de Quervain Tenosynovitis

Author(s): Jennifer Yang, MD, Philip DeMola, DO

Originally published:11/10/2011

Last updated:05/05/2016

1. DISEASE/DISORDER:

Definition

  1. De Quervain tenosynovitis is characterized by restricted, painful movement of the fibro-osseous sheath of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons.1
  2. It should be considered a tendinopathy because it is an overuse tendon injury not always associated with inflammation.2

Etiology

De Quervain tenosynovitis symptoms result from fibrous thickening of the tendon sheath of the first dorsal compartment of the wrist, surrounding the APL and EPB tendons. This thickening is usually associated with acute or repetitive trauma and restrains the gliding of the tendons through the sheath.3

Epidemiology including risk factors and primary prevention

  1. It is frequently seen in patients with repetitive overuse of the wrist in ulnar deviation when the thumb is extended or abducted;3 however the pain may be exacerbated by activity requiring the same ulnar deviation but with a clenched fist and thumb metacarpophalangeal joint flexion.4 Housekeeping tasks, typing, lifting, knitting, needlepoint, wrestling, or bowling have been associated with De Quervain tenosynovitis.3
  2. The dominant hand of active 30-50 years old adults is commonly affected.3
  3. It is more prevalent in females compared to males (approximately 3:1 ratio), and is commonly seen in pregnant and lactating women.3 In particular, a common mechanism of injury involves lifting a baby or a young child by picking the child up under the axillae, with the webbing between the thumb and index finger under the baby.

Patho-anatomy/physiology

The APL and EPB tendons pass through the first dorsal compartment sheath. They run beneath the extensor retinaculum on the dorsal aspect of the radial styloid process. The APL abducts the thumb at the carpometacarpal joint. The EPB extends the thumb at the carpometacarpal and metacarpophalangeal joints. The posterior interosseous branch of the radial nerve innervates both muscles. Continued strain and friction where the two tendons form a sharp angle over the radial styloid causes tendon thickening within their extensor sheath.

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 inflamed, followed by a fibroblastic response. Thickening and localized swelling of the tendon sheath and retinaculum then occur. Histopathology is consistent with disorientation of the collagen fibrils with mucoid changes (not inflammatory response).

Subacute: Crepitus may occur over time, and the pain becomes more “achy” while the swelling improves. The patient may be limited in or unable to perform tasks as activity restriction continues.

Chronic/stable: Involvement of the superficial radial nerve can manifest as numbness over the dorsolateral hand and first 3 digits. The pain can become a frustrating daily disability.

Specific secondary or associated conditions and complications

  1. Tendon rupture in chronic cases
  2. Carpal tunnel syndrome
  3. Inflammatory conditions such as rheumatoid arthritis (3)

2. ESSENTIALS OF ASSESSMENT

History

  • Patients describe pain over the radial aspect of the thumb and wrist normally associated with thumb movement or lifting, with duration of several weeks to months. Sharp, knifelike or searing pain may radiate proximally to the forearm and/or distally to the thumb.
  • De Quervain tenosynovitis may occur after trauma to the radial styloid, or from repetitive grasping or pinching with the thumb while moving the wrist. A gradual onset of pain along the radial aspect of the wrist is more typical in overuse injuries.
  • Patients may describe loss of grip strength, especially opposition grip.
  • Patients present with a painful, fusiform swelling with or without crepitus to palpation of the APL and EPB tendons of the thumb/radial aspect of the wrist. Painful nodules may develop later.
  • Desensitization or numbness may occur about the dorsolateral hand and first three digits.
  • The Finkelstein test is pathognomonic for the diagnosis. The 1939 description states “On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating.”1
  • More recently, Stahl and colleagues found the Finkelstein test lacks specificity, as it may be positive in cases of osteoarthritis of the wrist, first carpometaphalangeal joint tendonitis, or flexor/extensor hand-wrist tendonitis.5
  • Finklestein’s test is often incorrectly used to describe what is actually the Eichoff’s test, where the patient ulnarly deviates the wrist while the thumb is tucked into a clenched fist, then the examiner further ulnarly deviates, reproducing pain. Thumb extension then relieves the pain. This has been shown to have higher false positives than the true Finklestein test, and be less precise than the wrist hyperflexion and abduction of the thumb test (WHAT)6
  • A reliable diagnosis of De Quervain tenosynovitis may be hindered by “examiner-dependent variability in performing pain-provoking tests, variations and pain perception and expression, and secondary gain in an occupational setting”.7

Physical examination

  • Patients present with a painful, fusiform swelling with or without crepitus to palpation of the APL and EPB tendons of the thumb/radial aspect of the wrist. Painful nodules may develop later.
  • Desensitization or numbness may occur about the dorsolateral hand and first three digits.
  • The Finkelstein test is pathognomonic for the diagnosis. The 1939 description states “On grasping the patient’s thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating.”1
  • More recently, Stahl and colleagues found the Finkelstein test lacks specificity, as it may be positive in cases of osteoarthritis of the wrist, first carpometaphalangeal joint tendonitis, or flexor/extensor hand-wrist tendonitis.5
  • Finklestein’s test is often incorrectly used to describe what is actually the Eichoff’s test, where the patient ulnarly deviates the wrist while the thumb is tucked into a clenched fist, then the examiner further ulnarly deviates, reproducing pain. Thumb extension then relieves the pain. This has been shown to have higher false positives than the true Finklestein test, and be less precise than the wrist hyperflexion and abduction of the thumb test (WHAT)6
  • A reliable diagnosis of De Quervain tenosynovitis may be hindered by “examiner-dependent variability in performing pain-provoking tests, variations and pain perception and expression, and secondary gain in an occupational setting”.7

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.  Other activities such as wringing a washcloth, lifting a child and hammering a nail can also cause pain.4

Laboratory studies

De Quervain tenosynovitis may occur in conjunction with rheumatoid arthritis; therefore obtaining a complete blood count, erythrocyte sedimentation rate and rheumatoid panel may be indicated.

Imaging

  • Radiographs are not necessary to diagnose De Quervain tenosynovitis; however, they are useful in differentiating tenosynovitis from carpometacarpal degenerative arthritis, loose body, occult fracture, or more rarely bone tumor.8
  • Ultrasound (US) and US-guided injection may help to confirm the diagnosis and provide treatment. US can identify tendon or retinacular thickening, partial tears, and fluid in the tendon sheath. US may help evaluate for anatomic variants as well as ensure appropriate needle placement for injections. Further imaging is rarely required, but an MRI may be helpful in recalcitrant cases to evaluate for anatomic variants of the tendon sheaths or for soft tissue tumor.
  • Supplemental assessment tools: Electrodiagnostic studies may be needed in patients experiencing numbness or weakness.

Early predictions of outcomes

Symptom relief after treatment has been considered the gold standard of diagnosis.7 Corticosteroid injections have been shown to relieve pain from De Quervain tenosynovitis9,10.

Environmental

  • Repetitive wrist extension and rotation maneuvers used for a particular task are thought to cause this condition; therefore recurrence may be prevented by altering faulty technique or changing the home/work/environmental factors associated with those hand movements.
  • A systematic review by Stahl and colleagues, however, did not find a causal relationship between De Quervain tenosynovitis and occupational risk factors such as repetitive, forceful or ergonomically stressful manual work.5

Social role and social support system

The patient may need assistance with dressing and fine motor skills required for activities of daily living. 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 the family.

Professional Issues

Speed, repetitiveness and set-up of the involved task, as well as the worker’s technique, may have to be evaluated to prevent recurrence of the condition in the injured worker.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

While no definitive “white paper” has been written, many researchers have found corticosteroid injection into the first dorsal compartment performed early in the disease course to be safe and efficacious – better than immobilization or therapy. Harvey reported complete pain relief in patients who had a single corticosteroid injection.9

At different disease stages

  1. New onset/acute: Standard available treatments for acute injuries include ice, forearm-based thumb spica (long opponens) splint, oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroid injection into the first dorsal compartment of the wrist.
    1. Splinting has not been shown to provide long-lasting relief and is mainly utilized to allow the tendons to rest in an immobilized position. Weiss and colleagues compared use of steroid injection alone, immobilization splint alone, and combined injection and splint. Their results show complete relief in 28/42 of individuals receiving injection alone, and 8/14 receiving both injection and splint; however, only 7/37 among those treated by splinting alone experienced relief.11
    2. Steroid injections have been shown to be effective in several studies. Sawaizumi reported a 50% cure rate achieved with one injection, with a second injection permanently relieving symptoms in another 40-45% of patients. (10) A systematic review by Muhammad, et al showed steroid injection had an overall more favorable effect than splinting.3
  2. 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.
    1. Adaptive equipment or modified techniques (ergonomic keyboards, key holders, modification of tools) are encouraged to allow for neutral wrist positioning during activities.
    2. Physical and occupational therapy starts with cryotherapy to reduce pain, inflammation and local edema. Other possible modalities include galvanic electrical stimulation, phonophoresis or iontophoresis. Programs to address flexibility, strength and endurance of forearm musculature have shown mixed results.
    3. Patient education is also very important so that the therapy and techniques utilized by the OT are continued at home.4
  3. Chronic cases (or cases not responding to medical and injection treatment)
    1. Post-operative patients can benefit from an OT program including active and active-assisted range of motion exercises, stretching, gentle strengthening, resisted eccentric movements with the wrist and thumb and retrograde massage4
    2. Individuals with persistent symptoms may be appropriate for surgical release of the first dorsal compartment to relieve entrapment. 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.12
    3. 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 in order 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.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

  1. 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.4
  2. Injection compounds such as platelet-rich plasma (PRP) and stem cell mixtures have been utilized in other joint and tendon injuries, but have not been well-studied specifically for DeQuervain tenosynovitis. US-guided percutaneous needle tenotomy in conjunction with injection of 3 ml PRP was shown to be successful in one patient, who had pain relief 6 months post-procedure and a 63% drop in the pain visual analog scale.13

Emerging/unique interventions

  1. Hyaluronic acid in combination with steroid injections significantly improved pain and function at 6 months post-intervention in one study.14
  2. US-guidance for injections to the first dorsal compartment may be beneficial in ensuring correct needle placement avoiding intratendinous injections identifying variations in anatomy or locations of adjacent neurovascular structures.
  3. Acupuncture demonstrated short-term improvement in pain and function in one study.15

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

  • To date, review of the medical literature does not reveal any good large, controlled studies establishing the effectiveness and safety of US-guided percutaneous needle tenotomy and/or PRP injections for refractory De Quervain tenosynovitis.
  • More research is warranted to establish the effectiveness of steroid injection therapy as a first line conservative treatment for patients rather than 3rd or 4th 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. (3)

REFERENCES

  1. Dawson C, Mugdal C. Staged description of the Finklestein test. J Hand Surg. 2010;35A:1513-1515.
  2. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth. BMJ. 2002;324(7338):626-7.
  3. Ashraf MO, Devadoss VG. Systematic review and meta-analysis on steroid injection therapy for de Quervain’s tenosynovitis in adults. Eur J Orthop Surg Traumatol. 2014;24(2):149-57
  4. Goel R, Abzug JM. de Quervain’s tenosynovitis: a review of the rehabilitative options. Hand (N Y). 2015;10(1):1-5.
  5. Stahl S, Vida D, Meisner C, et al. Systematic review and meta-analysis on the work-related cause of de Quervain tenosynovitis: a critical appraisal of its recognition as an occupational disease. Plast Reconstr Surg. 2013;132(6):1479-91
  6. Goubau JF1, Goubau L, Van Tongel A, Van Hoonacker P, Kerckhove D, Berghs B. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff’s Test.J Hand Surg Eur Vol. 2014 Mar;39(3):286-92. doi: 10.1177/1753193412475043. Epub 2013 Jan 22.
  7. Stahl, S., Vida, D., Meisner, C., Stahl, A.S., Schaller, H.-E., Held, M. Work related etiology of de Quervain’s tenosynovitis: A case-control study with prospectively collected data Pathophysiology of musculoskeletal disorders. BMC Musculoskeletal Disorders. 2015;16(1), art. no. 126
  8. Darowish M, Sharma J. Evaluation and treatment of chronic hand conditions. Med Clin North Am. 2014;98(4):801-15, xii
  9. Harvey FJ, Harvey PM, Horsely MW. De Quervain’s disease: Surgical or non-surgical treatment. J Hand Surg. 1990;15(1):83-87.
  10. Sawaizumi T, Nanno M, Ito H. De Quervain’s disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. 2007;31(2):265-268.
  11. Weiss A, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg. 1994; 9(4):5955-98.
  12. Scheller A, Schuh R, Honie W, et al. Long-term results of surgical release of de Quervain’s stenosing tenosynovitis. Int Orthop. 2008;33(5):1301-1303.
  13. Peck E, Ely E. Successful treatment of de Quervain tenosynovitis with ultrasound-guided percutaneous needle tenotomy and platelet-rich plasma injection: a case presentation. PM R. 2013;5(5):438-41
  14. Orlandi D, Corazza A, Fabbro E, et al. Ultrasound-guided percutaneous injection to treat de Quervain’s disease using three different techniques: a randomized controlled trial. Eur Radiol. 2015;25(5):1512-9.
  15. Hadianfard M, Ashraf A, Fakheri M, Nasiri A. Efficacy of acupuncture versus local methylprednisolone acetate injection in De Quervain’s tenosynovitis: a randomized controlled trial. J Acupunct Meridian Stud. 2014;7(3):115-21.
  16. American Medical Association. AMA Guides to Evaluation of Impairment. 6th ed. Chicago, IL: AMA; 2009. 634
  17. vci S, Yimaz C, Sayli U. Comparison on nonsurgical treatment for measures for the de Quervain disease of pregnancy and lactation. J Hand Surg. 2002;27A(2):322-324.
  18. Finnoff, JT. Musculoskeletal problems of the upper limb. In: Braddom RL. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: WB Saunders; 2007. 842-842.
  19. Ilyas AM. Nonsurgical treatment for de Quervain’s tenosynovitis. J Hand Surg. May-June 2009;34A:928-929
  20. Wolf JM, Sturdivant RX, Owens BD. Incidence of de Quervain’s tenosynovitis in a young, active population. J Hand Surg. 2009;34A:112-115

Original Version of the Topic

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

Author Disclosures

Jennifer Yang, MD
Nothing to Disclose

Philip DeMola, DO
Nothing to Disclose

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