By Marc Darrow, MD, JD
A physical therapist describes a frustrating problem: persistent pain on the little-finger side of the left wrist after overuse. MRI shows degenerative changes in the triangular fibrocartilage complex, arthritis in the pisotriquetral joint, and a cyst in the triquetrum. The hand surgeon thinks the TFCC looks relatively good and suspects the cyst is responsible for most of the pain.
After five months of occupational therapy and strengthening, grip strength is good. Nevertheless, movements away from neutral remain painful. Even a rigid brace does not prevent pain when pressure is applied through the fingers. For someone who needs their hands to treat patients, that remaining limitation is substantial.
My first question would be: which structure reproduces the pain that limits your work? The MRI offers several possibilities. It does not, by itself, establish which one needs treatment. Nor does strong grip establish that the wrist can tolerate sustained pressure during hands-on care.
Three MRI findings, three different treatment questions
“Ulnar-sided” means the little-finger side of the wrist. Several small structures occupy this area, and their symptoms can overlap. A 2025 clinical review emphasizes a systematic assessment because this pain may have more than one source. (1)
| MRI finding | What it describes | The question that matters |
|---|---|---|
| TFCC degeneration | Changes in the fibrocartilage and supporting complex near the end of the ulna | Does the finding match symptoms and examination, and is there clinically important instability? |
| Pisotriquetral arthritis | Arthritis between the pisiform, the small bone on the palm side, and the triquetrum beneath it | Does examination of this joint reproduce the familiar pain? |
| Cyst in the triquetrum | A cystic area within a wrist bone | What kind of lesion is it, where is it located, and does it affect the surrounding bone or joint surface? |
The hand surgeon’s view that the TFCC is relatively preserved is relevant. It shifts attention toward the other findings, but the cyst still needs clinical and imaging correlation. It is also possible that arthritis and the adjacent bone lesion are related rather than two completely independent problems.
TFCC degeneration does not automatically explain the pain
The TFCC helps support the ulnar wrist and distal radioulnar joint. However, an MRI abnormality is not equivalent to a symptomatic injury.
A 2024 systematic review examined TFCC tears on MRI in symptomatic and asymptomatic wrists. It highlighted the presence of these findings in people without symptoms and the importance of interpreting MRI alongside the clinical picture. (2)
For this scenario, the useful distinction is between degeneration seen on a scan and a TFCC lesion that explains the particular pain under load. A report containing the word “degenerative” does not make TFCC-directed treatment necessary. Equally, a reassuring interpretation does not explain away the pain; another structure may be responsible.
The site’s TFCC article addresses a related condition. This situation requires a broader discussion because the suspected pain generator is a bone cyst or adjacent arthritic joint.
The pisotriquetral joint deserves attention
This small joint lies on the palm side of the ulnar wrist. Its location makes it relevant when pain occurs around the pisiform or during pressure-bearing activities. A focused examination can help distinguish pain there from pain closer to the TFCC, tendons, or distal radioulnar joint. (1)
A carefully targeted injection can sometimes contribute to localization. A published series described 42 ultrasound-guided pisotriquetral injections in 33 patients whose clinicians suspected that joint as the pain source. Fifteen patients reported immediate relief. This was a technique and case series, not a randomized treatment trial. (3)
Temporary relief after local anesthetic may support a joint contribution, but it is not an infallible test. Placement, anesthetic spread, and overlapping sources can affect interpretation. It also does not prove that PRP or stem cell treatment would provide lasting benefit. The diagnostic question and the treatment question are separate.
What does a cyst in the triquetrum mean?
The word “cyst” needs clarification. An intraosseous ganglion is a benign cystic lesion within bone. A subchondral cyst is a cystic change beneath a joint surface that may accompany arthritis. A ganglion in the soft tissues beside the TFCC is another finding altogether.
Without the images and radiologist’s description, it would be premature to assume which of these is present. The location relative to the pisotriquetral joint, lesion size, surrounding bone changes, and integrity of the outer bone shell are useful details to review with the hand surgeon. CT may help characterize bone architecture when that information would change management.
A review of carpal intraosseous ganglia describes their variable presentation and the need for clinical and radiographic assessment. Symptomatic lesions can cause persistent pain, and some can compromise bone strength. This does not mean every small cyst is dangerous or needs surgery. (4)
The important question is whether this particular lesion convincingly matches the symptoms. A cyst that is incidental and a cyst that is enlarging or structurally significant lead to different decisions.
Why can it hurt despite a strong grip and a rigid brace?
The case description separates two outcomes that are often treated as interchangeable: strength and tolerance for work.
A grip test measures force under a particular set of conditions. It does not reproduce every combination of wrist position, finger pressure, forearm rotation, and sustained contact required during manual therapy. In this account, strengthening has improved one aspect of function while the main occupational limitation remains.
A brace also changes movement without necessarily removing every load transmitted through the hand. Pain while braced does not identify the cyst, prove a TFCC tear, or establish instability. It shows that bracing has not made that task comfortable.
After five months of treatment, the persistence of the same limiting pain is a reason to reassess the working diagnosis and the aggravating tasks. It is not proof that therapy was ineffective overall, or that surgery is inevitable.
What does PRP research show for wrist pain?
PRP is prepared from a patient’s blood and concentrates platelets. It is not a stem cell injection. The site’s PRP overview explains the broader treatment concept.
In our published 2019 series, six patients with seven painful wrists received PRP. Diagnoses varied, and patients reported improvements of different magnitudes. The patient described with a TFCC injury reported 20% overall improvement at five months, with substantial pain remaining. (5)
That small uncontrolled series offers preliminary observations, not a predictable success rate. It did not establish that PRP eliminates triquetral cysts or repairs the structural defect inside a bone.
More recent TFCC evidence also requires caution. A 2024 retrospective study of 33 patients undergoing arthroscopic TFCC repair found that adding PRP did not improve function over repair alone. Because it investigated PRP alongside surgery, it does not answer whether an isolated injection helps nonsurgical TFCC degeneration. (6)
For this scenario, discussing PRP requires an identified target and an explanation of the limited evidence for that target. It should not be presented as a proven way to resolve all three MRI findings.
What about marrow-based or adipose-based treatment?
Bone marrow aspirate concentrate contains a mixture of cells, including a small stromal-cell population, and other marrow components. It is different from a purified stem cell product. The literature reviewed for this article did not establish that a marrow injection can eliminate a triquetral cyst or reliably treat isolated pisotriquetral arthritis.
There is early wrist research on another preparation: autologous microfat combined with PRP. A 2022 uncontrolled pilot study explored this combination for wrist osteoarthritis resistant to medical treatment. Its authors considered the preliminary findings promising. (7)
Microfat is a tissue preparation, not culture-expanded stem cells. However, a combined-product pilot study cannot establish which component produced a benefit, prove superiority over other care, or demonstrate effectiveness for a different wrist joint or an intraosseous cyst.
This distinction matters: symptom improvement in wrist arthritis is not evidence that a bone cavity has filled in or that its structural risk has changed. An injection proposed for joint symptoms and a procedure directed at the cyst have different goals.
When does a cyst-directed procedure enter the discussion?
If the lesion is convincingly symptomatic, disabling despite appropriate conservative care, enlarging, or affecting bone integrity, a hand surgeon may discuss removal of the cyst contents and management of the resulting defect. The procedure depends on the diagnosis and anatomy.
A 2022 retrospective series included 28 patients with carpal intraosseous ganglia, eight involving the triquetrum. After arthroscopic cyst treatment and bone grafting, pain disappeared in 25 patients and improved in three. Follow-up averaged ten months. These encouraging findings came from a selected surgical series without a comparison group. (8)
A 2026 series reported improvement following arthroscopic treatment and bone grafting in 14 patients. Follow-up was only three to six months, and none of the reported lesions were in the triquetrum. It adds information about carpal cyst treatment without establishing a specific success rate for this case. (9)
Bone grafting during cyst surgery is not the same procedure as injecting marrow concentrate into a wrist joint. These surgical results should not be cited as evidence that a regenerative injection alone resolves the lesion.
The goal is a hand that tolerates your actual work
For a physical therapist, a meaningful outcome includes sustained patient handling and controlled pressure through the fingers—not simply a stronger grip on a dynamometer.
The next discussion should clarify the cyst diagnosis, why the surgeon believes it is symptomatic, whether the pisotriquetral joint also contributes, and how a proposed treatment addresses the tasks that remain painful. Work modifications can be considered with the treating clinicians while that evaluation proceeds; the article cannot prescribe an individual loading plan from this description.
New numbness, progressive weakness, marked swelling, or a sudden increase in pain after an injury warrants timely reassessment rather than continued painful strengthening.
My central point is that the pain deserves an explanation that fits the examination and your work. The TFCC may be an incidental finding, the arthritic joint may be symptomatic, and the cyst may or may not be the dominant source. PRP and cell-containing preparations should be discussed with those distinctions intact, including the limits of the evidence.
References
- Satria O, Aprilya D, Hadinoto SA. Ulnar-Sided Wrist Pain: Systematic Clinical Approach and Principles of Treatment. Orthop Res Rev. 2025;17:199–212. doi:10.2147/ORR.S506374.
- Portnoff B, Casey JC, Thirumavalavan J, Abbott E, Faber R, Gil JA. Prevalence of asymptomatic TFCC tears on MRI: A systematic review. Hand Surg Rehabil. 2024;43(3):101684. doi:10.1016/j.hansur.2024.101684.
- Miller TT, Bis G. Ultrasound-guided injection of the pisotriquetral joint: technique and case series. Skeletal Radiol. 2022;51(8):1687–1694. doi:10.1007/s00256-022-03992-z.
- Osagie L, Gallivan S, Wickham N, Umarji S. Intraosseous ganglion cysts of the carpus: current practice. Hand (N Y). 2015;10(4):598–601. doi:10.1007/s11552-015-9750-2.
- Darrow M, Shaw B, Boeger G, Raspa S. The Effect of Platelet-Rich Plasma Therapy on Unresolved Wrist Pain. Orthop Muscular Syst. 2019;8(1):268. doi:10.4172/2161-0533.1000268.
- Asiry A, Dabbagh A, Mortada H, Merlini L. Effectiveness of Platelet-rich Plasma Injection as an Adjunct Treatment to Arthroscopy for TFCC Injury: A Retrospective Cohort Study. Plast Reconstr Surg Glob Open. 2024;12(10):e6237. doi:10.1097/GOX.0000000000006237.
- Mayoly A, Witters M, Jouve E, Bec C, Iniesta A, Kachouh N, Veran J, Grimaud F, Zavarro AC, Fernandez R, Bendahan D, Giraudo L, Dumoulin C, Chagnaud C, Casanova D, Sabatier F, Legré R, Jaloux C, Magalon J. Intra Articular Injection of Autologous Microfat and Platelets-Rich Plasma in the Treatment of Wrist Osteoarthritis: A Pilot Study. J Clin Med. 2022;11(19):5786. doi:10.3390/jcm11195786.
- Teng XF, He XK, Chen H, Ruan J. Arthroscopic Treatment of Intraosseous Ganglion Cysts of the Carpus. Front Surg. 2022;9:798432. doi:10.3389/fsurg.2022.798432.
- Ma Z, Zhang X, Pei Y, Zhu L, Wang G, Sun Y. Wrist-arthroscopy treatment of carpal bone cysts. JPRAS Open. 2026;48:473–482. doi:10.1016/j.jpra.2025.11.032.
