Author(s): Alexander M. Senk, MD, Meta W. Williams, DO, Mark W. Volker, MD, Kersten L. Schwanz, MD
Originally published: November 10, 2011 Last updated: January 25, 2024
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Disease/Disorder

Definition

  • De Quervain tenosynovitis is characterized by pain and/or tenderness along the radial aspect of the wrist with associated focal swelling and antalgic thumb and wrist motion.1 The condition is exacerbated by flexion/extension of the thumb and radial-ulnar deviation of the wrist.2
  • While commonly labeled as de Quervain tenosynovitis, the condition is more consistent with tendinopathy, as histopathological evidence demonstrates this condition is not characterized by inflammation but rather by thickening of the tendon sheath itself.3
  • Other common names include: de Quervain disease, de Quervain syndrome, de Quervain tendinopathy, stenosing tenosynovitis or tenovaginitis of the first dorsal compartment of the wrist, gamer’s thumb, and mother’s thumb.4,5

Etiology

While the exact etiology of de Quervain tenosynovitis is unknown, its symptoms are attributed to non-inflammatory fibrous thickening of the first extensor compartment tendon sheath, which surrounds the APL and EPB, at the level of the radial styloid process. Rather than secondary to an acute inflammatory process, the thickening is a result of fibrous tissue deposits and increased vascularity along the extensor retinaculum. Overall, the thickening results in repetitive tension on the tendons causing swelling which restricts gliding of the tendons through the sheath.6 Symptoms are triggered by repetitive thumb movement, along with ulnar and radial wrist deviation.

Epidemiology including risk factors and primary prevention

PrevalenceSecond most common entrapment tendinitis of the wrist7
0.5% in men
1.3% in women
Most commonly seen6,8Women
Non-white
Dominant Hand
Ages 40-59
Risk factors6Repetitive overuse of the wrist in ulnar or radial deviation with thumb extended or abducted*
Peri-menopausal women
Pregnancy**
Lactating women ***
Associated medial epicondylitis
Associated lateral epicondylitis
Systemic disease (Rheumatoid arthritis)
Cell phone use****
*Activities include housekeeping tasks, typing, texting, lifting, knitting, needlepoint, wrestling, bowling, and assembly line-, factory-, or garment-related work.9
**Attributed to fluid retention during pregnancy; there is a higher rate of bilateral de Quervain tenosynovitis in pregnant women than in the general population.10
***Tends to develop four to six weeks after delivery. Common mechanisms include lifting a baby or young child into the air by placing the phalanges under their axillae with the thumbs abducted
****Increasing prevalence of de Quervain tenosynovitis in younger populations has been associated with cell phone use, in a study of patients aged 18-25 years old.11

Patho-anatomy/physiology

The APL and EPB tendons pass through the first extensor compartment sheath, also known as the first dorsal wrist compartment. They are tightly secured by the extensor retinaculum on the dorsal aspect of the radial styloid process. The APL, the larger of the two tendons, abducts the thumb at the carpometacarpal joint. The smaller EPB extends the thumb at the carpometacarpal and metacarpophalangeal joints. Both muscles are innervated by the posterior interosseous branch of the radial nerve.

Repetitive thumb and wrist motion lead to strain and friction where the two tendons form a sharp angle over the radial styloid, leading to tendon thickening within their extensor sheath. Over time, this leads to thickening of the retinaculum as well. Both factors restrict normal gliding of the tendons within the sheath.

Notably, anatomical variants of the first extensor compartment have been shown to result in higher incidences of de Quervain tenosynovitis. In typical anatomy of the first extensor compartment, the APL and EPB tendons rest in a single fibro-osseous canal.12 The two most reported anatomical variants in the first compartment include two sub-compartments via the presence of a fibrous septum and multiple slips of the APL or EPB tendons. Both variants are believed to yield increased friction within the compartment and therefore more symptoms.13

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

New onset/acute
Tendons within the sheath become entrapped and irritated. This results in a fibroblastic and vascular response. This is followed by thickening and localized swelling of the tendon sheath and retinaculum. Histopathology is consistent with disorientation of the collagen fibrils with mucoid changes (not an inflammatory response).

Subacute
Crepitus may occur over time, and the pain becomes more “achy” while the swelling may or may not improve. Range of motion may become limited, corresponding with the patient having trouble performing tasks.

Chronic/stable
Involvement of the superficial radial nerve can manifest as numbness over the dorsolateral hand and first three digits. The pain can become a frustrating daily disability with impaired use of the wrist and hand.

Specific secondary or associated conditions and complications

  • Tendon rupture in chronic cases
  • Carpal tunnel syndrome
  • Inflammatory conditions such as rheumatoid arthritis

Essentials of Assessment

History

  • Patients may describe pain over the dorsoradial side of the wrist and the radial aspect of the forearm; pain may radiate proximally to the forearm and/or distally to the thumb. Pain is exacerbated by thumb movements, grasping and ulnar and/or radial deviation of the wrist.14  
  • Onset is usually gradual with a duration of several weeks to months.
  • There may be a history of repetitive grasping or pinching with the thumb while moving the wrist.
  • Rest and immobilization help relieve the pain.15
  • Direct trauma, such as a direct blow or fall, has occasionally been implicated.9
  • Patients may describe weakened grip strength, especially opposition grip.
  • Differential diagnosis may include thumb CMC arthritis, radial nerve compression, and intersection syndrome.2

Physical examination

  • Inspection
    • Swelling along with fullness of tissue due to thickening of retinaculum can be seen just proximal to radial styloid 6,16
  • Palpation
    • Tenderness may be present over first dorsal wrist compartment, with or without crepitus, one to two centimeters proximal to the radial styloid where the APL and EPB tendons come together. Painful nodules may develop in more severe cases.
      • If pain is located 4-8 cm proximal to radial styloid, consider intersection syndrome (pain at the intersection of the first and second dorsal extensor compartments, where the APL and EPB tendons cross over the extensor carpi radialis longus and brevis tendons).
    • Rarely, patients may note numbness of the dorsum of the thumb.17
  • Range of Motion/Strength
    • There may be pain on resisted thumb extension and abduction, along with weak pinch grip strength.18
  • Special Tests
    • Finkelstein Maneuver
      • Examiner grasps the patient’s thumb and quickly abducting the hand and wrist in an ulnar direction, resulting in pain over the styloid tip.1
  • Pathognomonic for the diagnosis.

Figure 1: Finkelstein Maneuver

  • Eichhoff Maneuver
    • The patient tucks the thumb into a clenched fist, and the wrist is passively ulnar deviated by the examiner, reproducing pain.16
    • Often mistaken as Finkelstein test, this exam maneuver is known to be less specific, have a higher false positive rate, and be more painful than the true Finkelstein test.19 It is also noted to be less precise than the Wrist Hyperflexion and Abduction of the Thumb test (WHAT).20

Figure 2: Eichhoff Maneuver

  • Wrist hyperflexion and abduction of the thumb (WHAT) Test:
    • The patient flexes the hand and abducts the thumb, causing active contraction of the tendons of the first dorsal wrist compartment (APL and EPB). The examiner then gradual increases resistance to thumb abduction.
    • This test is useful in diagnosing dynamic instability after successful decompression of first extensor compartment.21

Figure 3: WHAT Test

  • Physical exam findings must be considered along with the patient’s history, occupation, radiographs, and other physical findings.22

Functional assessment

  • Patients may have diminished range of motion in thumb opposition and abduction. Fine motor coordination requiring opposition and grasping becomes difficult due to localized radial wrist pain. The patient may have difficulty buttoning a shirt or fastening jewelry. 
  • Aggravating activities may include twisting/wringing objects (such as a washcloth, opening a jar), gripping items (such as a golf club), lifting (such as during caregiving), and repetitive ulnar deviation (such as hammering).23

Laboratory studies

De Quervain tenosynovitis may occur in the setting of inflammatory arthritis. Therefore, one can consider obtaining a complete blood count, erythrocyte sedimentation rate, and rheumatoid panel if more systemic disease is suspected.

Imaging

  • When clinical presentation and examination are clear, radiographs, and advanced imaging are not necessary. However, if etiology is unclear, imaging may be useful.15
    • If there is history of trauma or arthritis, x-ray may be done to rule out osseous pathology.16
  • Plain Radiograph:
    • While typically unremarkable, it may reveal soft tissue calcifications at the first dorsal wrist compartment in some patients with de Quervain tenosynovitis.
  • Ultrasound (US):
    • US can identify tendon or retinacular thickening, partial tears, fluid in the tendon sheath and presence of anatomic variants. It is important to assess for an intracompartmental septum, as the presence of a septum in the first extensor compartment is associated with increased risk of non-operative treatment failure.24
  • MRI
    • If ultrasound is equivocal, MRI can be used as it is very sensitive and specific for detecting mild disease. Findings of tenosynovitis include increased fluid within the tendon sheath (high T2 signal, intermediate T1 signal), debris within the sheath (intermediate T1 signal), thickened edematous retinaculum, and peritendinous subcutaneous edema.25
  • Supplemental assessment tools:
    • Electrodiagnostic studies may be needed if nerve pathology is suspected, as in patients experiencing numbness or weakness.

Early predictions of outcomes

  • Most patients experience resolution of symptoms over a period of months.21
  • The presence of an intracompartmental septum is associated with an increased risk of non-operative treatment failure.24
  • Triggering of the APL and/or the EPB in the setting of de Quervain’s tenosynovitis is rare, but it is associated with reduced likelihood of response to non-operative management.26,27

Environmental

  • While the etiology is not known, observational data suggests repetitive wrist extension and rotation maneuvers used for a particular task are attributed to the condition. However, a systematic review by Stahl and colleagues did not find a causal relationship between de Quervain tenosynovitis and occupational risk factors such as repetitive, forceful or ergonomically stressful manual work.9

Social role and social support system

The patient may need assistance with dressing and fine motor skills required for activities of daily living (ADLs). Many affected persons will require social support to get through their day, especially new mothers. In severe cases, inability to work can change a person’s social role in society.

Professional issues

Speed, set-up, and ability to perform certain tasks may be affected; and the worker’s technique or ergonomics may have to be evaluated to prevent exacerbation/recurrence of the condition.

Rehabilitation Management and Treatments

Available or current treatment guidelines

De Quervain tenosynovitis is frequently self-limited and can resolve without intervention. While first-line treatment is nonoperative, there remains to be no definitive treatment protocol for nonoperative management. Typically, NSAIDs, immobilization, and corticosteroid injections (CSIs) comprise early treatment, but debate remains over details.28 A 2016 review article of tenosynovitis in the hand and the wrist found grade-A evidence for the following29

  • Splinting alone is a less effective treatment modality than corticosteroid injection regardless of whether splinting was used as an initial treatment or later in the course of care.
  • Surgical release should be used when non-operative treatment fails.
  • Endoscopic release has similar long-term results compared to open release.

Non-invasive conservative treatments

  • New onset/acute: Standard available non-invasive treatments for acute injuries include ice, forearm-based thumb spica (long opponens) splint, and oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs).
    • Splinting has not been shown to provide long-lasting relief and is mainly utilized to allow the tendons to rest in an immobilized position.  There is no evidence for differences in effectiveness between different types of splints or full-time vs desired wearing of splints.30,31,32,33
  • Subacute: Rehabilitation strategies intended to stabilize or optimize function or prepare for further interventions at later disease stages can be helpful. An interdisciplinary approach is helpful when designing therapy protocols.
    • Adaptive equipment or modified techniques (ergonomic keyboards, key holders, modification of tools) are encouraged to allow for neutral wrist positioning during activities.
    • Physical (PT) and occupational therapy (OT) starts with cryotherapy to reduce pain, inflammation and local edema. Other possible modalities include galvanic electrical stimulation, phonophoresis, iontophoresis, paraffin bath, and ultrasound therapy. These modalities have shown mixed results in studies. A recent meta-analysis found no convincing evidence to support programs to address flexibility, strength and endurance of forearm musculature in addition to splinting in the short term.30
    • Patient education is also very important so that the therapy and techniques utilized by the OT are continued at home.34

Corticosteroid injection

  • Steroid injections to the first dorsal wrist compartment have been shown to be effective in several studies and can be used as initial treatment or after a trial of non-invasive conservative treatments. If symptoms persist after one corticosteroid injection, a second is typically offered four to six weeks later.29 Sawaizumi reported a 50% cure rate achieved with one injection, with a second injection permanently relieving symptoms in another 40-45% of patients.35 A systematic review by Ashraf et al. showed steroid injections had an overall more favorable effect than splinting.21 Harvey et al found 82% of patients had complete resolution after one or two corticosteroid injections, and of those that did not have relief, 10 out of 11 patients were found to have separate compartments for the APL and EPB tendons.36
  • One randomized controlled trial found no improvement in pain or recovery after three weeks with concomitant use of NSAID (nimesulide) and corticosteroid injection.37 A recent meta-analysis concluded there is no evidence to support concomitant NSAID use after corticosteroid injection in the short-term.30 
  • One study found significant improvement in function when comparing a novel four-point corticosteroid injection technique vs two-point injection at eight weeks. Patients with the four-point corticosteroid injection were more likely to be symptom free at 52 weeks.38
  • There is limited evidence that ultrasound-guided corticosteroid injections may be superior to traditional landmark-guided, or blind, injections.30 One study found similar effectiveness in relief of symptoms when comparing ultrasound-guided corticosteroid injection to traditional blind injection, but there were notably decreased complication rates in the ultrasound group.39 Another study found significant decreases in pain at four weeks post-injection in ultrasound-guided injections compared to blind injections.40
  • Literature discussing combination therapy of corticosteroid injection and immobilization remains inconsistent. A 2021 Larsen et al. review article summarizes three studies (two prospective RCTs and one retrospective cohort study), and ultimately suggests that immobilization adds little value to treatment in patients who undergo corticosteroid injection.28
  • As pregnancy and the post-partum state are known risk factors for de Quervain tenosynovitis, it is crucial for practitioners to know that evidence supports local injection of corticosteroid to be safe and effective in pregnant and lactating women.41

Surgical intervention

  • Individuals with persistent symptoms may be appropriate for surgical release of the first dorsal wrist compartment to relieve entrapment. Patients at a higher risk for requiring operative treatment include those with a higher body mass, Medicaid insurance, hypothyroidism, female sex, psychiatric comorbidities, extensor triggering of the thumb and other tendinopathies, trigger fingers, or carpal tunnel syndrome.42,43
  • Surgical intervention is generally recommended if pain does not resolve after two corticosteroid injections and at least six months of non-operative treatment.44One large double-blinded study reported surgical intervention to be 100% effective with results sustained after 15 years.45
  • The most common surgical complication is injury to the sensory branch of the radial nerve.29 Other reported potential postoperative complications include neuroma formation of superficial radial nerve, volar subluxation of the tendon, failure to find or release a separate aberrant tendon, and scar hypertrophy from a longitudinal skin incision.45
  • There are similar long-term outcomes between endoscopic vs open release. One study comparing these two surgical techniques demonstrated decreased pain and improved function at 12 weeks post-op in the endoscopic group, but this difference between groups was not sustained after 24 weeks.46
  • Post-operative immobilization is recommended for seven to 10 days to stabilize the surgical site.29
  • After immobilization, post-operative patients may benefit from an OT program including active and assisted range of motion exercises, stretching, gentle strengthening, resisted eccentric movements with the wrist and thumb, and retrograde massage.34
  • If surgery is not an option, the patient can learn to adjust activities to account for chronic pain, including using the contralateral hand more often.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Because at-risk populations include golfers, fly fishermen, racquet sports participants and persons involved in similar activities that require forceful grasp coupled with ulnar deviation, some knowledge of anatomy and biomechanics is helpful to change the injured person’s techniques.  De Quervain tenosynovitis is also commonly seen in physicians and surgeons who use their hands repetitively to perform injections or surgeries.

Cutting Edge/Emerging and Unique Concepts and Practice

  • New physical therapy techniques include the Graston technique, a form of augmented soft tissue mobilization (ASTM). The therapist stimulates the body’s own capacity for healing in patients with soft tissue degeneration, fibrosis or chronic inflammation.34 To date, there have not been any clinical trials studying the effectiveness of ASTM specifically for de Quervain tenosynovitis.
  • Percutaneous needle release (PNR) of the first dorsal wrist compartment has been noted in several case reports and studies but lacks the high-level randomized controlled trials to sufficiently back the procedure. A prospective case series of 35 patients from 2018 found that 91.4% of patients who underwent PNR had a negative Finkelstein at one-month post-procedure and continued to have improved outcomes at the six-month mark, allowing them to avoid open surgical release.47
  • There is limited evidence for the effectiveness of platelet-rich plasma (PRP) in treatment of de Quervain tenosynovitis. In one case study, US-guided percutaneous needle tenotomy in conjunction with injection of 3 mL of PRP was shown to be successful in one patient, who had pain relief six-months post-procedure and a 63% drop in the pain visual analog scale.48 One randomized controlled trial compared surgical intervention plus PRP to surgical intervention alone; it found greater improved pain and function at 6 and 12 month follow up in the combined surgery plus PRP group compared to surgery alone.49
  • Hyaluronic acid in combination with steroid injections significantly improved pain and function at six months post-intervention in one study.50
  • Acupuncture demonstrated short-term improvement in pain and function to a statistically significant extent in one study, but in the same study, a corticosteroid injection improved pain and function to a greater extent than acupuncture.51
  • A 2017 prospective cohort study included four patients who underwent wide-awake local anesthesia no tourniquet (WALANT) first dorsal compartment releases. The three patients who responded to their follow-up questionnaire expressed their approval of WALANT, which can be performed in the clinic setting, and saying they would prefer WALANT for future procedures.52
  • Psychological distress may play a significant role in severity of symptoms, evidenced by one study finding high levels of correlation between pain catastrophizing, emotional distress, illness perception, and worsening pain and function.53 There have not been any trials studying the effects of psychotherapy on outcomes related to de Quervain tenosynovitis, but referral to a psychologist may be considered in patients who display significant levels of psychological distress related to their symptoms.

Gaps in the Evidence-Based Knowledge

  • To date, review of the medical literature does not reveal any large, well-designed, controlled studies establishing the effectiveness and safety of the assortment of ultra minimally invasive percutaneous procedures (tenotomy vs release) and non-corticosteroid injections (prolotherapy, PRP, saline, etc.) injections for acute to refractory de Quervain tenosynovitis.  Furthermore, future trials would ideally compare the interventions with traditional treatments and surgical techniques.
  • More research is warranted to establish the effectiveness of steroid injection therapy as a first line conservative treatment for patients rather than third or fourth behind NSAIDs, splinting and therapy.
  • Studies comparing different steroid preparations, doses, injection techniques, with longer follow-up and in conjunction with (or comparison to) surgical treatment are needed.21

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Original Version of the Topic

Kristina Donovan, DO and Mark Ellen, MD. de Quervain Tenosynovitis. 11/10/2011

Previous Version(s) of the Topic

Jennifer Yang, MD, Philip DeMola, DO. de Quervain Tenosynovitis. 5/05/2016

Neyha Cherin, DO, Aliya Jafri, MD, Kevin Moser, MD. de Quervain Tenosynovitis. 8/18/2020

Author Disclosures

Alexander M. Senk, MD
Nothing to Disclose

Meta W. Williams, DO
Nothing to Disclose

Mark W. Volker, MD
Nothing to Disclose

Kersten L. Schwanz, MD
Nothing to Disclose