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Physical Medicine and Rehabilitation for De Quervain Tenosynovitis Clinical Presentation

  • Author: Patrick M Foye, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: Apr 27, 2016
 

History

Patients with de Quervain tenosynovitis typically report localized pain at the dorsolateral aspect of the wrist.

Occasionally, a patient's history may indicate isolated, acute trauma to the involved site.

More commonly, the history includes chronic, repetitive activities using the involved hand or thumb.

Inquire about specific repetitive activities that may have contributed to the onset of symptoms. Examples include work activities (eg, computer use, materials handling) or recreational activities (eg, knitting, golf, racket sports).

A thorough understanding of the ergonomics of precipitating activities contributes to making an accurate diagnosis and forms the basis for necessary ergonomic interventions.

Ask how the patient's symptoms limit the patient's ability to perform vocational or avocational activities.

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Physical

The most classic finding in de Quervain tenosynovitis is a positive Finkelstein test.

Perform the Finkelstein test by having the patient make a fist with the thumb inside the fingers. The clinician then applies passive ulnar deviation of the wrist to reproduce the chief complaint of dorsolateral wrist pain.

Perform the Finkelstein test bilaterally to compare the involved side with the uninvolved one.[9]

Carefully access the first carpometacarpal (CMC) joint, since pathology at this site can cause a false-positive Finkelstein test.

Look for swelling at the first dorsal compartment of the wrist.

Sensory examination specifically includes careful evaluation in distributions of the median and radial nerves, since either of these could cause pain/dysesthesias radiating into the thumb.

Because cervical radiculopathy also can cause thumb pain/dysesthesias, evaluation includes assessment for upper limb strength, muscle stretch reflexes, sensation, and provocative neck maneuvers (eg, the Spurling test to assess for cervical root impingement).

Because some cases of dorsolateral forearm pain are caused by lateral epicondylitis, evaluate for point tenderness in the region of the lateral epicondyle, at the elbow.

In some cases, de Quervain tenosynovitis may be associated with rheumatoid arthritis; therefore, assess the hands for rheumatologic deformities and malalignment.

A prospective study by Goubau et al indicated that the wrist hyperflexion and abduction of the thumb (WHAT) test is more sensitive and specific than the Finkelstein test for diagnosing de Quervain tenosynovitis. The WHAT test was devised to focus only on the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, without causing pain or stress at the thumb and wrist joints. During the test, the patient positions his or her wrist in hyperflexion, with the thumb in full extension (at the interphalangeal and metacarpophalangeal joints). The thumb is then actively abducted against the physician’s index finger, which provides resistance.[10]

The study involved 100 patients with de Quervain tendinopathy, with the results of the Finkelstein and WHAT tests compared with ultrasonographic findings. According to Goubau and colleagues, the WHAT test showed greater sensitivity (0.99) and specificity (0.29) than did the Finkelstein test, as well as increased positive and negative predictive values (0.95 and 0.67, respectively).[10]

A study by Lutsky et al found that among patients with De Quervain tenosynovitis, carpal tunnel syndrome, osteoarthritis, or trigger finger, the disorder occurred in the dominant and nondominant hands with roughly equal prevalence (although lateral epicondylitis was found to occur more commonly on the dominant side).[11]

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Causes

Minor cumulative (ie, repetitive) trauma commonly contributes to the development of de Quervain tenosynovitis. Activities that may cause repetitive trauma to the wrist include factory work, secretarial duties, golfing, or racket sport playing.

Isolated acute trauma also may contribute to the development of de Quervain tenosynovitis. In addition, the disorder may occur in association with rheumatoid arthritis.

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Contributor Information and Disclosures
Author

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Coauthor(s)

Todd P Stitik, MD Professor, Department of Physical Medicine and Rehabilitation, Director, Outpatient Occupational/Musculoskeletal Medicine, Rutgers New Jersey Medical School

Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Physiatric Association of Spine, Sports and Occupational Rehabilitation, Phi Beta Kappa

Disclosure: Nothing to disclose.

Varun Patibanda, MD Research Associate, Rutgers New Jersey Medical School

Varun Patibanda, MD is a member of the following medical societies: American Medical Association, New Jersey Society of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine

Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association for Physician Leadership, American Medical Association, Academy of Spinal Cord Injury Professionals

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear ($1,500).

Acknowledgements

Debra Ibrahim New York College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Evish Kamrava St George's University School of Medicine

Disclosure: Nothing to disclose.

Cyrus Kao St George's University School of Medicine

Disclosure: Nothing to disclose.

Jason Lee St George's University School of Medicine

Disclosure: Nothing to disclose.

Dev Sinha, MD American University of Antigua School of Medicine and Health Sciences

Disclosure: Nothing to disclose.

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The first dorsal compartment of the wrist includes the tendon sheath that encloses the abductor pollicis longus and the extensor pollicis brevis tendons at the lateral border of the anatomic snuffbox.
The Finkelstein test is performed by having the patient make a fist with the thumb inside the fingers. The clinician then applies ulnar deviation of the wrist to reproduce the presenting symptoms of dorsolateral wrist pain.
 
 
 
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