De Quervain's Tenosynovitis

Definition/Description

De Quervain's Tenosynovitis is a painful condition, historically termed an inflammatory tenosynovitis, 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]

Clinical Pearl: Tendon terminology

Tendinitis – active tendon inflammation, typically acute

Tendinosis – chronic, non-inflammatory tendon degeneration (the more accurate term for De Quervain's)

Tendinopathy – umbrella term for tendon pain/dysfunction where the underlying pathology isn't confirmed histologically

Tenosynovitis – pathology of the tendon sheath rather than the tendon body; anatomically correct for De Quervain's, though "-itis" overstates the inflammatory component
These terms are often used loosely and interchangeably in clinical practice; management doesn't hinge on which one is used.^[4]^[5]

Aetiology

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.

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.^[6] If left untreated, the inflammation and progressive narrowing (stenosis) can lead to scarring that further limits thumb motion. ^[2]^[3]

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. More recent histopathological analysis has identified inflammatory markers, including neutrophil elastase and macrophages, within De Quervain's tissue, suggesting an inflammatory component may still play a role, particularly in earlier stages of the condition.^[7]

Relevant Clinical Anatomy

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. ^[8]

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

Innervation: posterior interosseus branch of N. radialis
Artery: A. interossea posterior

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

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.^[9] It occures 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.^[10] 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

Osteoarthritis of the first carpometacarpal joint(main differential diagnosis for De Quervain's Tenosynovitis^[11])
Trigger thumb
Wartenberg's syndrome (superficial radial nerve neuritis)
Scaphoid or radial styloid fractures
Intersection syndrome

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.

History

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."^[12] Aggravated by repetitive lifting, gripping, or twisting motions of the hand (such as opening a jar lid).^[12]

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^[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 ^[13]
Other possible findings include: weakness and paraesthesia in the hand^[3] and a positive provocative Eichhoff manoeuvre. 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.^[10]

Clinical Pearl: Eichhoff manoeuvre vs Finkelstein test

Eichhoff manoeuvre – patient makes a fist around the thumb, then actively deviates the wrist ulnarly; this is the version most commonly performed in clinical practice

Finkelstein test – the original description; a graded, largely examiner-led sequence: active ulnar deviation first, then overpressure if needed, then passive thumb flexion into the palm by the examiner

The two are frequently confused and used interchangeably, a mix-up traced back to a 1958 paper that mislabelled the Eichhoff manoeuvre as "Finkelstein's test"

The Eichhoff version tends to produce more false positives than the original Finkelstein sequence, so bear this in mind when interpreting a positive result
Please see this optional Physiopedia Page for more information on this topic.

Treatment Tiers

Generally, there are three tiers of treatment for De Quervain's^[11]:

Tier 1: Conservative management, including: splinting, ultrasound, multimodal hand therapy, and 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.^[11]

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^[11]

Non-steroidal anti-inflammatory drugs (NSAIDs)

Ice/heat packs

Physical therapy^[14]

Occupational therapy

Thumb splinting. Literature supports the use of a forearm brace including the thumb to reduce ulnar deviation and thumb movement.^[11]^[15]^[16] 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.^[17] Weiss and colleagues^[18] 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.^[9] 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.^[19] Therapeutic ultrasound. Ferrara et al.^[20] 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.^[21] 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.^[21] Kume et al.^[22] 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.^[15] One or two injections are usually sufficient for pain-relief.^[23] 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.^[10] Patients with moderate to severe symptoms usually require cortisone injections in combination with splinting.^[11]

In individuals with persistent symptoms the most commonly non-surgical management includes: splinting, systemic anti-inflammatories, and corticosteroid injection.^[9]^[19] ^[24]

Surgical Treatment

Surgery is rare and is usually selected in cases where non-surgical treatment has failed and the patient experiences persistent inflammation affecting their function.^[25] 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.^[26]

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.^[10]

Rehabilitation Management

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: isometric, eccentric, concentric inner range, theraputy, radial nerve glides.^[11]

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.^[11] Below are some examples of strengthening exercises.