What Does Post-Surgical TFCC Rehab Look Like?

If someone walks into your clinic with ulnar-sided wrist pain, the Triangular Fibrocartilage Complex (TFCC) is probably somewhere on your differential list.

Yet despite being a common source of wrist pain, the TFCC is often one of those structures we don’t think much about until we’re faced with a patient who isn’t improving. It can be difficult to diagnose clinically, imaging findings aren’t always straightforward, and deciding whether someone needs surgery can be equally challenging.

When is conservative management enough? When should surgery be considered? And if surgery is the best option, what does rehabilitation actually look like?

These are exactly the questions Dr Ian Gatt explores in his Case Study. This blog draws on some of the key clinical takeaways to get physios TFCC-ready.

If you want to see exactly how an expert rehabilitates a post-surgical TFCC patient, watch Dr Ian Gatt’s full Case Study here.

TFCC anatomy refresher

The TFCC is much more than just a triangular piece of fibrocartilage. It’s a collection of structures that work together to stabilise the ulnar side of the wrist.

It includes:

• The dorsal and volar radioulnar ligaments
• The triangular fibrocartilage disc (the avascular articular disc)
• The meniscus homologue (ulnocarpal meniscoid): vascularised connective tissue between the ulnar styloid and triquetrum
• The ulnolunate and ulnotriquetral ligaments
• The ulnar collateral ligament connecting the ulnar styloid to the triquetrum
• The extensor carpi ulnaris tendon sheath, which contributes important dorsal stability

Together, these structures absorb load across the wrist, stabilise the distal radioulnar joint and allow smooth forearm rotation.

The case

The patient was a 29-year-old elite female welterweight boxer who had also undergone previous meniscal surgery.

As she returned to training, exercises such as SkiErg work and striking drills gradually triggered pain on the ulnar side of her dominant wrist. Four months later, despite treatment and reducing sport-specific training, her symptoms hadn’t settled.

MRI revealed a fairly extensive injury, including:

• A Palmer 1B peripheral tear (ulnar avulsion)
• A Palmer 1D tear (radial avulsion)
• Tendinopathic changes
• Bone marrow oedema involving the lunate, triquetrum and distal ulna

Treatment decisions

A really valuable part of Ian’s Case Study is that he talks us through his clinical reasoning for surgical decision-making.

The athlete had already spent several months away from sport-specific loading without meaningful improvement. Imaging suggested a repair would be more appropriate than a straightforward debridement, and she was already rehabilitating her knee following surgery, so rather than viewing the knee as another problem, it created an opportunity to combine rehabilitation timelines and minimise the total time away from competition.

See Ian talk through surgical considerations in this clip from his Case Study:

Post-surgical rehab

Following surgery, the initial priority is protecting the repair, so there’s typically a period of immobilisation for at least the first two weeks, depending on the surgeon’s protocol.

See Ian describe his rehab protocol in this snippet from his Case Study:

So how does he achieve this?

By combining objectively quantified loading with more qualitative loading strategies.

I’ve listed just some of the many of strategies he demonstrates:

• Gradually progressing weight bearing through the hand, quantified using weight-bearing scales
• Isometric loading with handheld dynamometry to quantify pushing and pulling capacity
• Closed kinetic chain loading (wall exercises, four-point kneeling and similar positions)
• Open kinetic chain strengthening using resistance bands and free weights

As loading tolerance improves, rehabilitation becomes increasingly sport-specific.

Ian commonly uses FlexBars to progressively challenge forearm rotation, while vibration through the FlexBar and impact tasks such as striking a tyre help reintroduce the mechanical demands required for returning to boxing.

Ian also discusses where adjunctive treatments may fit. While he doesn’t routinely reach for acupuncture, he may use manual therapy or shockwave therapy if they provide an opportunity for pain relief while continuing to progressively load the wrist. Providing adjunctive therapies also gives Ian the opportunity to check in with the athlete, discuss their experiences and monitor progress. So while these strategies aren’t necessarily healing the injury, they still have their place within the broader rehab program.

Wrapping up

Persistent TFCC injuries can be debilitating for athletes, and rehabilitation needs to go beyond simply strengthening the wrist. It should progressively prepare the athlete to tolerate the wide range of forces, positions and impact demands they’ll encounter when they return to sport.

While Ian’s case focuses on post-surgical rehabilitation, many of the principles translate well to conservative management too.

If you’d like to see exactly how Ian structures each phase of rehabilitation, progresses loading and plans the athlete’s return to boxing, watch his full Case Study here.