Author(s): Neyha Cherin, DO, Aliya Jafri, MD, Kevin Moser, MD
Originally published: November 10, 2011 Last updated: August 18, 2020
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DISEASE/DISORDER:

Definition

  1. De Quervain tenosynovitis is thickening of the fibrous sheaths of two tendons at the base of the thumb, the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). It is characterized by pain and/or tenderness along the radial aspect of the wrist with resultant swelling and in restricted, painful movements.1
  2. While commonly labeled as de Quervain tenosynovitis, a tendinopathy is more appropriate as histopathological evidence demonstrates this condition is not characterized by inflammation, but rather by thickening of the tendon sheath itself.2
  3.  Common names include: de Quervain disease, de Quervain syndrome, de Quervain tenosynovitis, de Quervain tendinopathy, stenosing tenosynovitis of the first dorsal compartment of the wrist, gamer’s thumb, and mother’s thumb. 21,22

Etiology

The exact etiology of de Quervain tenosynovitis is unknown. De Quervain tenosynovitis symptoms result from 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. This thickening results in repetitive tension on the tendons causing swelling which restricts gliding of the tendons through the sheath.3 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 wrist23
0.5% in men
1.3% in women
Most commonly seen 3Women
Non-white Dominant Hand
Ages 30-50*
Risk factors3Repetitive overuse of the wrist in ulnar or radial deviation with thumb extended or abducted**
Peri-menopausal women
Lactating women ***
Associated medial epicondylitis
Associated lateral epicondylitis
Systemic disease (Rheumatoid arthritis)
* Incidence increases with age over 40
** Activities include: Housekeeping tasks, typing, texting, lifting, knitting, needlepoint, wrestling, or bowling
*** Tends to develop 4-6 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

Patho-anatomy/physiology

The APL and EPB tendons pass through the first extensor compartment sheath. They are tightly secured by the extensor retinaculum on the dorsal aspect of the radial styloid process. The APL, which is 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. The posterior interosseous branch of the radial nerve innervates both muscles. Repetitive thumb and wrist motion leads to continued strain and friction where the two tendons form a sharp angle over the radial styloid, leading to tendon thickening within their extensor sheath. Overtime this leads to thickening of the retinaculum as well. Both of these factors restrict normal gliding within the sheath.

10% of patients are identified as having an intertendinous septum between the APL and EPB. The presence of an intertendinous septum increases the likelihood that surgical management will be required.47

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, along with the patient experiencing difficulty with performing tasks.

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 with impaired use of the wrist and hand.

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)

ESSENTIALS OF ASSESSMENT

History

  • Patients describe pain over the radial side of the wrist, exacerbated by thumb movements, grasping, and ulnar or radial deviation of the wrist.  Pain may radiate proximally to the forearm and/or distally to the thumb.37
  • 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.38
  • Direct trauma, such as a direct blow or fall, has occasionally been implicated.5
  • Patients may describe weakened grip strength, especially opposition grip.

Physical examination

  • Inspection:
    • Swelling can be seen just proximal to radial styloid and fullness of tissue due to thickening of retinaculum39
  • Palpation:
    • Tenderness to palpation over first dorsal compartment, with or without crepitus to palpation, 1 to 2 cm proximal to the radial styloid, where the APL and EPB tendons come together. Painful nodule 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 develop numbness of the dorsum of the thumb.41
  • Range of Motion/Strength:
    • There may be pain on resisted thumb extension and abduction, along with weak pinch grip strength.40
  • Special Tests:
    • Finkelstein Maneuver:   
      • Examiner grasps the patient’s thumb and quickly abducting the hand and wrist in an ulnarward direction, resulting in pain over the styloid tip.1
      • Pathognomonic for the diagnosis.

Figure 1: Finkelstein Maneuver

  • Eichoff Maneuver:
    • The patient tucks the thumb into a clenched fist, the examiner then quickly ulnarly deviates the wrist, reproducing pain. 39
    • Less specificity and have a higher false positive rate than the true Finklestein test, and to be less precise than the Wrist Hyperflexion and Abduction of the Thumb test (WHAT).6

         Figure 2: Eichoff Maneuver

  • Wrist hyperflexion and abduction of the thumb (WHAT) Test:
    • The patient flexes the hand and abuducts the thumb, causing active contraction of the tendons of the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis). The examiner then gradual increases resistance to thumb abduction.
    • Useful in diagnosing dynamic instability after successful decompression of first extensor compartment.47

  Figure 3: WHAT Test

  • Physical exam findings must be considered along with the patient’s history, occupation, radiographs, and other physical findings.42

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 gold club), lifting (such as during care-giving), and repetitive ulnar deviation (such as hammering).44

Laboratory studies

De Quervain tenosynovitis may occur in conjunction with rheumatoid arthritis. Therefore can consider obtaining a complete blood count, erythrocyte sedimentation rate, and rheumatoid panel if suspected.

Imaging

  • When clinical presentation is clear, radiographs and advanced imaging are not necessary. However, if etiology is unclear, imaging may be useful.38
    • If history of trauma, or arthritis, x-ray may be done to rule out bony pathology.39
  • Plain Radiograph:
    • Typically unremarkable, but may see soft tissue calcifications at the first dorsal compartment in some patients with de Quervain tenosynovitis.
  • Ultrasound (US):
    • Can identify tendon or retinacular thickening, partial tears, and fluid in the tendon sheath. US may help evaluate for anatomic variants. It is important to assess for an intracompartmental septum, as presence of septum in first extensor compartment is associated with increased risk of non-operative treatment failure.45
  • 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 tendon sheath (high T2 signal, intermediate T1 signal), debris within the sheath (intermediate T1 signal), thickened edematous retinaculum, and peritendinous subcutaneous edema.46
  • Supplemental assessment tools:
    • Electrodiagnostic studies may be needed in patients experiencing numbness or weakness, if nerve pathology is suspected.

Early predictions of outcomes

  • Most patients experience resolution of symptoms over a period of months.47
  • Presence of intracompartmental septum is associated with increased risk of non-operative treatment failure.45
  • Triggering of tendons with thumb motion is associated with reduced likelihood of response to non-operative management.39

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; 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 society.

Professional Issues

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

REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

While no definitive treatment guidelines exist, a recent review article found grade-A evidence for the following: 32

  1. Splinting alone is a less effective treatment modality than corticosteroid injection regardless of whether splinting was used as an initial treatment.
  2. Surgical release should be used when non-operative treatment fails.
  3. Endoscopic release has similar long-term results compared to open release.

Non-invasive conservative treatments

  1. 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)
    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 There is no evidence for differences in effectiveness between different types of splint 33 or full-time vs desired wearing of splints.31, 27
  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, 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 term27.
    3. Patient education is also very important so that the therapy and techniques utilized by the OT are continued at home.4

Corticosteroid Injection

  1. Steroid injections to the first dorsal 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 4-6 weeks later.32 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 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.
  2. One randomized controlled trial found no improvement in pain or recovery after 3 weeks with concomitant use of NSAID (nimesulide) and corticosteroid injection.35 A recent meta-analysis concluded there is no evidence to support concomitant NSAID use after corticosteroid injection in the short-term. 27 
  3. One study found significant improvement in function when comparing a novel 4-point corticosteroid injection technique vs 2-point injection at 8 weeks. Patients with the 4-point corticosteroid injection were more likely to be symptom free at 52 weeks.34
  4. There is moderate evidence for use of a thumb splint as an additive after corticosteroid injection, with studies showing significant improvement in pain, function, and success rate in the mid-term.27
  5. There is limited evidence that ultrasound-guided corticosteroid injections may be superior to traditional landmark-guided, or blind, injections.27 One study found similar effectiveness in relief of symptoms when comparing ultrasound-guided corticosteroid injection to traditional blind injection, but with decreased complication rates in the ultrasound group.28 Another study found significant decreases in pain at 4 weeks post-injection in ultrasound-guided injections compared to blind injections. 29

Surgical Intervention

  1. Individuals with persistent symptoms may be appropriate for surgical release of the first dorsal compartment to relieve entrapment. Surgical intervention is generally recommended if pain does not resolve after two corticosteroid injections and at least 6 months of non-operative treatment19.One large double-blinded study reported surgical intervention to be 100% effective with results sustained after 15 years.12
  2. The most common surgical complication is injury to the sensory branch of the radial nerve32. 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.12
  3. 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.36
  4. Post-operative immobilization is recommended for 7-10 days to stabilize the surgical site. 32
  5. 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 massage4
  6. 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.

CUTTING EDGE/EMERGING AND UNIQUE 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 To date, there have not been any clinical trials studying the effectiveness of ASTM specifically for de Quervain tenosynovitis.
  2. 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 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 One randomized controlled trial compared surgical intervention plus PRP to surgical intervention alone, and found greater improved pain and function at 6 and 12 month follow up in the combined surgery plus PRP group compared to surgery alone.25
  3. Hyaluronic acid in combination with steroid injections significantly improved pain and function at 6 months post-intervention in one study.14
  4. 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 acupuncture15
  5. One case report found improvement in symptoms after injection of methotrexate in a patient who had failed multiple previous corticosteroid injections and who did not wish to pursue surgical intervention.26
  6. 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. 30, 31 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

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)

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  47. Jenson Mak (December 10th 2018). De Quervain’s Tenosynovitis: Effective Diagnosis and Evidence-Based Treatment, Work-related Musculoskeletal Disorders, Orhan Korhan, IntechOpen, DOI: 10.5772/intechopen.82029. Available from: https://www.intechopen.com/books/work-related-musculoskeletal-disorders/de-quervain-s-tenosynovitis-effective-diagnosis-and-evidence-based-treatment

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.

Author Disclosures

Neyha Cherin, DO
Nothing to Disclose

Aliya Jafri, MD
Nothing to Disclose

Kevin Moser, MD
Nothing to Disclose