Volar Intercalated Segment Instability (VISI)

Volar Intercalated Segment Instability: A Physiotherapy Guide

Volar intercalated segment instability (VISI) is one of the lesser-known yet clinically significant forms of carpal instability. Unlike its counterpart, dorsal intercalated segment instability (DISI), VISI involves a volar (palmar) tilt of the lunate bone within the wrist's intricate carpal architecture. Left unaddressed, VISI can lead to chronic wrist pain, functional limitations, and progressive degenerative changes. This comprehensive guide explains what VISI is, the anatomy involved, what causes it, why physiotherapy is essential, rehabilitation timelines, evidence-based treatment approaches, prevention strategies, and answers to commonly asked questions.

What Is Volar Intercalated Segment Instability (VISI)?

Volar intercalated segment instability is a specific pattern of carpal malalignment in which the lunate bone tilts excessively toward the palmar (volar) side of the wrist. In a healthy wrist, the carpal bones of the proximal row — the scaphoid, lunate, and triquetrum — move together in a coordinated fashion. The lunate sits at the centre of this row and acts as a critical link between the radius (forearm bone) and the rest of the hand. When the ligaments that normally stabilize the lunate and its neighbouring bones are disrupted, the lunate may tilt abnormally.

In VISI, the lunate assumes an excessively flexed posture. On a lateral radiograph, the scapholunate angle typically remains normal or may be decreased, while the capitolunate angle increases beyond normal limits. The hallmark diagnostic finding is a lunate that appears tilted volarly, with the capitate shifting dorsally relative to the radius (Nathani et al., 2024, Cureus). This contrasts with DISI, where the lunate extends dorsally and is more commonly associated with scapholunate ligament injuries.

VISI is most frequently linked to disruption of the lunotriquetral (LT) ligament complex or generalized midcarpal instability. It may present as a static deformity — visible on standard radiographs — or a dynamic instability that only becomes apparent under stress or during certain wrist movements (Hakkesteegt et al., 2025, Plastic and Reconstructive Surgery). Many patients describe a painful "clunk" or "catch" during specific wrist motions, particularly when moving from radial to ulnar deviation.

Anatomy of the Wrist: Understanding the Structures Involved in VISI

To understand VISI, it is essential to appreciate the complex anatomy of the wrist. The wrist joint consists of two rows of small carpal bones arranged between the forearm bones (radius and ulna) and the metacarpals of the hand.

• The Proximal Carpal Row
• The proximal row includes the scaphoid, lunate, and triquetrum. These three bones have no direct tendon attachments and are therefore considered an "intercalated segment" — meaning their position and movement are governed entirely by the shape of their articular surfaces and the ligaments connecting them. This intercalated segment is inherently unstable and relies heavily on ligamentous support to maintain proper alignment.
• The Lunotriquetral Ligament Complex
• The lunotriquetral (LT) ligament is the primary restraint against VISI deformity. This C-shaped ligament connects the lunate to the triquetrum and consists of three distinct portions: volar, proximal (membranous), and dorsal. Recent cadaveric research by Le et al. (2026, Orthopedic Reviews) demonstrated that the volar portion of the LT ligament is the structurally dominant component, measuring an average of 5.04 mm in length and 2.12 mm in thickness — significantly larger than the dorsal and proximal portions. This finding underscores that the volar LT ligament is the most critical stabilizer against VISI deformity, and its disruption is often the primary mechanical cause of volar lunate tilting.
• Secondary Stabilizers
• Beyond the LT ligament, several secondary structures contribute to carpal stability. The dorsal radiocarpal ligament, the dorsal intercarpal ligament, the volar ulnocarpal ligaments (ulnolunate and ulnotriquetral), and the scaphotriquetral ligament all play supporting roles. The triangular fibrocartilage complex (TFCC) also contributes to ulnar-sided wrist stability. When the primary LT ligament is compromised, these secondary stabilizers may initially compensate, but progressive attenuation can eventually lead to a fixed VISI deformity.
• The Midcarpal Joint
• The midcarpal joint — between the proximal and distal carpal rows — is another important consideration. In cases of non-dissociative carpal instability (also called midcarpal instability), the problem arises not from ligament tears between bones in the same row but from laxity at the midcarpal joint itself. This form of instability can also produce a VISI pattern and is particularly common in patients with generalized ligamentous laxity (Hakkesteegt et al., 2025, Plastic and Reconstructive Surgery).

What Causes VISI?

VISI can result from several distinct mechanisms, and understanding the underlying cause is crucial for guiding treatment.

• Traumatic Lunotriquetral Ligament Injury
• The most common cause of VISI is acute disruption of the lunotriquetral ligament, typically from a fall on an outstretched hand with the wrist in extension and radial deviation. This mechanism applies a forceful load through the hypothenar eminence, stressing the ulnar side of the wrist and potentially tearing the LT ligament. A systematic review by Omar-Hossein et al. (2023, Hand) examining outcomes following surgical interventions for isolated LT ligament injuries found that these injuries remain challenging to diagnose and treat, with higher complication and reoperation rates associated with LT arthrodesis compared with other surgical approaches.
• Perilunate Injuries
• VISI can also occur as a component of more complex perilunate injuries, which involve progressive ligamentous disruption around the lunate bone. While the classic Mayieu arc of perilunate injuries typically progresses from the radial to the ulnar side, reverse or ulnar-sided patterns have been documented. Zampeli et al. (2025, Journal of Wrist Surgery) highlighted the importance of recognizing atypical patterns of perilunate injury that may initially present with VISI alignment before progressing to more severe instability.
• Non-Traumatic Midcarpal Instability
• Some patients develop VISI without a clear history of significant trauma. This form, often called carpal instability non-dissociative (CIND), typically occurs in individuals with inherent ligamentous laxity. In these cases, the midcarpal joint demonstrates excessive translation, allowing the proximal row to adopt a VISI posture. Patients often describe a characteristic "clunk" as the wrist moves from radial to ulnar deviation, representing the sudden reduction of the subluxated midcarpal joint.
• Degenerative and Inflammatory Causes
• Chronic inflammatory conditions such as rheumatoid arthritis can progressively weaken the carpal ligaments, leading to VISI deformity over time. Degenerative changes associated with aging, repetitive occupational stress, or chronic wrist loading in athletes may also contribute to gradual ligament attenuation and VISI development.
• Iatrogenic Causes
• In rare instances, VISI can develop following surgical procedures on the wrist, particularly if the LT ligament or its secondary stabilizers are inadvertently compromised during operations on nearby structures.

Why Physiotherapy Is Essential for VISI Recovery

Physiotherapy plays a foundational role in managing VISI, whether as the primary treatment for mild-to-moderate instability or as an essential component of post-surgical rehabilitation. Several evidence-based principles support the critical role of physiotherapy in VISI management.

• Restoring Neuromuscular Control
• The wrist's intrinsic ligaments provide crucial proprioceptive feedback that informs the central nervous system about joint position and movement. When these ligaments are injured, proprioceptive deficits develop, leading to impaired motor control and further vulnerability to re-injury. Physiotherapy interventions that target proprioception — including joint position sense training, balance board exercises for the upper extremity, and perturbation-based drills — help restore the neuromuscular control necessary for functional wrist stability. Nathani et al. (2024, Cureus) demonstrated successful conservative management of a VISI case using a multidisciplinary physiotherapy approach that included Mulligan's mobilization with movement, cryotherapy, laser therapy, and progressive exercises.
• Strengthening Dynamic Stabilizers
• While the carpal bones lack direct tendon attachments, the muscles and tendons crossing the wrist joint provide essential dynamic stability. The flexor carpi ulnaris (FCU), extensor carpi ulnaris (ECU), and the finger flexors and extensors all contribute to compressing the carpal bones together during activity. Targeted strengthening of these muscles — particularly the ECU and FCU, which directly influence ulnar-sided wrist stability — helps compensate for compromised ligamentous support.
• Pain Management and Inflammation Reduction
• Physiotherapy modalities such as cryotherapy, therapeutic ultrasound, laser therapy, and manual therapy techniques can effectively manage pain and reduce inflammation in the acute and subacute phases of VISI. These interventions enable patients to participate more fully in active rehabilitation, which is essential for long-term recovery.
• Avoiding Unnecessary Surgery
• For many patients with dynamic VISI or mild static VISI, a comprehensive physiotherapy programme may be sufficient to restore functional stability and alleviate symptoms. Conservative management is particularly appropriate for patients with non-traumatic midcarpal instability, where surgical outcomes remain variable. Hakkesteegt et al. (2025, Plastic and Reconstructive Surgery) noted that surgical intervention for midcarpal instability should only be considered after conservative therapy has been exhausted, underscoring the importance of an initial trial of physiotherapy.
• Optimizing Surgical Outcomes
• For patients who ultimately require surgical intervention — such as LT ligament reconstruction, capsulodesis, or tenodesis — pre-operative physiotherapy ("prehabilitation") and structured post-operative rehabilitation are essential for optimizing outcomes. Pre-operative conditioning helps maintain range of motion and muscle strength, while post-operative physiotherapy guides the gradual return to full function within the constraints of tissue healing.

Rehabilitation Timeline for VISI

The rehabilitation timeline for VISI varies depending on whether the patient is managed conservatively or following surgery, as well as the severity of the instability.

Conservative Management Timeline

• Weeks 1 to 3 — Acute Phase:
• The primary goals during this initial phase are pain and inflammation control, protection of the injured structures, and maintaining mobility in unaffected joints. A wrist splint or brace is typically prescribed to limit provocative movements while allowing functional use of the hand. Modalities such as cryotherapy, laser therapy, and gentle manual therapy may be introduced. Active range-of-motion exercises for the fingers, elbow, and shoulder prevent stiffness in adjacent joints.
• Weeks 3 to 6 — Early Rehabilitation Phase:
• As pain subsides, the focus shifts to gentle active wrist range-of-motion exercises within pain-free limits. Isometric strengthening of the wrist flexors and extensors begins, along with light grip strengthening. Proprioceptive training is introduced with simple exercises such as weight-bearing through the palm on a stable surface. The splint may be gradually weaned during non-provocative activities.
• Weeks 6 to 12 — Progressive Strengthening Phase:
• Resistance exercises are progressively advanced, targeting the ECU, FCU, and forearm pronators and supinators. Functional exercises simulating daily activities and work-related tasks are integrated. Proprioceptive training becomes more challenging, incorporating unstable surfaces and reactive drills. The splint is typically discontinued for most activities, though it may be retained for high-demand tasks.
• Weeks 12 to 24 — Return-to-Activity Phase:
• Sport-specific or occupation-specific training begins. Plyometric and power exercises for the wrist and forearm are introduced as tolerated. Full return to sport or heavy manual work is generally achieved by four to six months, provided pain-free strength and stability have been restored.

Post-Surgical Rehabilitation Timeline

Following surgical procedures such as LT ligament reconstruction or capsulodesis, the rehabilitation timeline is more conservative. Immobilization in a cast or rigid splint is typically maintained for six to eight weeks to protect the healing tissues. Gentle range-of-motion exercises begin after cast removal, with progressive strengthening introduced at eight to twelve weeks. Full return to unrestricted activity may take six to twelve months, depending on the specific surgical procedure and the individual's healing response. Hakkesteegt et al. (2025, Plastic and Reconstructive Surgery) reported that patients undergoing dorsal capsulodesis for midcarpal instability demonstrated significant improvements in pain and function at twelve months, with a seventy-two percent return-to-work rate.

Evidence-Based Treatment Approaches for VISI

Conservative (Non-Surgical) Treatment

Conservative management is the first-line approach for dynamic VISI, mild static VISI, and non-traumatic midcarpal instability. Key components include activity modification to avoid provocative postures, wrist bracing or taping for symptom control, a structured physiotherapy programme emphasizing proprioception and dynamic stabilization, ergonomic modifications for workplace and sporting activities, and anti-inflammatory medications as needed. The case report by Nathani et al. (2024, Cureus) detailed a successful conservative management protocol for a patient with VISI that included Mulligan's mobilization with movement for the wrist joint, cryotherapy for pain management, low-level laser therapy for tissue healing, and a progressive exercise programme targeting grip strength, wrist stability, and proprioception. The patient achieved significant improvements in pain, range of motion, and functional capacity.

Surgical Treatment

Surgical intervention is considered when conservative treatment fails to provide adequate symptom relief or when imaging reveals progressive instability. Several surgical options exist.

Lunotriquetral ligament repair or reconstruction involves directly repairing the torn LT ligament or reconstructing it using a tendon graft. Le et al. (2026, Orthopedic Reviews) described a reconstruction technique using a palmaris longus tendon autograft with a double V-shaped bone tunnel configuration, emphasizing the importance of restoring the volar portion of the LT ligament given its morphometric superiority.

Dorsal capsulodesis involves tightening the dorsal wrist capsule to restrict excessive volar tilting of the proximal carpal row. This procedure has shown promising results for midcarpal instability, with Hakkesteegt et al. (2025, Plastic and Reconstructive Surgery) reporting faster recovery and higher return-to-work rates compared with the three-ligament tenodesis technique.

Lunotriquetral arthrodesis (fusion) involves permanently fusing the lunate and triquetrum bones together, eliminating the abnormal motion between them. While this procedure reliably corrects the VISI deformity, Omar-Hossein et al. (2023, Hand) noted higher complication and reoperation rates with arthrodesis compared to other surgical approaches, including non-union of the fusion site.

Three-ligament tenodesis (3LT) uses a tendon graft to reconstruct the dorsal radiocarpal, dorsal intercarpal, and dorsal scaphotriquetral ligaments simultaneously. Although effective, this procedure was associated with slower recovery compared to capsulodesis in the comparative study by Hakkesteegt et al. (2025, Plastic and Reconstructive Surgery).

How to Prevent VISI and Protect Your Wrists

While not all cases of VISI are preventable — particularly those resulting from acute trauma — several strategies can reduce the risk of developing this condition or prevent recurrence after treatment.

• Strengthening and Conditioning
• Maintaining strong wrist and forearm muscles provides dynamic stability that protects the carpal ligaments during activity. Regular exercises targeting the wrist flexors, extensors, and forearm rotators are particularly beneficial for athletes and individuals in manual occupations.
• Proprioceptive Training
• Incorporating wrist proprioception exercises into regular training routines enhances neuromuscular control and helps the wrist respond more effectively to unexpected forces. Simple exercises such as weight-bearing on the hands, ball-rolling drills, and reaction-based catching activities can be highly effective.
• Appropriate Protective Equipment
• For athletes participating in contact sports, gymnastics, or activities with a high risk of falls, wearing wrist guards or supportive taping can help protect against the traumatic forces that commonly cause LT ligament injuries.
• Ergonomic Awareness
• Maintaining neutral wrist postures during occupational tasks, using ergonomic tools and workstation setups, and taking regular breaks from repetitive wrist activities all help reduce cumulative stress on the carpal ligaments.
• Early Assessment of Wrist Pain
• Ulnar-sided wrist pain that persists beyond a few days should prompt a clinical assessment. Early identification of LT ligament injuries or midcarpal instability allows for timely intervention, potentially preventing the development of a fixed VISI deformity.
• Managing Hypermobility
• Individuals with generalized joint hypermobility are at increased risk for non-traumatic midcarpal instability and VISI. A targeted exercise program focused on dynamic wrist stability, along with activity modification and supportive bracing during high-demand tasks, can help manage this predisposition.

Frequently Asked Questions About VISI

• What is the difference between VISI and DISI?
• VISI and DISI are both forms of carpal instability involving abnormal tilting of the lunate bone, but they tilt in opposite directions. In VISI, the lunate tilts excessively toward the palm (volar flexion), typically due to lunotriquetral ligament injury or midcarpal instability. In DISI, the lunate tilts toward the back of the hand (dorsal extension), most commonly caused by scapholunate ligament injury. DISI is generally more common and more widely recognized, but VISI can be equally disabling if left untreated.
• How is VISI diagnosed?
• Diagnosis of VISI involves a combination of clinical examination and imaging. During examination, your physiotherapist or hand surgeon will assess for ulnar-sided wrist tenderness, the ballottement test (testing LT ligament integrity), and the midcarpal shift test (assessing midcarpal stability). Standard wrist radiographs may reveal an increased volar tilt of the lunate, and stress views or fluoroscopic examination can capture dynamic instability. MRI or wrist arthroscopy may be used to confirm ligament tears and assess the severity of damage.
• Can VISI heal on its own without treatment?
• Mild dynamic VISI, particularly in cases of non-traumatic midcarpal instability, may improve with rest and activity modification. However, most cases of VISI resulting from significant LT ligament tears will not resolve spontaneously. Without appropriate treatment — whether conservative physiotherapy or surgical intervention — the instability often progresses, leading to chronic pain, functional limitations, and potentially degenerative arthritis over time.
• How long does recovery from VISI take?
• Recovery time depends on the severity of the instability and the type of treatment. With conservative management alone, most patients experience significant improvement within three to six months. Following surgical repair or reconstruction, full recovery typically requires six to twelve months, with structured post-operative rehabilitation playing a critical role in achieving optimal outcomes. Hakkesteegt et al. (2025, Plastic and Reconstructive Surgery) reported that patients treated with dorsal capsulodesis for midcarpal instability showed significant improvements by three months, with continued gains through twelve months post-surgery.
• Is it safe to exercise with VISI?
• Yes, exercise is not only safe but actively encouraged as part of VISI management — provided it is appropriately guided. Your physiotherapist will design an exercise programme that avoids provocative movements while progressively building the strength, endurance, and neuromuscular control needed to stabilize the wrist. Activities that involve extreme wrist extension, heavy loading through the hypothenar eminence, or repetitive ulnar deviation may need to be modified or temporarily avoided during early rehabilitation.
• When should I consider surgery for VISI?
• Surgery is typically recommended when a structured course of conservative treatment — usually lasting at least three to six months — fails to adequately improve symptoms and function. Additionally, patients with acute high-grade LT ligament tears, particularly in younger, active individuals, may benefit from early surgical repair. Progressive instability on serial imaging, persistent significant functional limitations despite rehabilitation, and failure to return to work or sport are all factors that may support a surgical recommendation.
• Can VISI lead to arthritis?
• Yes, untreated or inadequately managed VISI can contribute to the development of degenerative wrist arthritis over time. When the lunate sits in an abnormal position, the distribution of forces across the wrist joint surfaces changes, leading to accelerated cartilage wear in affected compartments. This is one of the important reasons why early diagnosis and appropriate management of VISI — whether through physiotherapy or surgery — is so important for long-term wrist health.

Take the Next Step Toward Recovery

If you are experiencing ulnar-sided wrist pain, a clicking or clunking sensation during wrist movements, or difficulty with grip and daily tasks, do not wait for symptoms to worsen. At Vaughan Physiotherapy, our experienced team provides thorough assessments and individualized treatment plans for complex wrist conditions including volar intercalated segment instability.

Whether you need conservative rehabilitation, pre-surgical conditioning, or post-operative recovery guidance, we are here to support you through every stage of your recovery. Our evidence-based approach ensures that your treatment is grounded in the latest clinical research and tailored to your unique goals.

Book your appointment today:

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