms. It is an overuse phenomenon which causes retinacular friction in the first extensor compartment of the wrist.
Although considered a single compartment the first extensor compartment can be divided by a septum which seperates the abductor pollicis longus (APL) and extensor pollic brevis (EPB) tendons. The incidence of this ‘double tunnel’ varies from 24% to 77.5% in cadaver studies. The US appearances of the septum in patients with de Quervain’s disease are described as by hypoechoic structure between APL and EPB tendons. Several studies have noted that the presence of a septum splitting the first extensor compartment into two subcompartments was more frequent in patients with de Quervain’s disease, this supports the claim that this anatomic variation is involved in the pathogenesis of de Quervain’s disease. The septum may be a cause of overcrowding in the fibroosseous tunnel and may predispose to local tendon friction, especially in the EPB tendon subcompartment. Recognition of this septum plays a role in the nonsurgical management of de Quervain’s disease. Injection into only one subcompartment is a well-known cause of unsuccessful blind injection of steroids. Sawaizumi et al., found that the outcome and the efficacy rate of local steroid injections increased to 100% when the two sites (APL and EPB tendons) were injected. US typically demonstrates hypoechoic tendinopathic changes with associated thickening and fibrosis of the tendon sheath which is seen as a low reflectivity, hypervascular halo around the tendon.
In stenosing de Quervain’s tenosynovitis, the APL and EPB tendons become painful and swollen. The tendon sheath is thickened, with the greatest thickening being over the styloid process. Here it may be three to four times the normal thickness of 3 to 4 millimetres. The sheath takes on a cartilaginous consistency. Filmy adhesions seen at surgery are usually present around and between the tendons.
The injury patterns and range of pathologies of elite golfers differ markedly from non professionals. Anatomical classification is a useful mechanism to narrow the differential. A working knowledge of the complex swing mechanics along with precise history taking and deft examination is essential in formulating a diagnosis and requesting the correct radiological test.