De Quervain's Tenosynovitis

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Definition/Description

File:Hand.png

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.  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.

Relevant Clinical Anatomy

• 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

Epidemiology/Etiology

De Quervain's (pronounced"duh-Kair-VAZ") syndrome or de Quervain's disease named after the Swiss surgeon Fritz de ‘Quervain, who identified it first in 1895. It’ describes inflammation of the sheath or tunnel that surrounds two tendons that control the movement of the thumb. The main cause is 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 against the processus styloideus and the frequent repetitive movement can cause friction which results in irritation of the tendons. The tendons swell, reducing the space in the tunnel.

Causes may include chronic overuse injury, direct trauma leading to scar tissue formation, or inflammatory arthritis. Patients typically report painful abduction of the thumb and decreased grip strength. The most common cause is chronic overuse. Activities 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 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.

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% in the left hand when a positive Finkelstein’s test was present. It is 10 times more frequent in women than men. In particular, women are commonly affected postpartum and in general the condition is most common between 30-50 years of age. With the advent of technology the condition has been labelled Blackberry Thumb.

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." 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

• 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 fall on an outstretched hand (FOOSH) in wrist extension and will present with radial sided wrist pain, tenderness and possible swelling in the anatomical snuff box, and limited range of motion (ROM) with pain, especially at the end range. If the patient presents with radial side wrist pain after a traumatic injury a scaphoid fracture must be ruled out.

• Superficial Radial Neuritis (Wartenberg’s Syndrome)
  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, in developing scar tissue after trauma or by tight jewelry. Compression will cause ischemia resulting in numbness and tingling in this distribution.

• C6 Cervical Radiculopathy
  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  carpometacarpal joint (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.

• Intersection Syndrome
  Intersection syndrome – pain will be more towards the middle of the back of the forearm and about 2-3 inches below the wrist

Outcome Measures

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

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 thumb and dorsolateral aspect of the wrist near radial styloid process
• Hand dominance
• Pregnant or currently in post-partum stage

Physical Exam

Vitals

• Height
• Body weight
• Blood Pressure
• Pulse Rate
• Respiration Rate
• Temperature (if indicated)

Establish a baseline for patients overall health status

Observation in Sitting

• Resting posture of the hand/thumb
• Inflammation around dorsal aspect of the base of the thumb and/or near the radial styloid process

Neurological Screen

If indicated by the presence of numbness and/or tingling and/or reproduction of pain with movement of the cervical spine: It is important to 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 pain, or actual weakness due to a neurological involvement

• Dermatomes (C4- T1)
• Myotomes (C4- T1)
• Reflexes (C5, C6, C7)
• Pathological (Hoffman’s)

Palpation

On palpation some key , significant findings will be tenderness 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. It is important to rule out arthritis or fracture of the scaphoid bone by palpation of the 1st CMC to assess joint line tenderness and/or deformity.

• Radial Dorsal Zone
  • Radial Styloid Process
  • “Anatomical Snuff Box” – Scaphoid, Trapezium, EPL, EPB, APL
  • 1st CMC joint.
  • Soft tissue surrounding involved area

Range of Motion (ROM)

Range of motion can also be used as a screening tool rule out involvement of the cervical spine, proximal joints and structures. When documenting your findings make not of any impaired ROM’s, thumb may have a “catching” or “snapping” sensation while moving due to decreased mobility of tendon through synovial sheath.

• Cervical ROM
  • Flexion, Extension, R&L SB, R&L Rotation

• Shoulder/Elbow/Forearm
  • Shldr Flex/Ext/Abd/Add
  • Elbow Flexion/Extension
  • FA Pronation/Supination

• Wrist
  • Flex/Ext/UD/RD
  • Digit 2-5
  • Flex/Ext (MCP, PIP, DIP)
  • AB/AD (MCP)

• Thumb
  • Flex/Ext (CMC,MCP,IP)
  • AB/AD (CMC,MCP)
  • Opposition

Resisted Muscle Tests

It is normal to find a decrease in strength secondary to pain, Document the maximum power within pain free limits, This can be a useful tool to track a patient's progress throughout the treatment programme.

• Fist Grip Strength
• Pinch Strength (pinch gauge)

Muscle Length

Look for signs of hyper/hypomobility, Treatment will be impairment based, Important to note that areas of hypomobility may be referring pain

• Intrinsic flexibility-(intrinsic minus)
• Wrist flexors & extensors

Joint Accessory Mobility

• Distal Radial Ulna Joint (DRUJ)
• Wrist
  • Radial carpal (RC), Mid carpal (MC)
• Thumb
  • CMC,MCP, IP
• Hand
  • Intercarpal Joints
    

Special Tests

• Rule in
  File:Finkel.png

  Finkelstein's Test
  • Finkelsteins
    *Provocative test so perform with caution*

• Rule Out
  • Grind Test- 1st CMC OA
  • Palpation of scaphoid-Scaphoid Fx
  • ULTT B-Superficial Radial Neuritis
  • Cervical Radiculopathy CPR
  • Joint Accessory Mobility- Intercarpal Instabilities
    

Neurologic Tests

• Upper Limb Tension Test B (ULTT B)
  • Radial nn
• Superficial Radial NN
  • Tinel’s Sign

Be aware of patient's thumb position while performing this maneuver

Circulatory

• Blanching/Capillary Refill

Capsuloligamentous

This is important to observe in an acute traumatic injury

• Thumb and Digit collateral ligament stress testing (varus/valgus)

Medical Management

The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling.

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 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.
• Avoiding repetitive or aggravating movements
• Applying ice to the affected area
• Nonsteroidal anti-inflammatory drugs (NSAIDS)
• Injections of corticosteroid medications into the tendon sheath
• Physical Therapy

Patients may also be prescribed for immobilization 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%.

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

Another effective treatment of conservative management is steroid injection, but more research is needed to establish the full benefits of the treatment.

The direct injection of a small dose of cortisone into each of the two tendons is highly effective, about 60 to 70% for the first incidence unless dealing with an “-its” type. Accurate positioning of the needle into each tendon should be confirmed by observing the needle movements as flexing the first MC joint passively moves the APL. After the APL has been injected, the needle is placed for injection into small EPB sheath, with confirmation done by passively flexing the thumb’s MP joint.

Technique for steroid injection of tendon illustrated in treating de Quervain’s tenosynovitis. First good anaesthesia is obtained by intradermal injection of the skin allowing unhurried precise placement of the needle for the tendon steroid injections. A fine needle without an attached syringe is placed and repositioned as necessary until its position in the tendon sheath is confirmed with passive movement of the first MC joint for the APL and the thumb’s MP joint for the EPB. The syringe is attached after needle placement for the steroid injection. 

Multiple case series and clinical trials ,  studied the Corticosteroid injections, often in combination with other modalities like NSAID’s and splints and have found a positive results from 62% up to 93%.

Because they are usually combined with other treatment interventions, it is difficult to determine the efficacy alone but, it was found to relieve inflammation of the extensor pollicis brevis and the abductor pollicis longus tendons.

Surgical Treatment

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.

Endoscopic release for de Quervain’s tenosynovitis provides early improvement after surgery; there are fewer superficial radial nerve complications and greater scarf satisfaction, compared with open release surgery. Endoscopic release of the first extensor compartment is reported as an effective and safe procedure for patients who are not responsive to non-operative treatments over an open release surgery.

Short-term clinical results showed that one-quarter partial resection of the extensor retinaculum on the dorsal side of the wrist, is a safe operative treatment and there aren’t any serious complications.

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 demonstrated complete relief of symptoms.Despite the type of surgery patient should receive hand therapy post-operatively to restore motion and strength to promote function with daily activities.

When surgical treatment is recommended (for patients not responding to conservative treatment), a longitudinal incision is better than a transverse one as there are less complications of surgical treatment with a longitudinal incision. Patients with longitudinal scars had five hypertrophic scars, including some painful ones (less painful than transverse incisions). The hypertrophic scars are treated with corticosteroid injections, with no injuries to the nerve or vein.

Postoperatively, the wrist is splinted in a neutral position until the skin sutures are removed. This will minimize the probability of tendon anterior subluxation. The prognosis for permanent recovery is excellent.

Physical Therapy 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.

Massage

Deep tissue massage at the thenar eminence can help relax tight musculature that causes pain. (See video)

Stretching

Stretching the thenar eminence muscles into thumb extension and abduction can relax and lengthen this tight musculature that causes pain. (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.

Decreasing Swelling

To decrease swelling you can use:

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

Home Management Programme

Any of 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.

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.

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.

Resources

Mayo Clinic Overview of DeQuervain's Tenosynovitis

MedicineNet Overview of DeQuervain's Tenosynovitis

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. 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.