De Quervain's Tenosynovitis


Definition/Description

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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 (EPB) and the abductor pollicis longus (APL). 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. [1] [2] The pain, which is the main complaint, gets worse with the abduction of the thumb, grasping action of the hand, and an ulnar deviation of the wrist. Thickening and swelling can also be present. [3] [4][5][6]

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Relevant Clinical Anatomy

The tendon sheaths around the abductor pollicis longus and extensor pollicis brevis pass through the fibro-osseous tunnel located along the radial styloid at the distal wrist.

M. extensor pollicis brevis (EPB)

  • 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: N. radialis
  • Artery: A. interossea posterior

M. 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: N. radialis
  • Artery: A. interossea posterior
Aetiology

De Quervain tenosynovitis

  • 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. This deposition results in thickening of the tendon sheath, painfully entrapping the abductor pollicis longus and extensor pollicis brevis tendons.
  • It is associated with repetitive wrist motion, specifically motion requiring thumb radial abduction and simultaneous extension and radial wrist deviation.
  • The classic patient population is mothers of newborns who are repeatedly lifting a newborn with thumbs radially abducted and wrists going from ulnar to radial deviation.
  • The most common cause is chronic overuse.
  • Activities such as golfing, playing the piano, fly fishing, carpentry, office workers and musicians can lead to chronic overuse injuries.
  • Repetitive 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 lead to scarring that further limits thumb motion. [4][5][6]

Epidemiology

  • The estimated prevalence of de Quervain tenosynovitis is about 0.5% in men and 1.3% in women with peak prevalence among those in their forties and fifties.
  • It may be seen more commonly in individuals with a history of medial or lateral epicondylitis.
  • Bilateral involvement is often reported in new mothers or child care providers in whom spontaneous resolution typically occurs once lifting of the child is less frequent[7]
  • In industrial settings, studies have shown a point prevalence of 8% when wrist pain and a positive Finkelstein’s test is present.[4]

Characteristics/Clinical Presentation

The primary complaint 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."[8] Pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand.[8] Swelling in the anatomical snuff box, 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.[9] Other possible findings include weakness and paresthesia in the hand.[6] Finkelstein’s diagnostic test will present positive provoking the patient’s symptoms.

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:

History
  • Overuse injury vs acute trauma
  • Prior history of symptoms
  • Repetitive movements of the upper extremity with work or activities of daily living (ADL)
  • Pain localized over the base of the thumb and dorsolateral aspect of the wrist near the radial styloid process
  • Hand dominance
  • Pregnant or currently in the post-partum stage
Physical Exam
  • Patients present with radial-sided wrist pain which is typically worsened by thumb and wrist motion.
  • The condition may be associated with pain or difficulty with tasks such as opening a jar lid.
  • Tenderness overlying the radial styloid is usually present, and fusiform swelling in this region may also be appreciated.
  • On palpation, some key, significant findings will be tenderness over the base of the thumb and/or 1st dorsal compartment extensor tendons on the thumb side of wrist particularly over the radial styloid process[4]
  • The provocative Finkelstein test, in which the thumb is flexed and held inside a fist, and the patient actively clearly deviates the wrist, causes sharp pain along the radial wrist at the first dorsal compartment.[7]

Medical Management

De Quervain tendinopathy can be self-limited and may resolve without intervention.

  • For those individuals with persistent symptoms, splinting, systemic anti-inflammatories, and corticosteroid injection are the most frequently utilized non-surgical treatment options.
  • Splinting with a thumb spica brace may offer patients temporary relief, but failure and recurrence are often high and compliance low
Non-Surgical Treatment

The aim of non-surgical management is to reduce pain and swelling; initial treatment of de Quervain's tenosynovitis may include:

  • Immobilizing your thumb and wrist with a splint or brace to help rest your tendons. Clinicians do not agree on the 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.[5]
  • Avoiding repetitive or aggravating movements
  • Applying ice to the affected area
  • Nonsteroidal anti-inflammatory drugs (NSAIDS)
  • Physical Therapy

Patients may also be prescribed for immobilization for up to 6 weeks. A splint for thumb immobilization can do this. When used a 19% improvement was observed but when they combined it with NSAID’s they found an even bigger improvement of 57%. [10]

Ultrasound is thought to improve the treatment outcome and can be used as a diagnostic tool in the management of de Quervain’s disease.[11]  Success with ultrasound-guided injections was better than it was reported in the literature and without adverse reactions.[12] Ultrasound-guided injections targeting the M. Extensor Pollicis Brevis with septation is more effective than manual injection. [13]

Surgical Treatment

The 1-minute video shows the simple surgery performed.

  • 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.
    [14]
  • Corticosteroid injection has been reported to provide near-complete relief with one or two injections. The injection is performed into the tendon sheath about 1 cm proximal to the radial styloid where the tendons are palpable.
  • If symptoms fail to improve or recur after two corticosteroid injections, operative management is an option. Surgery is usually performed in an outpatient setting. It can entail local, regional, or general anesthesia.[7]
  • Post-operative care is usually limited. A simple dressing or wrap is frequently utilized with no need for complex wound care. Patients are advised to begin early use for activities of daily living and other light activities. Once sutures are removed, usually by two weeks, patients are typically released to resume normal activities. Patients may continue to experience mild swelling and tenderness at the surgical site for a few months.[7]

Physical Therapy Management

This video shows the technique, used a lot in practice, by R McKenzie

[15]

Ice/Heat Packs - Heat can help relax and loosen tight musculature, and ice can be used to help relieve inflammation of the extensor sheath.

Massage - Deep tissue massage at the thenar eminence can help relax tight musculature that causes pain. (See video). Graston Technique of manual soft tissue mobilization along with the eccentric exercise is also helpful. Graston technique includes breaking down fascia restriction, stretching connective tissue, and promoting a better healing environment.[16]

Stretching - Stretching the thenar eminence muscles into thumb extension and abduction can relax and lengthen this tight musculature that causes pain.[16] (See video )

Increasing Strength

  • Resisted finger and thumb extension
  • Palm up position - for thumb extension and abduction strength
  • Thumb up position - for thumb extension and abduction strength
  • Resisted radial deviation
  • In thumb up position
  • Resisted supination
  • In thumb up position
  • Resisted thumb opposition
  • In thumb up position

Improving Range of Motion Stretching as explained above can be used to improve range of motion. Ice/Heat packs can relax tight musculature so that you can attain a bigger range of motion.

Mobilization with movement has shown effectiveness in decreasing the pain, improving range of motion, and improving the function of a patient with De-Quervain tenosynovitis. The therapist provides a manual radial glide of the proximal row of carpals, then asked the patient to move her thumb into radial abduction-adduction.[17] Mobilization with movement performed for 3 sets of 10 repetitions and followed by eccentric hammer curl exercise with theraband and high voltage electrical stimulation has shown effective result after 6 months followup, [18]

Kinesio-taping Technique can also be used to decrease pain and improve function.[19]

Therapeutic Ultrasound has also better outcomes in pain reduction and healing. [16]

Decreasing Swelling To decrease swelling you can use:

  • Thumb splinting
  • Corticosteroid injections
  • NSAIDs
  • Ice/heat packs
  • Massage
  • Stretching

Home Management Programme

Any of the above stretching and strengthening exercises can be done as a home exercise program (HEP). Patients can also use ice and heat packs at home. After education, patients can perform self-massage techniques at home, and if chosen as the preferred intervention.

Evidence for Management

Conflicting, the below is a summary

  • Corticosteroid injection is superior to splinting in relieving pain[20]
  • An Impairment-based approach using manual interventions (specifically grade IV radiocarpal, intercarpal, and 1st CMC joint mobilization) relieves pain and dysfunction in radial wrist pain.[8]
    Oral anti-inflammatory medication coupled with night splinting and relative rest is of use (relative rest approach, in which a patient avoids aggravating activities while remaining otherwise active).[4]
  • Splinting is the most important component of treatment for tenosynovitis. It was found that a splint that allowed for some movement was superior to complete immobilization of the thumb with respect to duration of the disability.[21]
  • Time off from work was neither necessary nor desirable.
Differential Diagnosis
Outcome Measures
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. As the patient nears discharge, education should include a component on the importance of avoiding repetitive motions that could play an aggravating role, or potentially lead to a relapse of the condition.

References

  1. SCHUNKE, M., SCHULTE, E., SCHUMACHER, U., VOLL, M., WESKER, K., Prometheus, Bohn Stafleu van Loghum, Houten, 2005.
  2. MEEUSEN, R., Praktijkgids pols- en handletsels, Kluwer editorial, Diegem, 1999.
  3. Thomas Pagonis, Konstantinos Ditsios. Improved Corticosteroid Treatment of Recalcitrant de Quervain Tenosynovitis With a Novel 4-Point Injection Technique. Am J Sports Med 2011 (Level of evidence 2B)
  4. 4.0 4.1 4.2 4.3 4.4 Ashurst JV, Turco DA, Lieb BE. Tenosynovitis Caused by Texting: An Emerging Disease. JAOA 2010:110(5).
  5. 5.0 5.1 5.2 Harvard Women's Health Watch. Harvard Health Publications. Copyright 2010 by President and Fellows of Harvard College. www.healthharvard.edu. Accessed 11/27/11.
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  11. Hajder E., The role of ultrasound-guided triamcinolone injection in the treatment of de Quervain’s disease: treatment and diagnostic tool?, Chirurgie de la main, 2013, vol.6, p. 403-7,( level of evidence: 2B).
  12. James D. McDermott, Ultrasound-guided injections for de Querain’s tenosynovitis, Clin. Othop. Relat. Res., 2012, vol. 7, p. 1925-1931,( level of evidence: 4.)
  13. Kume K., 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, vol. 6, p.523-7,( level of evindence: 1B).
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  15. Bob abd Brad Dequervains https://www.youtube.com/watch?v=eRCE501w0-s Available from:https://www.youtube.com/watch?v=eRCE501w0-s (last accessed 31.3.2020)
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