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De Quervain’s Tenosynovitis

Wrist and/or thumb pain? A condition we sometimes see causing these symptoms is De Quervain's Tenosynovitis.

What is it?

De Quervain’s tenosynovitis is inflammation of the tendons and synovial sheaths of the thumb muscles (specifically the abductor pollicis longus and extensor pollicis brevis muscles). This condition is caused from repetitive friction and microtrauma causing the tendons and sheath to swell, making normal motions painful.



Some movements that provoke pain include lifting, grasping, and pinching, particularly when combined with wrist radial or ulnar deviation (moving the wrist on the pinky side toward your forearm). This is because these activities force the thumb tendons to rub against the radial styloid process (a bony projection off the radius bone).


Activities like gardening, knitting, cooking, playing a musical instrument, carpentry, walking a pet on a leash, video gaming can cause De Quervain’s. Some sports like golfing, volleyball, fly fishing, and racquet sports are known to be possible factors of this condition.


There is a significant association between excessive cellphone use and De Quervain’s tenosynovitis.


It is sometimes associated with systemic conditions like diabetes and rheumatoid arthritis. De Quervain is common during pregnancy when changes in estrogen levels are suspected.

Clinical Presentation

Symptoms include pain on the lateral aspect (thumb side) of the wrist. The pain can begin abruptly but more commonly is a gradual onset, increasing over weeks or months. The pain is usually provoked by movement of the thumb or hand, especially forceful pinching, grasping, or twisting.


There may be visible swelling over the medial aspect of the wrist in the acute phase. There may also be presence of a fluid-filled cyst in the region. In some instances, the patient could experience some numbness on the top aspect of the thumb and index finger from concurrent irritation to the radial nerve.


Patients typically complain of a slight “squeaking” sound or sensation associated with movement of the wrist. Catching or snapping is a possible sensation as well.


Clinical evaluation demonstrates tenderness over the attachment of the thumb to the wrist in what is known as the anatomical snuff box. A decrease of the active range of motion of the thumb is possible. The patient may also show a diminished pinch grip.


Diagnosis

Ultrasound is a useful tool for diagnosing tenosynovitis and identifying the presence of an intracompartmental septum. MRI is a good alternative to an ultrasound. Imaging of tenosynovitis patients should be reserved for those with a history of trauma or other red flags and those who fail an initial trial of conservative care.


Management

Initial treatment can include cryotherapy (ice), NSAIDs, and moderate rest. Patients should avoid activities that provoke pain. Athletes would benefit from being shown alternative ways to perform certain activities.


Those who excessively text or play video games should consider taking frequent breaks and hold their wrists straighter. Patients should limit pinching, gripping, and twisting of their wrists.


There are different perspectives and studies that suggest a thumb spica splint is helpful towards the management of De Quervains. However, other studies counter that the isolated use of a splint may actually slow progress when combined with conservative care.


Stretching exercises should be implemented for the thumb muscles, wrist flexors, extensors, and brachioradialis. Initial rehab of acute cases may consist of isometric (no muscle movement only a contraction) contractions for thumb extension and abduction. Then as symptoms allow, the patient can transition to isotonic strengthening with resistance bands or free weights and add wrist supination and pronation movements.


IASTM (instrument assisted soft tissue mobilization) may be implemented in the treatment plan to release adhesions in the first dorsal compartment and other associated tissue. Soft tissue manipulation and myofascial release techniques may be needed for the affected muscles. Manipulation of wrist and cervical restrictions is appropriate.


Kinesiotape may provide some benefit.


While many patients report resolution of symptoms through conservative management, there are certain factors that suggest a poor prognosis. Those factors include a pain greater than an 8 out of 10, involvement of the sensory branch of the radial nerve, inability or unwillingness to perform home therapy, failure to implement changes in activities of daily living, and severe swelling.


For patients who do not respond to a brief trial of conservative therapy, cortisone injection is effective in about 80% of cases. Surgery is rarely necessary and should be reserved for patients who fail to conservative treatment and cortisone injections.




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