De Quervain's Tenosynovitis

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Lead Editors - Corin Arundale, David Cameron, John Fite, Bryan Purkey, John Winkelhaus

Search Strategy

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Definition/Description

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Epidemiology/Etiology

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. 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 [Harvard women’s].

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.

Characteristics/Clinical Presentation

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." Pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand. 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. Other possible findings include weakness and paresthesia in the hand. Finkelstein’s diagnostic test will present positive provoking the patient’s symptoms.

Differential Diagnosis

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.

Intersection Syndrome
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.

Intercarpal Instabilities
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.

Scaphoid Fracture
A scaphoid fracture most commonly occurs by a FOOSH in wrist extension and will present with radial sided wrist pain, tenderness and possible swelling in the anatomical snuff box, and limited ROM with pain especially at end ranges. If the patient presents with radial side wrist pain after a traumatic injury a scaphoid fracture must be ruled out.

Superficial Radial Neuritis
The superficial radial nerve supplies sensation to the dorsal surfaces of digits 1-2 and the first 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.

C6 Cervical Radiculopahy
Compression on a spinal nerve root can cause sensory disturbances, myotomal weakness, and diminished reflexes throughout the root's 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 thorough screen of the cervical spine is necessary.

Osteoarthritis of the 1st CMC
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, tenderness along the joint line, and a positive grind test.

Outcome Measures

IN PROGRESS

• DASH Outcome Measure
• Numeric Pain Rating Scale (NPRS)
• Symptom Severity Scale
• Patient Specific Functional Scale (PSFS)

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Examination

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Medical Management

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Physical Therapy Management

IN PROGRESS

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."

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.

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) performed. This case study provides support for a relative rest approach, in which a patient avoids aggravating activities, while remaining otherwise active.

Key Research

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Resources

Mayo Clinic Overview of DeQuervain's Tenosynovitis

WebMD Overview of DeQuervain's Tenosynovitis

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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