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Physical Medicine and Rehabilitation for De Quervain Tenosynovitis Treatment & Management

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

Rehabilitation Program

Physical Therapy

Various forms of physical therapy (PT) or occupational therapy (OT) may be used in the treatment of patients with de Quervain tenosynovitis. In the acute stage, the therapist may use cryotherapy (eg, cold packs, ice massage) to reduce the inflammation and edema. Local inflammation also can be treated with topical corticosteroids (eg, hydrocortisone), which are driven into the subcutaneous tissues using ultrasound (ie, phonophoresis) or electrically charged ions (ie, iontophoresis).[17]

PT or OT also may be indicated for individuals who have undergone surgical correction at the first dorsal compartment. Once the patient has recovered, the goals of therapy are to strengthen and regain range of motion (ROM) at the thumb, hand, and wrist.[18]

Occupational Therapy

An occupational therapist can perform an assessment of a patient's activities of daily living (ADL) to help determine possible precipitating factors in the development of de Quervain syndrome; he/she can then suggest activity modifications. Although off-the-shelf orthotic devices usually are adequate, sometimes a custom-made thumb spica can be fabricated by a trained occupational therapist.

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Medical Issues/Complications

Please see Other Treatment, which includes a discussion of potential complications of corticosteroid injections.

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Surgical Intervention

For severe, unresponsive cases of de Quervain tenosynovitis in which injections, splinting, and ergonomic modification of activities have failed, a referral for surgical treatment to decompress the first dorsal compartment is needed.[6, 19]

In a study of 94 patients with de Quervain tenosynovitis, Scheller et al investigated the long-term results of simple decompression of the abductor pollicis longus and extensor pollicis brevis tendons combined with partial resection of the extensor ligament.[20] The outcome was successful in all patients, as demonstrated by a negative Finkelstein test. See the image below.

The Finkelstein test is performed by having the pa 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.

Complications consisted of 4 transient lesions of the radial nerve, 1 instance of delayed wound healing, and 1 superficial wound infection.

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Consultations

Clinicians who are inexperienced or uncomfortable with performing corticosteroid injections for de Quervain's tenosynovitis can refer the patient to a musculoskeletal physiatrist or other physician who is skilled in these procedures.

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Other Treatment

Using a thumb spica splint or performing local corticosteroid injection can be very effective in treating de Quervain tenosynovitis.[6]

Splinting with a thumb spica - Unlike a typical wrist splint, a spica has a component that wraps around the thumb, providing some degree of immobilization at the first CMC joint but, classically, leaving the interphalangeal joint free.

Data from a pooled, quantitative literature review by Richie and Briner indicated that corticosteroid injection alone produces an 83% cure rate for de Quervain tenosynovitis, compared with a 14% cure rate when a thumb spica splint alone is used and, interestingly, a 61% cure rate when a combination of splint and injection is employed. These results suggest that corticosteroid injection should be a first-line treatment for de Quervain tenosynovitis.[21]

A recent study aimed to further elucidate whether treatment with splinting alone versus treatment with corticosteroid injection plus splinting yielded better outcomes. Success was defined as an absence of wrist pain and tenderness, as well as negative Finkelstein test results and 90% or greater improvement in pain score. The overall success rate was 86.4% in the injection-plus-cast group versus 36% in the cast-only group.[22]

Corticosteroid injection for de Quervain tenosynovitis[23, 24] involves mixing 40 mg (1 mL) of corticosteroid with a few milliliters of local anesthetic. Inject the mixture into the tendon sheath of the first dorsal compartment. Take care to avoid injecting directly into the tendons, since direct injection can cause weakening and potential rupture. Avoid injecting within the very superficial layer of the subcutaneous tissue, because of the possibility of skin depigmentation, which is particularly noticeable in dark-skinned individuals.

Inform the patient that the procedure may cause a mild, transient increase in local tenderness; this will disappear within a few days, when the corticosteroid begins to have a noticeable, therapeutic effect.

Evaluate the patient immediately for sensation in the first web space of the hand to assess for any anesthetic effect to the superficial radial nerve.

If sensory deficit is present, reassure the patient that the deficit is usually transient and should most likely resolve within a few hours.

An orthopedic study compared different techniques for corticosteroid injections for de Quervain disease; the investigation examined outcomes in 38 hands (of 36 patients).[25] Half of the patients received corticosteroid injections made at a single point immediately above the indurated tendon sheath in the first dorsal compartment. The rest of the patients received injections at 2 points (each point receiving half of the therapeutic injectate volume), which corresponded with the paths of the extensor pollicis brevis (EPB) and abductor pollicis brevis (APB) tendons. Repeat injections, for the patients receiving them, were performed after a 2-week interval, with no significant difference in the number of repeat injections between the groups. Comparing the 1-point injection and the 2-point injection, the outcomes were, respectively, excellent in 50% versus 75% of patients, good in 28% versus 25% of patients, and fair in 22% versus 0% of patients. Thus, the 2-point injections seemed to be superiortothe1-point injections.

Another recent study proposed a 4-point injection protocol designed to overcome anatomic variations in the first dorsal compartment that may inhibit the success of conservative treatment. In the 4-point injection model, the point of maximal tenderness over the first dorsal compartment was identified and the injections were then administered, 2 distally and 2 proximally to this point, along the course of the EPB and APL tendons. When compared with patients receiving injections at 2 points, there were significantly more symptom-free patients in the 4-point injection group. Furthermore, those patients in the 4-point injection group needed less repeat injections and were operated on less than those getting injections at 2 points.[26]

A prospective study of 103 patients found suprafibrous injection with corticosteroids to be easier to perform than is intrasynovial injection and to have the same effects.[27]

Ultrasonography-guided injections of corticosteroids avoid the complication of intratendinous injections, allowing accurate visualization of correct needle placement. These injections also reduce fat atrophy and depigmentation complications of steroid injections.[28]

Several potential complications of injection must be taken into account. They include the following:

  • Bleeding or bruising can occur, especially in individuals with bleeding disorders or in patients taking anticoagulants.
  • Infection at the injection site is rare but possible. Minimize risk through the use of sterile technique for the procedure.
  • In patients with diabetes, a transient elevation of the blood glucose level may occur after corticosteroid injection.
  • Allergic reactions to injected medications are rare, but possible.
  • Given the proximity to the superficial radial nerve, injection at this site may cause transient anesthesia in the first web space of the dorsal hand. Lack of sensation at the site generally resolves within a few hours unless significant direct needle trauma has been delivered to the radial nerve. Such trauma is a rare complication that can cause persistent pain within the distribution of that nerve (cheiralgia paresthetica).
  • Skin hypopigmentation can occur, particularly if injection is performed within superficial layers of the skin, rather than within the tendon sheath alone. The mechanism behind hypopigmentation is not fully understood but is thought to be a loss of melanocyte function rather than actual loss of melanocytes. [29]
  • Tendon weakening and rupture is rare, but possible.
  • A combination of cheiralgia paresthetica and linear atrophy have been observed as a rare complication of local steroid injection for de Quervain tenosynovitis. The atrophy is thought to result from a lymphatic spread of the steroid. [30]
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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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