De Quervain's Tenosynovitis: Difference between revisions

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<div class="noeditbox">Welcome to [[Texas State University Evidence-based Practice Project|Texas State University's Evidence-based Practice project space]]. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
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'''Lead Editors''' - [[User:Corin Arundale|Corin Arundale]], [[User:David Cameron|David Cameron]], [[User:John Fite|John Fite]], [[User:Bryan Purkey|Bryan Purkey]], [[User:John Winkelhaus|John Winkelhaus]]
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== Search Strategy  ==


<u>Databases</u>: CINAHL, PUBMED, MEDLINE


<u>Keywords</u>: DeQuervain's, tenosynovitis, radial wrist pain, conservative management, rehabilitation, physical therapy<br>  
== Definition/Description ==
[[File:Snuff box.png|thumb|250x250px|Anatomical snuffbox]]
De Quervain's Tenosynovitis is a painful,  inflammatory condition caused by tendons on the side of the wrist at the base of the thumb.  Pain, which is the main complaint, gets worse with abduction of the thumb, a grasping action of the hand, and an ulnar deviation of the wrist. Thickening and swelling can also be present. <ref name="thomas">Pagonis T, Ditsios K, Toli P, Givissis P, Christodoulou A. Improved corticosteroid treatment of recalcitrant de Quervain tenosynovitis with a novel 4-point injection technique. The American journal of sports medicine. 2011 Feb;39(2):398-403.</ref> <ref name="Ashurst">Ashurst JV, Turco DA, Lieb BE. Tenosynovitis caused by texting: an emerging disease. Journal of Osteopathic Medicine. 2010 May 1;110(5):294-6.</ref><ref name="Gonzalez-Inglesias">González-iGlesias J, Huijbregts P, Fernández-de-Las-Peñas C, Cleland JA. Differential diagnosis and physical therapy management of a patient with radial wrist pain of 6 months' duration: a case report. journal of orthopaedic & sports physical therapy. 2010 Jun;40(6):361-8.</ref>


<u>Timeline</u>: 10/20/2011 - 11/28/2011<br>
=='''Aetiology'''==
* The most common cause is chronic overuse.
* Activities&nbsp; such as golfing, playing the piano, fly fishing, carpentry, or activities by office workers and musicians can lead to chronic overuse injuries.
* The classic patient population is mothers of newborns who are repeatedly lifting their baby with their thumbs radially abducted and wrists going from ulnar to radial deviation.
*[[File:Dequervains anatomy.jpg|thumb|De Quervain's Anatomy|alt=]]Repetitive&nbsp; gripping, grasping or wringing of objects can cause inflammation of the tendons and tendon sheaths which narrows the first dorsal compartment limiting motion of the tendons.  If left untreated, the inflammation and progressive narrowing (stenosis) can lead to scarring that further limits thumb motion. <ref name="Ashurst" /><ref name="Gonzalez-Inglesias" />


== Definition/Description ==
*De Quervain's has been "attributed to myxoid degeneration (the process in which the connective tissues are replaced by a gelatinous substance)  with fibrous tissue deposits and increased vascularity rather than acute inflammation of the synovial lining."<ref name=":0" /> It is for this reason that is thought to be a tendinosis rather than a tendonitis.<ref name=":2">Kate Thorn. De Quervain's Tenosynovitis. Plus Course. 2021</ref> This deposition of the fibrous tissues causes thickening of the tendon sheath, and this can entrap the [[abductor pollicis longus]] and [[Extensor Pollicis Brevis|extensor pollicis brevis]] tendons and cause pain.


De Quervain's tenosynovitis is a painful inflammation of tendons on the side of the wrist at the base of the thumb. These tendons include the extensor pollicis brevis and the abductor pollicis longus tendons. If you have De Quervain's tenosynovitis, you're likely to feel discomfort every time you turn your wrist, grasp anything or make a fist.<br>'''(http://www.medicinenet.com/de_quervains_tenosynovitis/article.htm)'''
== Relevant Clinical Anatomy ==
De Quervain's syndrome affects the [https://www.physio-pedia.com/Extensor_Pollicis_Brevis extensor pollicis brevis] (EPB) tendon and the [[abductor pollicis longus]] (APL) tendon. These muscles are located on the dorsal side of the forearm and go to the lateral side of the thumb through a fibrous-osseous tunnel made of the processus styloideus radii and the [[Extensor Retinaculum (Wrist)|extensor retinaculum]]. <ref name="Schunke">Katechia D, Gujral S. De Quervain's tenosynovitis. InnovAiT. 2017 Sep;10(9):505-9.</ref>


'''&nbsp;(http://www.mayoclinic.com/health/de-quervains-tenosynovitis/DS00692)'''&nbsp;
# Extensor pollicis brevis (EPB)[[File:Forearm muscles.png|thumb|500x500px|Forearm Anatomy|alt=]]
#*Origin: ½ dorsal side of the radius, the membrana interossea
#*Insertion: base of the proximal phalanx of the thumb
#*Function:
#**Wrist joint: radial abduction
#**Thumb: extension
#*Innervations: posterior interosseus branch of [[Radial nerve|N. radialis]]
#*Artery: A. interossea posterior<br>
# Abductor pollicis longus (APL<u>)</u>
#*Origin: dorsal side of the radius and the ulna, the membrana interossea
#*Insertion: base of ossis metacarpi
#*Function:
#**Wrist joint: radial abduction
#**Thumb: abduction
#*Innervations: posterior interosseus branch of N. radialis
#*Artery: A. interossea posterior
== Epidemiology ==
* Estimated prevalence is  0.5% in men and 1.3% in women.  Peak prevalence is usually among individuals between the ages of 40 -50 years<ref name=":3" />
* More commonly found in people with a history of [[Medial Epicondyle Tendinopathy|medial]] or [[Lateral Epicondylitis|lateral epicondylitis]]
* New mothers or child care providers often experience bilateral symptoms, but these symptoms usually subside once the child is lifted less often.<ref name=":0">Satteson E, Tannan SC. [https://www.ncbi.nlm.nih.gov/books/NBK442005/ De Quervain Tenosynovitis.] StatPearls [Internet]. 2021 Aug 8.</ref>
* In industrial settings, studies have shown a point prevalence of 8% when wrist pain and a positive [http://www.physio-pedia.com/Finkelstein_Test Finkelstein’s test] is present.<ref name="Ashurst" />


De Quervain’s tenosynovitis may be referred to “baby wrist” or “mother’s thumb” because it often develops in new mothers, possibly due to the repetitive movements when caring for an infant. Other causes include an injury to the thumb, an inflammatory condition such as rheumatoid arthritis, and often the source is unknown. '''(Tendon trouble in the hands: de Quervain's tenosynovitis and trigger finger. Harvard Women's Health Watch)'''. Epidemiological studies in industrial settings have shown a point prevalence of 8% for De Quervain syndrome, when wrist pain and a positive Finkelstein test, with or without tender¬ness to palpation of the radial wrist, were used as diagnostic criteria. More rel¬evant to nonindustrial settings, in 485 patients with upper extremity musculo¬skeletal disorders consisting mostly of computer users and musicians, 17% were diagnosed with De Quervain syndrome on the right and 5% on the left, based solely on a positive Finkelstein test.'''(Gonzalez)'''<br><br>
== Differential Diagnosis ==
* Osteoarthritis of the first carpometacarpal joint(main differential diagnosis for De Quervain's Tenosynovitis<ref name=":2" />)
* Trigger thumb
* Wartenberg's syndrome (superficial radial nerve neuritis)
* Scaphoid or radial styloid fractures
* Intersection syndrome


== Epidemiology/Etiology  ==
== Clinical Presentation ==
=== Examination ===
The evaluation of a patient with signs and symptoms of De Quervain’s Tenosynovitis begins with a thorough history followed by a physical examination.


The cause of DeQuervain’s Tenosynovitis can occur with a chronic overuse injury, a direct trauma that can causes tissue scarring, or inflammatory arthritis (ex. Rheumatoid Arthritis). Patients with DeQuervain’s Tenosynovitis typically report painful abduction of the thumb and decreased grip strength.<ref name="Ashurst">Ashurst JV, Turco DA, Lieb BE. Tenosynovitis Caused by Texting: An Emerging Disease. JAOA 2010:110(5).</ref> The most common cause is chronic overuse. Activities and professions such as golfing, playing the piano, fly fishing, carpentry, office workers, musicians, and carrying a child in the arms for prolonged periods can lead to chronic overuse injuries. The two major tendons (extensor pollicis brevis and abductor pollicis longus) connect the thumb to the forearm and passes through the first dorsal compartment of the extensor retinaculum. Repetitive motions of gripping, grasping, clenching, pinching, or wringing of objects can cause inflammation of the tendons and tendon sheaths and narrows the first dorsal compartment and causes limitation of motion of the tendons. If left untreated, the inflammation and progressive narrowing (stenosis) can cause scarring that further limits thumb motion. <ref name="Ashurst">Ashurst JV, Turco DA, Lieb BE. Tenosynovitis Caused by Texting: An Emerging Disease. JAOA 2010:110(5).</ref><ref name="Harvard">Harvard Women's Health Watch. Harvard Health Publications. Copyright 2010 by President and Fellows of Harvard College. www.healthharvard.edu. Accessed 11/27/11.</ref><ref name="Gonzalez-Inglesias">Gonzalez-Inglesias J, et al. Differential Diagnosis and Physical Therapy Management of a Patient With Radial Wrist Pain of 6 Months Duration: A Case Report. J Orthop Sports Phys Ther 2010:40(6).</ref>  
==== History ====
[[File:Wrist pain.jpeg|thumb|Wrist pain|alt=]]
* Overuse injury vs acute trauma
* Prior history of symptoms
* Repetitive movements of the upper extremity with work or activities of daily living (ADL)
* Hand dominance
* Pregnant or currently in the post-partum stage
* Pain:
** The primary complaint is radial sided wrist pain (base of thumb and dorsolateral aspect of the wrist near the radial styloid process) that radiates up the forearm with grasping or extension of the thumb
** Described as a “constant aching, burning, pulling sensation."<ref name="Walker">Walker MJ. Manual physical therapy examination and intervention of a patient with radial wrist pain: a case report. Journal of orthopaedic & sports physical therapy. 2004 Dec;34(12):761-9.</ref>
** Aggravated by repetitive lifting, gripping, or twisting motions of the hand (such as opening a jar lid).<ref name="Walker" />


<br>In industrial settings, studies have shown that DeQuervain’s syndrome has a point prevalence of 8% when wrist pain and a positive Finkelstein’s test is present. In non-industrial settings, one study with 485 patients with upper extremity musculoskeletal disorders (mostly musicians and computer users) found that 17% were diagnosed with DeQuervain’s on the right hand and 5% on the left hand when a positive Finkelstein’s test was present. Risk factors for DeQuervain’s Tenosynovitis can include patients who are female and in the age range of 30-50. <ref name="Gonzalez-Inglesias">Gonzalez-Inglesias J, et al. Differential Diagnosis and Physical Therapy Management of a Patient With Radial Wrist Pain of 6 Months Duration: A Case Report. J Orthop Sports Phys Ther 2010:40(6).</ref><br><br>
===='''Physical Examination'''====
* On palpation, some key, significant findings will be tenderness over the base of the thumb and/or first dorsal compartment extensor tendons on the thumb side of the wrist, particularly over the radial styloid process<ref name="Ashurst" />
* Swelling in the [[Anatomical snuff box|anatomical snuffbox&nbsp;]]
* Decreased carpometacarpal (CMC) abduction range of motion (ROM) of the first digit
* Palpable thickening of the extensor sheaths of the first dorsal compartment and crepitus of the tendons moving from the extensor sheath <ref name="Anderson">Anderson M, Tichenor CJ. A patient with de Quervain's tenosynovitis: a case report using an Australian approach to manual therapy. Physical therapy. 1994 Apr 1;74(4):314-26.</ref>
* Other possible findings include:
** Weakness and paraesthesia in the hand<ref name="Gonzalez-Inglesias" />
** A provocative [[Finkelstein Test|Finkelstein test]]
*** During this test, the thumb is flexed and held inside a fist. The patient actively deviates the wrist towards the ulnar side. This causes sharp pain along the radial wrist at the first dorsal compartment.<ref name=":0" />


== Characteristics/Clinical Presentation  ==
<clinicallyrelevant id="84104022" title="Finkelstein Test" />


The primary complaint with De Quervain’s is radial sided wrist pain that radiates up the forearm with grasping or extension of the thumb. The pain has been described as a “constant aching, burning, pulling sensation."<ref name="Walker">Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004:34(12).</ref> Pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand.<ref name="Walker">Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004:34(12).</ref> Swelling in the anatomical snuff box,&nbsp;tenderness at the radial styloid process, decreased CMC abduction ROM of the 1st digit, palpable thickening of the extensor sheaths of the 1st dorsal compartment and crepitus of the tendons moving from the extensor sheath may be found upon examination.<ref name="Anderson">Anderson M, Tichenor C. A Patient With De Quervain’s Tenosynovitis: A Case Report Using an Australian Approach to Manual Therapy. Phys Ther 1994:74(4).</ref> Other possible findings include weakness and paresthesia in the hand.<ref name="Gonzalez-Inglesias">Gonzalez-Inglesias J, et al. Differential Diagnosis and Physical Therapy Management of a Patient With Radial Wrist Pain of 6 Months Duration: A Case Report. J Orthop Sports Phys Ther 2010:40(6).</ref> Finkelstein’s diagnostic test will present positive provoking the patient’s symptoms.<br>
=== Treatment Tiers ===
Generally, there are three tiers of treatment for De Quervain's<ref name=":2" />:


== Differential Diagnosis  ==
* Tier 1: Conservative management
** splinting
** ultrasound
** multimodal hand therapy
** activity modification
* Tier 2: Corticosteroid injection
* Tier 3: Surgery


There are a number of conditions that present with radial sided wrist and forearm pain. These include intersection syndrome, intercarpal instabilities, scaphoid fracture, superficial radial neuritis, C6 cervical radiculopathy, and osteoarthritis of the first CMC, IC, or radiocarpal joints.  
Tiers 1 and 2 can be combined dependent on patient presentation and willingness to get a corticosteroid injection.<ref name=":2" />


'''Intersection Syndrome<br>'''Intersection syndrome is described as friction of the tendon bellies of the APL and EPB as they cross over the ECRL and ECRB. There will be tenderness to palpation approximately 4-8 centimeters proximal to the radial styloid process, and possibly crepitus upon wrist extension and radial deviation. Finkelstein’s may provoke the symptoms but usually more proximal than with De Quervain’s.<ref name="Walker">Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004:34(12).</ref>
=== Non-Surgical Treatment ===
The aim of non-surgical management is to reduce pain and swelling. Interventions can include:
* Patient education regarding avoiding repetitive or aggravating movements<ref name=":2" />
* Non-steroidal anti-inflammatory drugs (NSAIDs)
* Ice/heat packs
* Physical therapy<ref>Földvári-Nagy L, Takács J, Hetthéssy JR, Mayer ÁA, Szakács N, Szávin-Pósa Á, Lenti K. Treatment of De Quervain's tendinopathy with conservative methods. Orvosi Hetilap. 2020 Mar 1;161(11):419-24.</ref>
* Occupational therapy
* Thumb splinting[[File:Dequervain's splint.jpeg|thumb|De Quervain's Splint|alt=]]
** Literature supports the use of a forearm brace including the thumb to reduce ulnar deviation and thumb movement.<ref name=":2" />
** Clinicians do not agree on the frequency and duration of splint use; some think it should be worn continually for four to six weeks; others recommend wearing it only as needed for pain.<ref name="Harvard">Huisstede BM, Gladdines S, Randsdorp MS, Koes BW. Effectiveness of conservative, surgical, and postsurgical interventions for trigger finger, Dupuytren disease, and De Quervain disease: a systematic review. Archives of physical medicine and rehabilitation. 2018 Aug 1;99(8):1635-49.</ref>
** Weiss and colleagues<ref name="weiss">Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. The Journal of hand surgery. 1994 Jul 1;19(4):595-8.</ref> found that a 19% improvement was observed when splints were used, but when splint use was combined with NSAIDs, the improvement was 57%. Cavaleri et al.<ref name=":3" /> reported that combined orthosis/corticosteroid injection approaches are more effective than either intervention alone in the treatment of de Quervain's disease.


<br>'''Intercarpal Instabilities<br>'''The wrist has many small bones and ligaments and is a complex structure. Injury to these structures through trauma or degeneration can cause instability between the articulating bones. This can lead to altered biomechanics of the wrist accompanied by pain. Scapholunate disassociation, scapho-trapezio-trapezoidal joint degeneratioin, and lunatotriquetral dissociation could all present with radial sided wrist pain.<ref name="Linscheid">Linscheid R, Dobyns J. Dynamic Carpal Instability. Keio J Med 2002:51(3).</ref>
* [http://www.physio-pedia.com/Ultrasound_therapy Ultrasound] may improve treatment outcomes<ref name=":4" />:
** Therapeutic ultrasound
*** Ferrara et al.<ref>Ferrara PE, Codazza S, Cerulli S, Maccauro G, Ferriero G, Ronconi G. Physical modalities for the conservative treatment of wrist and hand's tenosynovitis: A systematic review. InSeminars in arthritis and rheumatism 2020 Dec 1 (Vol. 50, No. 6, pp. 1280-1290). WB Saunders.</ref> reported that therapeutic ultrasound may effectively control pain. However, the studies in this systematic review were heterogenous, with poor sample sizes and wide variations in outcome measures.
** Ultrasound-guided injections 
*** McDermott et al.<ref name="james" /> found that ultrasound-guided injections were beneficial for De Quervain's tenosynovitis. Their results were slightly better than was previously reported in the literature and they reported no adverse reactions.<ref name="james">McDermott JD, Ilyas AM, Nazarian LN, Leinberry CF. Ultrasound-guided injections for de Quervain’s tenosynovitis. Clinical Orthopaedics and Related Research®. 2012 Jul;470(7):1925-31.</ref>
*** Kume et al.<ref name="kume">Kume K, Amano K, Yamada S, Amano K, Kuwaba N, Ohta H. In de Quervain’s with a separate EPB compartment, ultrasound-guided steroid injection is more effective than a clinical injection technique: a prospective open-label study. Journal of Hand Surgery (European Volume). 2012 Jul;37(6):523-7.</ref> found that ultrasound-guided injections which target the Extensor Pollicis Brevis with septation was more effective than manual injection.
* Corticosteroid injection has been reported to be be effective. One or two injections are usually sufficient for pain-relief. 
** If there is no significant improvement in symptoms following two corticosteroid injections, surgical management may be considered. Surgery is usually done in an outpatient setting and the anaesthetic may be local, regional or general.<ref name=":0" />
** Patients with moderate to severe symptoms usually require cortisone injections in combination with splinting.<ref name=":2" />


<br>'''Scaphoid Fracture<br>'''A scaphoid fracture most commonly occurs by a FOOSH in wrist extension and will present with radial sided wrist pain,&nbsp;tenderness and possible swelling in the anatomical snuff box, and limited ROM with pain especially at end ranges. If&nbsp;the patient presents with radial side wrist pain after a traumatic injury a scaphoid fracture must be ruled out.<ref name="Walker">Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004:34(12).</ref>
<nowiki>**</nowiki> In individuals with persistent symptoms the most commonly non-surgical management includes: splinting, systemic anti-inflammatories, and corticosteroid injection.<ref name=":3">Cavaleri R, Schabrun SM, Te M, Chipchase LS. Hand therapy versus corticosteroid injections in the treatment of de Quervain's disease: A systematic review and meta-analysis. Journal of Hand Therapy. 2016 Jan 1;29(1):3-11.</ref><ref name=":4">Abi-Rafeh J, Kazan R, Safran T, Thibaudeau S. Conservative management of de Quervain stenosing tenosynovitis: review and presentation of treatment algorithm. Plastic and reconstructive surgery. 2020 Apr 15;146(1):105-26.</ref> <ref>Başar B, Aybar A, Basar G, Başar H. The effectiveness of corticosteroid injection and splint in diabetic de Quervain's tenosynovitis patients: A single-blind, randomized clinical consort study. Medicine. 2021 Sep 3;100(35).</ref>


<br>'''Superficial Radial Neuritis''' <br>The superficial radial nerve supplies sensation to the dorsal surfaces of digits 1-2 and the first&nbsp;web space. The nerve can become compressed between the tendons of the extensor carpi radialis brevis and the brachioradialis or in developing scar tissue after trauma. Compression will cause ischemia resulting in numbness and tingling in this distribution.<ref name="Gonzalez-Inglesias">Gonzalez-Inglesias J, et al. Differential Diagnosis and Physical Therapy Management of a Patient With Radial Wrist Pain of 6 Months Duration: A Case Report. J Orthop Sports Phys Ther 2010:40(6).</ref>
=== Surgical Treatment ===
* Surgery is rare and is usually selected in cases where non-surgical treatment has failed and the patient experiences persistent inflammation affecting his or her function. The goal of surgery is to open the dorsal compartment covering to make more room for the irritated tendons. The opening allows pressure relief of the tendons, to ultimately restore free tendon gliding.<ref>Saaiq M. Management Outcome of de Quervain’s Disease with Corticosteroid Injection Versus Surgical Decompression. Archives of Bone and Joint Surgery. 2021 Mar;9(2):167.</ref>


'''C6 Cervical Radiculopahy<br>'''Compression on a spinal nerve root can cause sensory disturbances, myotomal weakness, and diminished reflexes throughout the root's&nbsp;distribution. The dermatomal keypoint for the C6 nerve root is the radial aspect of the 2nd metacarpal and index finger which is close to the area of pain experienced with De Quervain’s. Since a radiculopathy can present much like De Quervain’s a&nbsp;thorough screen of the&nbsp;cervical spine&nbsp;is necessary.<ref name="Walker">Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004:34(12).</ref><ref name="Wainner">Wainner RS, Irrgang JJ, Delitto A. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine 2003:28(1).</ref>
* Post-operative care is usually straight forward with a simple dressing and no complicated wound care necessary. Individuals are encouraged to start with early use of the hand for light activities of daily living. Sutures are removed after 14 days and individuals are allowed to continue with normal activities. Mild swelling and tenderness around the surgical site may be present for a few months.<ref name=":0" />
== Rehabilitation Management ==


'''Osteoarthritis of the 1st CMC<br>'''Osteoarthritis of the 1st CMC typically occurs in individuals greater than 50 years old, and will most frequently present with morning stiffness of the 1st CMC joint, a general decrease in ROM of the joint,&nbsp;tenderness along the joint line, and a positive grind test.<ref name="Walker">Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004:34(12).</ref> <br>
* '''Ice/Heat Packs'''  
** Heat can help relax and loosen tight musculature, and ice can be used to help relieve inflammation of the extensor sheath
* '''Strengthening'''
**The progression of exercise therapy is as follows:<ref name=":2" />
*** Isometric
*** Eccentric
*** Concentric inner range
*** Theraputy
*** Radial nerve glides


== Outcome Measure ==
Patients can start with strengthening exercises once their pain has settled to a manageable level. The strengthening programme should be graded and very gradual. Only progress patients through the strengthening programme if they are able to tolerate their current strength programme for at least 1 week. It is important to progress slowly and that patients strengthen in a pain-free range of motion, to avoid aggravation of symptoms.<ref name=":2" /> Below are some examples of strengthening exercises.<div class="row">
 
  <div class="col-md-4"> {{#ev:youtube|watch?v=3_8SIqWZ8w4&t=9s|250}} <div class="text-right"><ref>Rehab my Patient. Abductor pollicis longus strengthening. Available from: https://www.youtube.com/watch?v=3_8SIqWZ8w4&t=9s[last accessed 10 November 2021]</ref></div></div>
*[[DASH Outcome Measure|DASH Outcome Measure]] -&nbsp;questionnaire that measures an individual’s ability to complete tasks and the severity of symptoms <ref name="Gummesson">Gummesson C., Ward M.M., Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskeletal Disorders. 2006; 7(44): 1-7.</ref>  
  <div class="col-md-4"> {{#ev:youtube|watch?v=JlNiPRTe4Rw|250}} <div class="text-right"><ref>Rehab my Patient. Isometric thumb extension. Available from: https://www.youtube.com/watch?v=JlNiPRTe4Rw [last accessed 10 November 2021]</ref></div></div>
*<u>Numeric Pain Rating Scale (NPRS)</u> - 0-10, 0 = no pain, 10 = extremely painful
<div class="col-md-4"> {{#ev:youtube|watch?v=rSzba5Cq6SM|250}} <div class="text-right"><ref>Rehab my Patient. Radial deviation isometric. Available from: https://www.youtube.com/watch?v=rSzba5Cq6SM [last accessed 10 November 2021]</ref></div></div>
*<u>Patient Specific Functional Scale (PSFS)</u> - Self report patient specific measure that aims to assess functional change. Includes identification of up to five important activities the patient is unable to perform. Patients rate level of difficulty on an 11 point scale (0-10, 0 = unable to perform, 10 = able to perform) <ref name="Horn">Horn KK, Jennings S, Richardson G, et al. The Patient-Specific Functional Scale: psychometric, clinimetrics, and application as a clinical outcome measure. Graduate, School of Physiotherapy, University of Otago, New Zealand. 2010.</ref><br>
</div>
 
<div class="row">
== Examination  ==
  <div class="col-md-4"> {{#ev:youtube|v=5kp45nPJxa8 |250}} <div class="text-right"><ref>Rehab my Patient. Thumb and finger band strengthening Available from: https://www.youtube.com/watch?v=5kp45nPJxa8 [last accessed 11 November 2021]</ref></div></div>
  <div class="col-md-4"> {{#ev:youtube|v=0me9b2Kjkbc |250}} <div class="text-right"><ref>Rehab my Patient.Thumb strengthening with band part 1 Available from: https://www.youtube.com/watch?v=0me9b2Kjkbc [last accessed 6/6/2009]</ref></div></div>
<div class="col-md-4"> {{#ev:youtube|v=IgokBrYeIy8|250}} <div class="text-right"><ref>Rehab my Patient. Thumb strengthening with band part 2 Available from: https://www.youtube.com/watch?v=IgokBrYeIy8 [last accessed 11 November 2021]</ref></div></div>
</div>
<div class="row">
  <div class="col-md-4"> {{#ev:youtube|v=qSLGFWWQjfU|250}} <div class="text-right"><ref>Rehab my Patient. Wrist flexion with a band. Available from: https://www.youtube.com/watch?v=qSLGFWWQjfU[last accessed 11 November 2021]</ref></div></div>
  <div class="col-md-4"> {{#ev:youtube|v=YetNUU3sCH4|250}} <div class="text-right"><ref>Rehab my Patient. Wrist band strengthening. Available from: https://www.youtube.com/watch?v=YetNUU3sCH4 [last accessed 11 November 2021]</ref></div></div>
<div class="col-md-4"> {{#ev:youtube|v=a_92x8kpOqo|250}} <div class="text-right"><ref>Rehab my Patient. Radial deviation band Available from: https://www.youtube.com/watch?v=a_92x8kpOqo [last accessed 11 November 2021]</ref></div></div>
</div>
<gallery widths="250px" heights="150px">
File:Wrist extension eccentric.png|Eccentric wrist extension
File:Wrist flexion eccentric.png|Eccentric wrist flexion
File:Wrist radial deviation eccentric.png|Eccentric wrist radial deviation  </gallery>
* '''Mobilisation'''
** Mobilisation with movement has shown effectiveness in decreasing the pain, improving range of motion, and improving the function of a patient with De-Quervain's tenosynovitis. The therapist provided a manual radial glide of the proximal row of carpals, then asked the patient to move her thumb into radial abduction-adduction.<ref>Backstrom KM. Mobilization with movement as an adjunct intervention in a patient with complicated de Quervain's tenosynovitis: a case report. Journal of Orthopaedic & Sports Physical Therapy. 2002 Mar;32(3):86-97.</ref> Mobilisation with movement performed for 3 sets of 10 repetitions and followed by eccentric hammer curl exercise with theraband and high voltage electrical stimulation was shown to be effective at 6 months follow-up.<ref>Rabin A, Israeli T, Kozol Z. Physiotherapy Management of People Diagnosed with de Quervain's Disease: A Case Series. Physiotherapy Canada. 2015 Aug;67(3):263-7.</ref> Savva et al.<ref>Savva C, Karagiannis C, Korakakis V, Efstathiou M. The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review. Journal of Manual & Manipulative Therapy. 2021 Mar 28:1-2.</ref> investigated the analgesic effect of joint mobilisation in tendinopathy and concluded that the literature on joint mobilisations in tendinopathies such as De Quervain's remains limited since the effect of these techniques have been sparsely reported in a few retrospective case-series and case studies.
{{#ev:youtube|eRCE501w0-s|300}}<ref>Bob & Brad | KDe Quervain's Syndrome-How to Stop It When It Just Keeps Hurting! Available from: https://youtu.be/eRCE501w0-s [last accessed 26/10/2021]</ref>


The evaluation of a pt. with signs and symptoms of De Quervain’s Tenosynovitis begins with a thorough history followed by a physical examination:  
* '''Taping'''
** Taping can also be used to decrease pain and improve function.<ref>Kaçmaz İE, Koca A, Basa CD, Zhamilov V, Reisoğlu A. Efficacy of Kinesiologic Taping in de Quervain's Tenosynovitis: Case Series and Review of Literature. Medical Journal of Bakirkoy. 2019 Sep 1;15(3).</ref>


'''History'''
{{#ev:youtube|n-m9RT7sdUA|300}}<ref>STRENGTHTAPE®| Kinesiology Tape | De Quervain.  Available from: https://youtu.be/n-m9RT7sdUA [last accessed 26/10/2021]</ref>


• Overuse injury vs acute trauma<br>• Prior hx of sxs<br>• Repetitive movements of the UE with work or ADL<br>• Pn localized over the base of thumb and dorsolateral aspect of the wrist near radial styloid process<br>• Hand dominance<br>• Pregnant or currently in post-partum stage
* '''Ultrasound'''
** Therapeutic ultrasound has also better outcomes in pain reduction and healing. <ref name=":1">Goel R, Abzug JM. De Quervain's tenosynovitis: a review of the rehabilitative options. Hand. 2015 Mar;10(1):1-5.</ref>


'''Physical Exam'''  
* '''Education ideas for mothers or care takers with De Quervain's'''
{{#ev:youtube|sILt995Pgqo|300}}<ref>
Grampians Health Ballarat| Looking after your baby when you have De Quervain's.  Available from: https://www.youtube.com/watch?v=sILt995Pgqo [last accessed 18/10/2023]</ref>


'''Vitals:'''<br>• Height<br>• Body weight<br>• Blood Pressure<br>• Pulse Rate<br>• Respiration Rate<br>• Temperature (if indicated)<br>''*Establish a baseline for patients overall health status*''


'''Observation in Sitting:'''<br>• Resting posture of the hand/thumb<br>• Inflammation around dorsal aspect of the base of the thumb and/or near the radial styloid process
=== Red Flags ===
[[File:Red flag photo.jpg|thumb|165x165px]]
Red flags to look out for in patients with De Quervain's can include:<ref name=":2" />


'''Neurological Screen –If indicated (1. Pt. complains of numbness and/or tingling 2. Reproduction of pn with movement of the cervical spine):'''
* Signs of infection such as unresolved redness or swelling
* High levels of pain (≥ 7/10) after 4 weeks of conservative treatment
* High demand workplace or someone who is forced to continue with aggravating activities


• Dermatomes (C4- T1)<br>• Myotomes (C4- T1)<br>• Reflexes (C5, C6, C7)<br>• Pathological (Hoffman’s)
== Conclusion ==
Effective management of DeQuervain’s tenosynovitis will involve a highly individualised, impairment driven approach for the patient in question. Early splinting during the acute phase will prevent aggravation of the tissues, and allow the patient to perform activities essential to self-care and employment. The patient will need to be educated on the tissue healing timetables, as well as why it is important to avoid activities that are aggravating to their symptoms. The progression of exercise therapy is from isometric to eccentric to concentric inner range. Patients should be pain-free before progressing to the next level of strengthening. 


''*Identify if there is any involvement with the CNS, Possible decreased sensation of skin innervated by superficial radial sensory nn (dorsal aspect of the thumb and index finger), take note of weakness secondary to pn, or actual weakness due to a neurological involvement*''
== References ==
 
<br>'''Palpation:'''<br>• Radial Dorsal Zone <br>&nbsp; &nbsp;o Radial Styloid Process <br>&nbsp; &nbsp;o “Anatomical Snuff Box” – Scaphoid, Trapezium, EPL, EPB, APL <br>&nbsp; &nbsp;o 1st CMC jt. <br>• Soft tissue surrounding involved area
 
''*Key Findings: TTP over the base of thumb and/or 1st dorsal compartment extensor tendons on thumb side of wrist particularly over the radial styloid process, may also find palpable thickening of the synovial sheaths*<br>*Rule Out: palpate over the musculotendinous junction of the wrist extensors at the lateral epicondyle of the humerus to R/O lat. Epicondylitis, palpate 1st CMC for joint line tenderness and/or deformity to r/o OA, scaphoid bone to r/o scaphoid fx*''
 
'''Range of Motion:'''<br>• Cervical ROM<br>&nbsp; &nbsp;o Flexion, Extension, R&amp;L SB, R&amp;L Rotation<br>''*Screening to rule out cervical involvement*''
 
• Shldr/Elbow/Forearm<br>&nbsp; &nbsp;o Shldr Flex/Ext/Abd/Add<br>&nbsp; &nbsp;o Elbow Flexion/Extension<br>&nbsp; &nbsp;o FA Pronation/Supination<br>''*Screening to rule out proximal joints and structures*''
 
• Wrist<br>&nbsp; &nbsp;o Flex/Ext/UD/RD<br>• Digit 2-5<br>&nbsp; &nbsp;o Flex/Ext (MCP, PIP, DIP)<br>&nbsp; &nbsp;o AB/AD (MCP)<br>• Thumb<br>&nbsp; &nbsp;o Flex/Ext (CMC,MCP,IP)<br>&nbsp; &nbsp;o AB/AD (CMC,MCP)<br>&nbsp; &nbsp;o Opposition<br>''*Document impaired ROM’s, thumb may have a “catching” or “snapping” sensation while moving due to decreased mobility of tendon through synovial sheath*''
 
'''Resisted Muscle Tests: '''<br>• Fist Grip Strength <br>• Pinch Strength (pinch gauge)<br>''*Expect a decrease in strength secondary to pn, document max amount within pn free strength, can use as patients asterick to track progression throughout treatment*''
 
'''Muscle Length:'''<br>• Intrinsic flexibility<br>• Wrist flexors &amp; extensors
 
'''Joint accessory mobility: '''<br>• DRUJ<br>• Wrist<br>&nbsp; &nbsp;o RC, MC<br>• Thumb<br>&nbsp; &nbsp;o CMC,MCP, IP<br>• Digits<br>&nbsp; &nbsp;o MCP, PIP, DIP<br>''*Looking for areas of hyper/hypomobility, treatment will be impairment based, important to note that areas of hypomobility may be referring pn which appears to be De Quervain’s*''
 
'''Special Tests: '''<br>• Rule in<br>&nbsp; &nbsp;o Finkelsteins<br>''*Provocative test so perform with caution*''
• Rule Out<br>&nbsp; &nbsp;o Grind-CMC OA<br>&nbsp; &nbsp;o Palpation of scaphoid-Scaphoid Fx<br>&nbsp; &nbsp;o ULTT A-Superficial Radial Neuritis<br>&nbsp; &nbsp;o Cervical Radiculopathy CPR<br>&nbsp; &nbsp;o Joint Accessory Mobility- Intercarpal Instabilities<br>
 
'''Neurologic Tests:'''<br>• ULTT<br>&nbsp; &nbsp;o Radial nn<br>• Radial NN<br>&nbsp; &nbsp;o Tinel’s Sign<br>''*Superficial Radial nn may be involved due to its anatomical location near the 1st dorsal compartment of extensor tendons*''
 
'''Circulatory:'''<br>• Blanching/Capillary Refill
 
'''Capsuloligamentous-if an acute injury:'''<br>• Thumb &amp; Digit collateral ligament stress testing (varus/valgus)<br><br>
 
== Medical Management <br>  ==
 
The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling.
 
'''Non-Surgical Treatment:'''<br>To reduce pain and swelling, initial treatment of de Quervain's tenosynovitis may include:<br>• Immobilizing your thumb and wrist with a splint or brace to help rest your tendons. Clinicians do not agree on frequency and duration of the splint; some think it should be worn continually for four to six weeks; others recommend wearing it only as needed for pain. '''(Tendon trouble in the hands: de Quervain's tenosynovitis and trigger finger. Harvard Women's Health Watch )'''<br>• Avoiding repetitive or aggravating movements <br>• Applying ice to the affected area<br>• NSAIDs<br>• Injections of corticosteroid medications into the tendon sheath <br>• Physical Therapy <br> <br>'''Surgical Treatment:'''<br>Surgery is rare and is usually for those when non-surgical treatment has failed and the patient experiences persistent inflammation affecting his or her function. The goal of surgery is to open the dorsal compartment covering to make more room for the irritated tendons. The opening allows pressure relief of the tendons, to ultimately restore free tendon gliding. One study showed effective outcomes for compartmental reconstruction for De Quervain stenosing tenosynovitis. The surgical technique included lengthening of the first dorsal compartment with two incomplete parallel incisions in opposite directions. This technique allowed the compartment to not be completed disrupted and did not include sutures. The study reported that the advantages of the technique included simplicity of the surgery, restoration of normal anatomy, and prevention of complications (scarring, adhesions, and subluxation of tendons). The results reported 10 out of the 12 patients who were received the wrist operation demostrated complete relief of symptoms.'''( El Rassi)''' Despite the type if surgery patient should receive hand therapy post operatively to restore motion and strength to promote function with daily activities.<br><br>
 
== Physical Therapy Management <br> ==
 
There have not been any high quality studies examining the effects of conservative management as a standalone intervention. The vast majority of the literature focuses on corticosteroid and other injections in comparison to placebo. In studies where injections have been shown superior to splinting, the long term outcomes were not examined.
 
A Cochrane Review concluded that there is Silver Level evidence that corticosteroid injection is superior to splinting in relieving pain. The authors, however, concede that "the evidence is based on one very small controlled clinical trial of short duration and poor methodological quality, which included only pregnant and lactating women."<ref name="Cochrane">Peters-Veluthamaningal C, van der Windt DAWM, Winters JC, Meyboom-de Jong B. Corticosteroid injection for de Quervain’s tenosynovitis. Cochrane Database of Systematic Reviews 2009, Issue 3.</ref><br>
 
Walker presented a case study which examined the use of an impairment-based approach to direct manual interventions in a patient with radial wrist pain. Although deQuervain's was ultimately ruled out as the condition at hand, this report serves to support an impairment-based approach, using manual interventions - specifically grade IV radiocarpal, intercarpal, and 1st CMC joint mobilization - to relieve pain and dysfunction in radial wrist pain.<ref name="Walker">Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004:34(12).</ref>
 
Ashurst presented a case study in which a patient with diagnosed deQuervain's was prescribed oral anti-inflammatory medication coupled with night splinting and relative rest. The patient wore cock-up wrist splints at night and was instructed minimize the amount of text messaging (the action that preceded the condition)&nbsp;performed. This case study provides support for a relative rest approach, in which a patient avoids aggravating activities, while remaining otherwise active.<ref name="Ashurst">Ashurst JV, Turco DA, Lieb BE. Tenosynovitis Caused by Texting: An Emerging Disease. JAOA 2010:110(5).</ref>
 
Viikari-Juntura performed a literature review, and found that splinting is the most important component of treatment for tenosynovitis. It was found that a splint which allowed for some movement was superior to complete immobilization of the thumb with respect to duration of disability. It was also determined that time off from work was neither necessary nor desirable. It was also found that heat, massage, “motion,” and electrotherapy were not effective for reducing disability.<ref name="Viikari">Viikari-Juntura E. Tenosynovitis, peritendinitis and the tennis elbow syndrome. Scand J Work Environ Health 1984;10(6):443-449.</ref>
 
== Key Research  ==
 
[http://www.sjweh.fi/show_abstract.php?abstract_id=2314 Viikari-Juntura E. Tenosynovitis, peritendinitis and the tennis elbow syndrome. Scand J Work Environ Health 1984;10(6):443-449.]
 
[http://www.ncbi.nlm.nih.gov/pubmed/15643731 Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient With Radial Wrist Pain: A Case Report. J Orthop Sports Phys Ther 2004:34(12).]<br>
 
== Resources <br> ==
 
[http://www.mayoclinic.com/health/de-quervains-tenosynovitis/DS00692 Mayo Clinic Overview of DeQuervain's Tenosynovitis]
 
[http://www.webmd.com/rheumatoid-arthritis/de-quervains-disease WebMD Overview of DeQuervain's Tenosynovitis]
 
== Clinical Bottom Line ==
 
Effective management of DeQuervain’s tenosynovitis will involve a highly individualized, impairment driven approach for the patient in question. Early splinting during the acute phase will prevent aggravation of the tissues, and allow the patient to perform activities essential to self-care and employment. The patient will need to be educated on the tissue healing timetables, as well as why it is important to avoid activities that are aggravating to their symptoms. Once symptoms have decreased to the point that a splint is no longer necessary, the therapist will need to perform a thorough examination and evaluation to determine the residual effects from immobilization. Some losses in ROM may occur, and grade III-IV mobilizations of the radiocarpal, scapholunate, and 1st CMC joint would then be warranted.
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1L37KAMf2b_h4VDNYGinJ-AnU4o92fKIf7IY2Tt-5c3fPA9UuQ|charset=UTF-8|short|max=10</rss>
</div>
== References&nbsp; ==


<references />
<references />  


[[Category:Texas_State_University_EBP_Project]]
[[Category:Assessment]]
[[Category:Hand]]
[[Category:Wrist]]
[[Category:Special_Tests]]
[[Category:Tendons]]
[[Category:Texas_State_University_EBP_Project]]
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:EIM_Residency_Project]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Primary Contact]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Conditions]]
[[Category:Wrist - Conditions]]
[[Category:Hand - Conditions]]
[[Category:Hand - Special Tests]]
[[Category:Wrist - Special Tests]]
[[Category:Course Pages]]
[[Category:Plus Content]]

Latest revision as of 18:54, 18 October 2023

Original Editor - Elizabeth Dallas, Boris Alexandra, Robin Tacchetti

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Definition/Description[edit | edit source]

Anatomical snuffbox

De Quervain's Tenosynovitis is a painful, inflammatory condition caused by tendons on the side of the wrist at the base of the thumb. Pain, which is the main complaint, gets worse with abduction of the thumb, a grasping action of the hand, and an ulnar deviation of the wrist. Thickening and swelling can also be present. [1] [2][3]

Aetiology[edit | edit source]

  • The most common cause is chronic overuse.
  • Activities  such as golfing, playing the piano, fly fishing, carpentry, or activities by office workers and musicians can lead to chronic overuse injuries.
  • The classic patient population is mothers of newborns who are repeatedly lifting their baby with their thumbs radially abducted and wrists going from ulnar to radial deviation.
  • De Quervain's Anatomy
    Repetitive  gripping, grasping or wringing of objects can cause inflammation of the tendons and tendon sheaths which narrows the first dorsal compartment limiting motion of the tendons. If left untreated, the inflammation and progressive narrowing (stenosis) can lead to scarring that further limits thumb motion. [2][3]
  • De Quervain's has been "attributed to myxoid degeneration (the process in which the connective tissues are replaced by a gelatinous substance) with fibrous tissue deposits and increased vascularity rather than acute inflammation of the synovial lining."[4] It is for this reason that is thought to be a tendinosis rather than a tendonitis.[5] This deposition of the fibrous tissues causes thickening of the tendon sheath, and this can entrap the abductor pollicis longus and extensor pollicis brevis tendons and cause pain.

Relevant Clinical Anatomy[edit | edit source]

De Quervain's syndrome affects the extensor pollicis brevis (EPB) tendon and the abductor pollicis longus (APL) tendon. These muscles are located on the dorsal side of the forearm and go to the lateral side of the thumb through a fibrous-osseous tunnel made of the processus styloideus radii and the extensor retinaculum. [6]

  1. Extensor pollicis brevis (EPB)
    Forearm Anatomy
    • Origin: ½ dorsal side of the radius, the membrana interossea
    • Insertion: base of the proximal phalanx of the thumb
    • Function:
      • Wrist joint: radial abduction
      • Thumb: extension
    • Innervations: posterior interosseus branch of N. radialis
    • Artery: A. interossea posterior
  2. Abductor pollicis longus (APL)
    • Origin: dorsal side of the radius and the ulna, the membrana interossea
    • Insertion: base of ossis metacarpi
    • Function:
      • Wrist joint: radial abduction
      • Thumb: abduction
    • Innervations: posterior interosseus branch of N. radialis
    • Artery: A. interossea posterior

Epidemiology[edit | edit source]

  • Estimated prevalence is 0.5% in men and 1.3% in women. Peak prevalence is usually among individuals between the ages of 40 -50 years[7]
  • More commonly found in people with a history of medial or lateral epicondylitis
  • New mothers or child care providers often experience bilateral symptoms, but these symptoms usually subside once the child is lifted less often.[4]
  • In industrial settings, studies have shown a point prevalence of 8% when wrist pain and a positive Finkelstein’s test is present.[2]

Differential Diagnosis[edit | edit source]

  • Osteoarthritis of the first carpometacarpal joint(main differential diagnosis for De Quervain's Tenosynovitis[5])
  • Trigger thumb
  • Wartenberg's syndrome (superficial radial nerve neuritis)
  • Scaphoid or radial styloid fractures
  • Intersection syndrome

Clinical Presentation[edit | edit source]

Examination[edit | edit source]

The evaluation of a patient with signs and symptoms of De Quervain’s Tenosynovitis begins with a thorough history followed by a physical examination.

History[edit | edit source]

Wrist pain
  • Overuse injury vs acute trauma
  • Prior history of symptoms
  • Repetitive movements of the upper extremity with work or activities of daily living (ADL)
  • Hand dominance
  • Pregnant or currently in the post-partum stage
  • Pain:
    • The primary complaint is radial sided wrist pain (base of thumb and dorsolateral aspect of the wrist near the radial styloid process) that radiates up the forearm with grasping or extension of the thumb
    • Described as a “constant aching, burning, pulling sensation."[8]
    • Aggravated by repetitive lifting, gripping, or twisting motions of the hand (such as opening a jar lid).[8]

Physical Examination[edit | edit source]

  • On palpation, some key, significant findings will be tenderness over the base of the thumb and/or first dorsal compartment extensor tendons on the thumb side of the wrist, particularly over the radial styloid process[2]
  • Swelling in the anatomical snuffbox 
  • Decreased carpometacarpal (CMC) abduction range of motion (ROM) of the first digit
  • Palpable thickening of the extensor sheaths of the first dorsal compartment and crepitus of the tendons moving from the extensor sheath [9]
  • Other possible findings include:
    • Weakness and paraesthesia in the hand[3]
    • A provocative Finkelstein test
      • During this test, the thumb is flexed and held inside a fist. The patient actively deviates the wrist towards the ulnar side. This causes sharp pain along the radial wrist at the first dorsal compartment.[4]

Finkelstein Test video provided by Clinically Relevant

Treatment Tiers[edit | edit source]

Generally, there are three tiers of treatment for De Quervain's[5]:

  • Tier 1: Conservative management
    • splinting
    • ultrasound
    • multimodal hand therapy
    • activity modification
  • Tier 2: Corticosteroid injection
  • Tier 3: Surgery

Tiers 1 and 2 can be combined dependent on patient presentation and willingness to get a corticosteroid injection.[5]

Non-Surgical Treatment[edit | edit source]

The aim of non-surgical management is to reduce pain and swelling. Interventions can include:

  • Patient education regarding avoiding repetitive or aggravating movements[5]
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Ice/heat packs
  • Physical therapy[10]
  • Occupational therapy
  • Thumb splinting
    De Quervain's Splint
    • Literature supports the use of a forearm brace including the thumb to reduce ulnar deviation and thumb movement.[5]
    • Clinicians do not agree on the frequency and duration of splint use; some think it should be worn continually for four to six weeks; others recommend wearing it only as needed for pain.[11]
    • Weiss and colleagues[12] found that a 19% improvement was observed when splints were used, but when splint use was combined with NSAIDs, the improvement was 57%. Cavaleri et al.[7] reported that combined orthosis/corticosteroid injection approaches are more effective than either intervention alone in the treatment of de Quervain's disease.
  • Ultrasound may improve treatment outcomes[13]:
    • Therapeutic ultrasound
      • Ferrara et al.[14] reported that therapeutic ultrasound may effectively control pain. However, the studies in this systematic review were heterogenous, with poor sample sizes and wide variations in outcome measures.
    • Ultrasound-guided injections
      • McDermott et al.[15] found that ultrasound-guided injections were beneficial for De Quervain's tenosynovitis. Their results were slightly better than was previously reported in the literature and they reported no adverse reactions.[15]
      • Kume et al.[16] found that ultrasound-guided injections which target the Extensor Pollicis Brevis with septation was more effective than manual injection.
  • Corticosteroid injection has been reported to be be effective. One or two injections are usually sufficient for pain-relief.
    • If there is no significant improvement in symptoms following two corticosteroid injections, surgical management may be considered. Surgery is usually done in an outpatient setting and the anaesthetic may be local, regional or general.[4]
    • Patients with moderate to severe symptoms usually require cortisone injections in combination with splinting.[5]

** In individuals with persistent symptoms the most commonly non-surgical management includes: splinting, systemic anti-inflammatories, and corticosteroid injection.[7][13] [17]

Surgical Treatment[edit | edit source]

  • Surgery is rare and is usually selected in cases where non-surgical treatment has failed and the patient experiences persistent inflammation affecting his or her function. The goal of surgery is to open the dorsal compartment covering to make more room for the irritated tendons. The opening allows pressure relief of the tendons, to ultimately restore free tendon gliding.[18]
  • Post-operative care is usually straight forward with a simple dressing and no complicated wound care necessary. Individuals are encouraged to start with early use of the hand for light activities of daily living. Sutures are removed after 14 days and individuals are allowed to continue with normal activities. Mild swelling and tenderness around the surgical site may be present for a few months.[4]

Rehabilitation Management[edit | edit source]

  • Ice/Heat Packs
    • Heat can help relax and loosen tight musculature, and ice can be used to help relieve inflammation of the extensor sheath
  • Strengthening
    • The progression of exercise therapy is as follows:[5]
      • Isometric
      • Eccentric
      • Concentric inner range
      • Theraputy
      • Radial nerve glides

Patients can start with strengthening exercises once their pain has settled to a manageable level. The strengthening programme should be graded and very gradual. Only progress patients through the strengthening programme if they are able to tolerate their current strength programme for at least 1 week. It is important to progress slowly and that patients strengthen in a pain-free range of motion, to avoid aggravation of symptoms.[5] Below are some examples of strengthening exercises.

[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
  • Eccentric wrist extension

    Eccentric wrist extension

  • Eccentric wrist flexion

    Eccentric wrist flexion

  • Eccentric wrist radial deviation

    Eccentric wrist radial deviation

  • Mobilisation
    • Mobilisation with movement has shown effectiveness in decreasing the pain, improving range of motion, and improving the function of a patient with De-Quervain's tenosynovitis. The therapist provided a manual radial glide of the proximal row of carpals, then asked the patient to move her thumb into radial abduction-adduction.[28] Mobilisation with movement performed for 3 sets of 10 repetitions and followed by eccentric hammer curl exercise with theraband and high voltage electrical stimulation was shown to be effective at 6 months follow-up.[29] Savva et al.[30] investigated the analgesic effect of joint mobilisation in tendinopathy and concluded that the literature on joint mobilisations in tendinopathies such as De Quervain's remains limited since the effect of these techniques have been sparsely reported in a few retrospective case-series and case studies.

[31]

  • Taping
    • Taping can also be used to decrease pain and improve function.[32]

[33]

  • Ultrasound
    • Therapeutic ultrasound has also better outcomes in pain reduction and healing. [34]
  • Education ideas for mothers or care takers with De Quervain's

[35]


Red Flags[edit | edit source]

Red flag photo.jpg

Red flags to look out for in patients with De Quervain's can include:[5]

  • Signs of infection such as unresolved redness or swelling
  • High levels of pain (≥ 7/10) after 4 weeks of conservative treatment
  • High demand workplace or someone who is forced to continue with aggravating activities

Conclusion[edit | edit source]

Effective management of DeQuervain’s tenosynovitis will involve a highly individualised, impairment driven approach for the patient in question. Early splinting during the acute phase will prevent aggravation of the tissues, and allow the patient to perform activities essential to self-care and employment. The patient will need to be educated on the tissue healing timetables, as well as why it is important to avoid activities that are aggravating to their symptoms. The progression of exercise therapy is from isometric to eccentric to concentric inner range. Patients should be pain-free before progressing to the next level of strengthening.

References[edit | edit source]

  1. ↑ Pagonis T, Ditsios K, Toli P, Givissis P, Christodoulou A. Improved corticosteroid treatment of recalcitrant de Quervain tenosynovitis with a novel 4-point injection technique. The American journal of sports medicine. 2011 Feb;39(2):398-403.
  2. ↑ 2.0 2.1 2.2 2.3 Ashurst JV, Turco DA, Lieb BE. Tenosynovitis caused by texting: an emerging disease. Journal of Osteopathic Medicine. 2010 May 1;110(5):294-6.
  3. ↑ 3.0 3.1 3.2 González-iGlesias J, Huijbregts P, Fernández-de-Las-Peñas C, Cleland JA. Differential diagnosis and physical therapy management of a patient with radial wrist pain of 6 months' duration: a case report. journal of orthopaedic & sports physical therapy. 2010 Jun;40(6):361-8.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Satteson E, Tannan SC. De Quervain Tenosynovitis. StatPearls [Internet]. 2021 Aug 8.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 Kate Thorn. De Quervain's Tenosynovitis. Plus Course. 2021
  6. ↑ Katechia D, Gujral S. De Quervain's tenosynovitis. InnovAiT. 2017 Sep;10(9):505-9.
  7. ↑ 7.0 7.1 7.2 Cavaleri R, Schabrun SM, Te M, Chipchase LS. Hand therapy versus corticosteroid injections in the treatment of de Quervain's disease: A systematic review and meta-analysis. Journal of Hand Therapy. 2016 Jan 1;29(1):3-11.
  8. ↑ 8.0 8.1 Walker MJ. Manual physical therapy examination and intervention of a patient with radial wrist pain: a case report. Journal of orthopaedic & sports physical therapy. 2004 Dec;34(12):761-9.
  9. ↑ Anderson M, Tichenor CJ. A patient with de Quervain's tenosynovitis: a case report using an Australian approach to manual therapy. Physical therapy. 1994 Apr 1;74(4):314-26.
  10. ↑ Földvári-Nagy L, Takács J, Hetthéssy JR, Mayer ÁA, Szakács N, Szávin-Pósa Á, Lenti K. Treatment of De Quervain's tendinopathy with conservative methods. Orvosi Hetilap. 2020 Mar 1;161(11):419-24.
  11. ↑ Huisstede BM, Gladdines S, Randsdorp MS, Koes BW. Effectiveness of conservative, surgical, and postsurgical interventions for trigger finger, Dupuytren disease, and De Quervain disease: a systematic review. Archives of physical medicine and rehabilitation. 2018 Aug 1;99(8):1635-49.
  12. ↑ Weiss AP, Akelman E, Tabatabai M. Treatment of de Quervain's disease. The Journal of hand surgery. 1994 Jul 1;19(4):595-8.
  13. ↑ 13.0 13.1 Abi-Rafeh J, Kazan R, Safran T, Thibaudeau S. Conservative management of de Quervain stenosing tenosynovitis: review and presentation of treatment algorithm. Plastic and reconstructive surgery. 2020 Apr 15;146(1):105-26.
  14. ↑ Ferrara PE, Codazza S, Cerulli S, Maccauro G, Ferriero G, Ronconi G. Physical modalities for the conservative treatment of wrist and hand's tenosynovitis: A systematic review. InSeminars in arthritis and rheumatism 2020 Dec 1 (Vol. 50, No. 6, pp. 1280-1290). WB Saunders.
  15. ↑ 15.0 15.1 McDermott JD, Ilyas AM, Nazarian LN, Leinberry CF. Ultrasound-guided injections for de Quervain’s tenosynovitis. Clinical Orthopaedics and Related Research®. 2012 Jul;470(7):1925-31.
  16. ↑ Kume K, Amano K, Yamada S, Amano K, Kuwaba N, Ohta H. In de Quervain’s with a separate EPB compartment, ultrasound-guided steroid injection is more effective than a clinical injection technique: a prospective open-label study. Journal of Hand Surgery (European Volume). 2012 Jul;37(6):523-7.
  17. ↑ Başar B, Aybar A, Basar G, Başar H. The effectiveness of corticosteroid injection and splint in diabetic de Quervain's tenosynovitis patients: A single-blind, randomized clinical consort study. Medicine. 2021 Sep 3;100(35).
  18. ↑ Saaiq M. Management Outcome of de Quervain’s Disease with Corticosteroid Injection Versus Surgical Decompression. Archives of Bone and Joint Surgery. 2021 Mar;9(2):167.
  19. ↑ Rehab my Patient. Abductor pollicis longus strengthening. Available from: https://www.youtube.com/watch?v=3_8SIqWZ8w4&t=9s[last accessed 10 November 2021]
  20. ↑ Rehab my Patient. Isometric thumb extension. Available from: https://www.youtube.com/watch?v=JlNiPRTe4Rw [last accessed 10 November 2021]
  21. ↑ Rehab my Patient. Radial deviation isometric. Available from: https://www.youtube.com/watch?v=rSzba5Cq6SM [last accessed 10 November 2021]
  22. ↑ Rehab my Patient. Thumb and finger band strengthening Available from: https://www.youtube.com/watch?v=5kp45nPJxa8 [last accessed 11 November 2021]
  23. ↑ Rehab my Patient.Thumb strengthening with band part 1 Available from: https://www.youtube.com/watch?v=0me9b2Kjkbc [last accessed 6/6/2009]
  24. ↑ Rehab my Patient. Thumb strengthening with band part 2 Available from: https://www.youtube.com/watch?v=IgokBrYeIy8 [last accessed 11 November 2021]
  25. ↑ Rehab my Patient. Wrist flexion with a band. Available from: https://www.youtube.com/watch?v=qSLGFWWQjfU[last accessed 11 November 2021]
  26. ↑ Rehab my Patient. Wrist band strengthening. Available from: https://www.youtube.com/watch?v=YetNUU3sCH4 [last accessed 11 November 2021]
  27. ↑ Rehab my Patient. Radial deviation band Available from: https://www.youtube.com/watch?v=a_92x8kpOqo [last accessed 11 November 2021]
  28. ↑ Backstrom KM. Mobilization with movement as an adjunct intervention in a patient with complicated de Quervain's tenosynovitis: a case report. Journal of Orthopaedic & Sports Physical Therapy. 2002 Mar;32(3):86-97.
  29. ↑ Rabin A, Israeli T, Kozol Z. Physiotherapy Management of People Diagnosed with de Quervain's Disease: A Case Series. Physiotherapy Canada. 2015 Aug;67(3):263-7.
  30. ↑ Savva C, Karagiannis C, Korakakis V, Efstathiou M. The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review. Journal of Manual & Manipulative Therapy. 2021 Mar 28:1-2.
  31. ↑ Bob & Brad | KDe Quervain's Syndrome-How to Stop It When It Just Keeps Hurting! Available from: https://youtu.be/eRCE501w0-s [last accessed 26/10/2021]
  32. ↑ Kaçmaz İE, Koca A, Basa CD, Zhamilov V, Reisoğlu A. Efficacy of Kinesiologic Taping in de Quervain's Tenosynovitis: Case Series and Review of Literature. Medical Journal of Bakirkoy. 2019 Sep 1;15(3).
  33. ↑ STRENGTHTAPE®| Kinesiology Tape | De Quervain. Available from: https://youtu.be/n-m9RT7sdUA [last accessed 26/10/2021]
  34. ↑ Goel R, Abzug JM. De Quervain's tenosynovitis: a review of the rehabilitative options. Hand. 2015 Mar;10(1):1-5.
  35. ↑ Grampians Health Ballarat| Looking after your baby when you have De Quervain's. Available from: https://www.youtube.com/watch?v=sILt995Pgqo [last accessed 18/10/2023]
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