The FCU tendon inserts primarily on the pisiform, using it as a sesamoid to redirect force to the hamate (via pisohamate ligament) and fifth metacarpal (via pisometacarpal ligament). The FCU's ulnar location makes it the primary ulnar deviator working synergistically with the ECRL during wrist radial and ulnar deviation control. FCU tendinopathy produces ulnar wrist pain at the pisiform insertion.
Wrist flexion and ulnar deviation; pisiform mobilisation as a sesamoid
FCU tendinopathy at the pisiform produces ulnar wrist pain reproduced by direct pisiform palpation and resisted wrist flexion-ulnar deviation. It is distinguished from pisotriquetral arthritis by the Shear test (pisiform shear against the triquetrum). Ultrasound confirms tendon signal change at the pisiform insertion. Conservative management with eccentric loading and injection resolves most cases.
FCU insertion tendinopathy producing ulnar wrist pain managed with eccentric loading and ultrasound-guided injection.
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