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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'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} - [[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]]
'''Original Editor '''- [[User:Elizabeth Dallas|Elizabeth Dallas]], [[User:Boris Alexandra|Boris Alexandra]]  
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== Search Strategy  ==


<u>Databases</u>: CINAHL, PUBMED, MEDLINE
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  &nbsp; 
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== Clinically Relevant Anatomy<br> ==


<u>Keywords</u>: DeQuervain's, tenosynovitis, radial wrist pain, conservative management, rehabilitation, physical therapy<br>
[[Image:APL and EPB.png|thumb|right|200px|APL & EPB]]


<u>Timeline</u>: 10/20/2011 - 11/28/2011<br>
De Quervain's tenosynovitis involves the abductor pollicis longus and the extensor pollicis brevis tendons.<br>  


== [[Image:Hand.png|thumb|right|184x165px]]Definition/Description  ==
<u>'''M. extensor pollicis brevis (EPB)'''</u>


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. 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.<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> <br>
*origin: ½ dorsal side of the radius, the membrana interossea
*insertion: base of the proximal phalanx of the thumb  
*function: - wrist joint: radial abduction<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - thumb: extension
*innervations: N. radialis
*artery: A. interossea posterior


== Epidemiology/Etiology  ==
<br>


Causes&nbsp;may include&nbsp;chronic overuse injury, direct trauma&nbsp;leading to scar tissue formation, or inflammatory arthritis. Patients&nbsp;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&nbsp;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. Repetitive&nbsp;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>  
<u>'''M. abductor pollicis longus (APL)'''</u>  


<br>In industrial settings, studies have shown 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 in the right hand and 5%&nbsp;in the left hand when a positive Finkelstein’s test was present. Risk factors include patients who are female (commonly in postpartum) and within 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>
*origin: dorsal side of the radius and the ulna, the membrana interossea
*insertion: base of ossis metacarpi I
*function: - wrist joint: radial abduction<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - thumb: abduction
*innervations: N. radialis
*artery: A. interossea posterior


== Characteristics/Clinical Presentation  ==
The extensor retinaculum is a strong, fibrous structure that holds all the wrist extensors into place. It is located on the dorsal side of the wrist.<br>


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."<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>
== Definition/Description  ==


== Differential Diagnosis&nbsp; ==
De Quervain 's tenosynovitis is a painful wrist condition situated in the first dorsal compartment of the wrist.<ref name="Muhammad">Muhammad Omer Ashraf • V. G. Devadoss Systematic review and meta-analysis on steroid injection therapy for de Quervain’s tenosynovitis in adult. Eur J Orthop Surg Traumatol (2014) (Level of Evidence 1A )</ref><ref name="hassan">Hassan MK, Rahman MH. Role of Ultrasound In The Management of De'Quervain's Disease. Medicine today 2012 (Level of Evidence 1B)</ref> It's a painfil&nbsp; inflammation of the tendons of 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. <ref name="Schunke">SCHUNKE, M., SCHULTE, E., SCHUMACHER, U., VOLL, M., WESKER, K., Prometheus, Bohn Stafleu van Loghum, Houten, 2005.</ref> <ref name="Meeusen">MEEUSEN, R., Praktijkgids pols- en handletsels, Kluwer editorial, Diegem, 1999.</ref>&nbsp;The pain, which is the main complaint, gets worse with abduction of the thumb, grasping action of the hand and an ulnar deviation of the wrist. Thickening and swelling can also be present. <ref name="thomas">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)</ref><br>


<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>
== Epidemiology /Etiology  ==


<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>  
It’s caused by repetitive use of the thumb in combination with radial deviation of the wrist. (pinching, wringing, lifting, grasping, gardening, knitting). In this position the tendons of the EPB and the APL are pressed to the processus styloideus and when the movement is repeated frequently it can cause irritation of the tendons by friction. The tendons swell, the tunnel becomes too small.&nbsp;<ref name="Meeusen" /> <ref name="Van Dongen">VAN DONGEN, L.M., PILON, J.H.J., Handboek voor handrevalidatie theorie en praktijk, Bohn Stafleu van Loghum, Houten/Mechelen, 2002.</ref>&nbsp;It is often diagnosed in patients between 30-50 years. De Quervain syndrome is 10 times more frequent in women than men.<ref>Louis Patry, Michel Rossignol; Guide to the diagnosis of work- related musculoskeletal Disorders; Edition Multimonde, 1998, pag 1</ref>&nbsp;It’s common in sports like golf, bowling, tennis, mountain bike and it includes mothers of young children, computer keyboards operators, engine drivers.


<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>  
<span style="line-height: 1.5em;">In the technology age is has been nicknamed “Blackberry Thumb”</span><ref name="Wikipedia">Wikipedia. De Quervain syndrome. www.en.wikipedia.org/wiki/DeQuervain's_syndrome (accessed 13 Dec 2009)</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>
== Clinical Presentation  ==


'''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>
DeQuervains&nbsp;occurs in&nbsp;women 8-10 times more often than men. <ref name="web MD">What is de Quervain's Disease? www.webmd.com/rheumatoid-arthritis/de-quervains-disease (accessed 15 Dec 2009)</ref>The condition can be sudden or gradual. Presents most commonly with pain, swelling and tenderness&nbsp;on the radial side of the wrist at the base of the thumb (first dorsal compartment) as well in rest as in radial deviating of the wrist. Abduction of the thumb is also painful. The pain can radiate into the forearm and distally into the thumb. [3] [4] Symptoms increase with pinching, grasping, and gripping activities. New mothers are prone to this due to child care tasks with lifting, holding and feeding placing the hand in awkward positions; as well as hormonal changes. <ref name="hand">assh.org/Public/HandConditions/Pages/deQuervain'sTendonitis.aspx (accessed 13 Dec 2009)</ref>'''<u><br></u>'''


== Outcome Measure ==
== Differential Diagnosis<br> ==


*[[DASH Outcome Measure|DASH Outcome Measure]]&nbsp;<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>  
1. Osteoarthritis of the first CMC joint<ref name="Wikipedia" /><ref name="Wheeless">DeQuervain's Disease - Wheeless' Textbook of Orthopaedics www.wheelssonline.com/ortho/dequervains_disease (accessed 13 Dec 2009)</ref><br>2. Intersection syndrome – pain will be more towards the middle of the back of the forearm and about 2-3 inches below the wrist<ref name="Wikipedia" /><ref name="Wheeless" /><br>3. Wartenberg’s Syndrome - isolated neuritis of the superficial radial nerve, can be caused by tight jewelry<ref name="Wikipedia" /><ref name="Wheeless" /><br>  
*<u>Numeric Pain Rating Scale (NPRS)</u>&nbsp;
*<u>Patient Specific Functional Scale (PSFS)</u> <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>


== Examination ==
== Diagnostic Procedures ==


The evaluation of a pt. with signs and symptoms of De Quervain’s Tenosynovitis begins with a thorough history followed by a physical examination:
[[Image:Finkelstein Test.jpg|thumb|right|300px|Finkelstein's Test]]


'''History'''  
<u>'''Symptoms&nbsp;<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;74(4):314-326</ref>'''</u><br>


• 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
*Pain, tenderness and swelling at the base of the thumb.
*Pain can also radiate proximally into the forearm and distally into the thumb.
*Difficulty of movement of the thumb and wrist with activities such as grasping, pinching and crepitus (creaking sound).<ref name="Anderson" />


'''Physical Exam'''
[[Finkelstein_Test|Finkelstein-test]]


'''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*''
It’s a pain provocation test.<ref name="Van Dongen" />


'''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
== Examination ==
 
'''Neurological Screen –If indicated (1. Pt. complains of numbness and/or tingling 2. Reproduction of pn with movement of the cervical spine):'''<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>
 
• Dermatomes (C4- T1)<br>• Myotomes (C4- T1)<br>• Reflexes (C5, C6, C7)<br>• Pathological (Hoffman’s)
 
''*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*''
 
<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*<ref name="Ashurst">Ashurst JV, Turco DA, Lieb BE. Tenosynovitis Caused by Texting: An Emerging Disease. JAOA 2010:110(5).</ref><br>*Rule Out: 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 be used to track pt. progression throughout treatment*''
 
'''Muscle Length:'''<br>• Intrinsic flexibility-(intrinsic minus)<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>• Hand<br>&nbsp; &nbsp;o Intercarpal Joints<br>''*Looking for areas of hyper/hypomobility, Treatment will be impairment based, Important to note that areas of hypomobility may be referring pain*''
 
'''Special Tests: '''[[Image:Finkel.png|thumb|right|248x174px|Finkelstein's Test]]<br>• Rule in<br>&nbsp; &nbsp;o [http://www.physio-pedia.com/index.php5?title=Finkelstein_Test Finkelsteins]<br>''*Provocative test so perform with caution*''
 
• Rule Out<br>&nbsp; &nbsp;o [http://www.physio-pedia.com/index.php5?title=Thumb_CMC_Grind Grind Test]- 1st CMC OA
 
&nbsp; &nbsp;o Palpation of scaphoid-Scaphoid Fx<br>&nbsp; &nbsp;o ULTT B-Superficial Radial Neuritis<br>&nbsp; &nbsp;o Cervical Radiculopathy CPR<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> <br>&nbsp; &nbsp;o Joint Accessory Mobility- Intercarpal Instabilities<br>


'''Neurologic Tests:'''<br>• ULTT B<br>&nbsp; &nbsp;o Radial nn<br>• Superficial Radial NN<br>&nbsp; &nbsp;o Tinel’s Sign
[http://www.physio-pedia.com/index.php5?title=Finkelstein_Test Finkelstein test&nbsp;]


''*Be aware of pt's thumb position while performing this maneuver*''
The patient has to make an thumb adduction or an clenched fist in combination with an ulnar deviation. The patient feels pain on the radial side of the wrist around the processus styloideus.<br>


<br>'''Circulatory:'''<br>• Blanching/Capillary Refill
== Medical Management (current best evidence)  ==


'''Capsuloligamentous-if an acute traumatic injury:'''<br>• Thumb &amp; Digit collateral ligament stress testing (varus/valgus)<br><br>
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| {{#ev:youtube|roGXYRnUJZQ|250}} <ref>uwhand. Dequervain's Tenosynovitis. Available from: http://www.youtube.com/watch?v=roGXYRnUJZQ [last accessed 28/03/13]</ref>
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== Medical Management <br> ==
Surgery is indicated if conservative therapy doesn’t help to improve the symptoms and complains of the patient. It’s also indicated when the patient relapses. <ref name="Van Dongen" />&nbsp;The sheath of the first dorsal compartment is opened longitudinally for decompression.<br>  


The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling.
== Physical Therapy Management (current best evidence)  ==


'''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.<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>
The goals are to decrease the pain and the inflammation


• 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.<ref name="El Rassi">El Rassi G, Bleton R, Laporte D. Compartmental reconstruction for de Quervain stenosing tenosynovitis. Scandanavian Journal of Plastic and Reconstructive Surgery and Hand Surgery [serial online]. 2006;40(1):46-8.</ref>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>
<u>Conservative therapy consists of</u>: <ref name="Meeusen" /> <ref name="Van Dongen" /><br>- Rest by activity modification and the use of a thumb and wrist splint for 6 weeks<br>- Ice or cold packs<br>- Use of Non-Steroidal Anti-Inflammatory Drugs (NSAID’s): oral medication, phonophoresis or&nbsp;iontophoresis<br>- corticosteroid injections<br>  


== Physical Therapy Management <br> ==
Exercise is not practised because it can increase the pain and irritation of the tendons. There is not enough information about the benefit of exercise on De Quervain's syndrome.<ref>BACKSTROM, K.M., ‘Mobilization With Movement as an Adjunct Intervention in a Patient With Complicated De Quervain’s Tenosynovitis: A Case Report’, Journal of orthopaedic &amp;amp;amp; sports physical therapy, 2002, vol 32, p. 86 -97.</ref><ref name="Van Dongen" /><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  ==
== 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.]
*KANEKO, S., TAKASAKI, H., MAY, S., ‘Application of Mechanical Diagnosis and Therapy to a Patient Diagnosed with de Quervain’s Disease: A Case Study’, Journal of hand therapy, 2009.  
 
*KNOBLOCH, K., GOHRITZ, A., SPIES, M., VOGT, M.P., ‘Neovascularisation in de Quervain’s disease of the wrist: novel combined therapy using sclerosing therapy with polidocanol and eccentric training of the forearms and wrists—a pilot report’, Springer, 2008.
[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>
*FOURNIER, K., BOURBONNAIS, D., BRAVO, G., ARSENAULT, J., HARRIS, P., GRAVEL, D., ‘Reliability and Validity of Pinch and Thumb Strength Measurements in de Quervain’s Disease’, Journal of hand therapy, 2006.
 
*ANDERSON, M., TICHENOR, C.J., ‘A Patient With De Quervain's Tenosynovitis: A Case Report Using an Australian Approach to Manual Therapy’, Physical therapy, 1994, nr 4, vol 74, p. 314 – 326.
== Resources <br> ==
 
[http://www.mayoclinic.com/health/de-quervains-tenosynovitis/DS00692 Mayo Clinic Overview of DeQuervain's Tenosynovitis]
 
[http://www.medicinenet.com/de_quervains_tenosynovitis/article.htm MedicineNet Overview of DeQuervain's Tenosynovitis]
 
[http://www.webmd.com/rheumatoid-arthritis/de-quervains-disease WebMD Overview of DeQuervain's Tenosynovitis]


== Clinical Bottom Line ==
== Resources <br> ==


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 repetetive motions that could play an aggravating role, or potentially lead to a relapse of the condition.
*http://www.medicinenet.com/de_quervains_tenosynovitis/article.htm<br>


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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== References&nbsp; ==
== References<br> ==


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[[Category:Texas_State_University_EBP_Project]]
[[Category:Vrije_Universiteit_Brussel_Project]]  [[Category:Assessment]] [[Category:EIM_Residency_Project]] [[Category:Hand]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Special_Tests]]

Revision as of 18:14, 23 May 2014

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Clinically Relevant Anatomy
[edit | edit source]

APL & EPB

De Quervain's tenosynovitis involves the abductor pollicis longus and the extensor pollicis brevis tendons.

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 I
  • function: - wrist joint: radial abduction
                 - thumb: abduction
  • innervations: N. radialis
  • artery: A. interossea posterior

The extensor retinaculum is a strong, fibrous structure that holds all the wrist extensors into place. It is located on the dorsal side of the wrist.

Definition/Description[edit | edit source]

De Quervain 's tenosynovitis is a painful wrist condition situated in the first dorsal compartment of the wrist.[1][2] It's a painfil  inflammation of the tendons of 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. [3] [4] The pain, which is the main complaint, gets worse with abduction of the thumb, grasping action of the hand and an ulnar deviation of the wrist. Thickening and swelling can also be present. [5]

Epidemiology /Etiology[edit | edit source]

It’s caused by repetitive use of the thumb in combination with radial deviation of the wrist. (pinching, wringing, lifting, grasping, gardening, knitting). In this position the tendons of the EPB and the APL are pressed to the processus styloideus and when the movement is repeated frequently it can cause irritation of the tendons by friction. The tendons swell, the tunnel becomes too small. [4] [6] It is often diagnosed in patients between 30-50 years. De Quervain syndrome is 10 times more frequent in women than men.[7] It’s common in sports like golf, bowling, tennis, mountain bike and it includes mothers of young children, computer keyboards operators, engine drivers.

In the technology age is has been nicknamed “Blackberry Thumb”[8]

Clinical Presentation[edit | edit source]

DeQuervains occurs in women 8-10 times more often than men. [9]The condition can be sudden or gradual. Presents most commonly with pain, swelling and tenderness on the radial side of the wrist at the base of the thumb (first dorsal compartment) as well in rest as in radial deviating of the wrist. Abduction of the thumb is also painful. The pain can radiate into the forearm and distally into the thumb. [3] [4] Symptoms increase with pinching, grasping, and gripping activities. New mothers are prone to this due to child care tasks with lifting, holding and feeding placing the hand in awkward positions; as well as hormonal changes. [10]

Differential Diagnosis
[edit | edit source]

1. Osteoarthritis of the first CMC joint[8][11]
2. Intersection syndrome – pain will be more towards the middle of the back of the forearm and about 2-3 inches below the wrist[8][11]
3. Wartenberg’s Syndrome - isolated neuritis of the superficial radial nerve, can be caused by tight jewelry[8][11]

Diagnostic Procedures[edit | edit source]

Finkelstein's Test

Symptoms [12]

  • Pain, tenderness and swelling at the base of the thumb.
  • Pain can also radiate proximally into the forearm and distally into the thumb.
  • Difficulty of movement of the thumb and wrist with activities such as grasping, pinching and crepitus (creaking sound).[12]

Finkelstein-test

It’s a pain provocation test.[6]

Examination[edit | edit source]

Finkelstein test 

The patient has to make an thumb adduction or an clenched fist in combination with an ulnar deviation. The patient feels pain on the radial side of the wrist around the processus styloideus.

Medical Management (current best evidence)[edit | edit source]

[13]

Surgery is indicated if conservative therapy doesn’t help to improve the symptoms and complains of the patient. It’s also indicated when the patient relapses. [6] The sheath of the first dorsal compartment is opened longitudinally for decompression.

Physical Therapy Management (current best evidence)[edit | edit source]

The goals are to decrease the pain and the inflammation

Conservative therapy consists of: [4] [6]
- Rest by activity modification and the use of a thumb and wrist splint for 6 weeks
- Ice or cold packs
- Use of Non-Steroidal Anti-Inflammatory Drugs (NSAID’s): oral medication, phonophoresis or iontophoresis
- corticosteroid injections

Exercise is not practised because it can increase the pain and irritation of the tendons. There is not enough information about the benefit of exercise on De Quervain's syndrome.[14][6]

Key Research[edit | edit source]

  • KANEKO, S., TAKASAKI, H., MAY, S., ‘Application of Mechanical Diagnosis and Therapy to a Patient Diagnosed with de Quervain’s Disease: A Case Study’, Journal of hand therapy, 2009.
  • KNOBLOCH, K., GOHRITZ, A., SPIES, M., VOGT, M.P., ‘Neovascularisation in de Quervain’s disease of the wrist: novel combined therapy using sclerosing therapy with polidocanol and eccentric training of the forearms and wrists—a pilot report’, Springer, 2008.
  • FOURNIER, K., BOURBONNAIS, D., BRAVO, G., ARSENAULT, J., HARRIS, P., GRAVEL, D., ‘Reliability and Validity of Pinch and Thumb Strength Measurements in de Quervain’s Disease’, Journal of hand therapy, 2006.
  • ANDERSON, M., TICHENOR, C.J., ‘A Patient With De Quervain's Tenosynovitis: A Case Report Using an Australian Approach to Manual Therapy’, Physical therapy, 1994, nr 4, vol 74, p. 314 – 326.

Resources
[edit | edit source]

Recent Related Research (from Pubmed)[edit | edit source]

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References
[edit | edit source]

  1. ↑ Muhammad Omer Ashraf • V. G. Devadoss Systematic review and meta-analysis on steroid injection therapy for de Quervain’s tenosynovitis in adult. Eur J Orthop Surg Traumatol (2014) (Level of Evidence 1A )
  2. ↑ Hassan MK, Rahman MH. Role of Ultrasound In The Management of De'Quervain's Disease. Medicine today 2012 (Level of Evidence 1B)
  3. ↑ SCHUNKE, M., SCHULTE, E., SCHUMACHER, U., VOLL, M., WESKER, K., Prometheus, Bohn Stafleu van Loghum, Houten, 2005.
  4. ↑ 4.0 4.1 4.2 MEEUSEN, R., Praktijkgids pols- en handletsels, Kluwer editorial, Diegem, 1999.
  5. ↑ 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)
  6. ↑ 6.0 6.1 6.2 6.3 6.4 VAN DONGEN, L.M., PILON, J.H.J., Handboek voor handrevalidatie theorie en praktijk, Bohn Stafleu van Loghum, Houten/Mechelen, 2002.
  7. ↑ Louis Patry, Michel Rossignol; Guide to the diagnosis of work- related musculoskeletal Disorders; Edition Multimonde, 1998, pag 1
  8. ↑ 8.0 8.1 8.2 8.3 Wikipedia. De Quervain syndrome. www.en.wikipedia.org/wiki/DeQuervain's_syndrome (accessed 13 Dec 2009)
  9. ↑ What is de Quervain's Disease? www.webmd.com/rheumatoid-arthritis/de-quervains-disease (accessed 15 Dec 2009)
  10. ↑ assh.org/Public/HandConditions/Pages/deQuervain'sTendonitis.aspx (accessed 13 Dec 2009)
  11. ↑ 11.0 11.1 11.2 DeQuervain's Disease - Wheeless' Textbook of Orthopaedics www.wheelssonline.com/ortho/dequervains_disease (accessed 13 Dec 2009)
  12. ↑ 12.0 12.1 Anderson M; Tichenor CJ. A Patient with de Quervain's Tenosynovitis: A Case Report Using an Australian Approach to Manual Therapy. Physical Therapy. 1994;74(4):314-326
  13. ↑ uwhand. Dequervain's Tenosynovitis. Available from: http://www.youtube.com/watch?v=roGXYRnUJZQ [last accessed 28/03/13]
  14. ↑ BACKSTROM, K.M., ‘Mobilization With Movement as an Adjunct Intervention in a Patient With Complicated De Quervain’s Tenosynovitis: A Case Report’, Journal of orthopaedic &amp;amp; sports physical therapy, 2002, vol 32, p. 86 -97.


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