eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
De Quervain Tenosynovitis: Treatment & Medication
Updated: Dec 15, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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's 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).13
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.14
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's 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.
Medical Issues/Complications
Please see Other Treatment, which includes a discussion of potential complications of corticosteroid injections.
Surgical Intervention
For severe, unresponsive cases of de Quervain's 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.6,15
In a study of 94 patients with de Quervain's 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.16 The outcome was successful in all patients, as demonstrated by a negative Finkelstein test. (See image below and Image 2.) Complications consisted of 4 transient lesions of the radial nerve, 1 instance of delayed wound healing, and 1 superficial wound infection.
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.
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.
Other Treatment
Using a thumb spica splint or performing local corticosteroid injection can be very effective in treating de Quervain's 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's 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’s tenosynovitis.17
- Corticosteroid injection for de Quervain's tenosynovitis18,19
- Mix 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's disease; the investigation examined outcomes in 38 hands (of 36 patients).20
- 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 superior to the 1-point injections.
- 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.21
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.
- 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's tenosynovitis. The atrophy is thought to result from a lymphatic spread of the steroid.22
Medication
Medications for de Quervain's tenosynovitis serve primarily to decrease pain and inflammation. The most commonly used agents are oral nonsteroidal anti-inflammatory drugs (NSAIDs) and focally injected corticosteroid medication; these are employed in conjunction with the rest of the rehabilitation plan.
Nonsteroidal anti-inflammatory drugs
Oral NSAIDs may decrease pain and inflammation in de Quervain's tenosynovitis. Various oral NSAIDs may be used, although, none holds a clear distinction as the drug of choice. The choice of NSAID is largely a matter of convenience (eg, how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost. Many NSAIDs are available either with or without a prescription.23
In contrast with the widespread systemic distribution of an oral anti-inflammatory drug, a topical patch can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation, with minimal systemic distribution.
Ibuprofen (Motrin, Advil, Nuprin, Rufen)
DOC for patients with mild to moderate pain. Ibuprofen inhibits inflammatory reactions and pain, possibly by decreasing prostaglandin synthesis.
Adult
200-800 mg PO tid/qid
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; avoid coadministration of other NSAIDs to minimize side effects; special caution in patients on anticoagulants or systemic corticosteroids, with bleeding disorder, or significant alcohol use; avoid during third trimester of pregnancy (potential risk of affecting closure of ductus arteriosus); caution in patients with history of GI bleed, hypertension, CHF, and in elderly patients; please see manufacturer's product information for further details
Diclofenac Topical Patch (Flector)
Inhibits inflammatory reactions and pain, possibly by decreasing prostaglandin synthesis.
Adult
Apply 1 patch to painful area q12h PRN pain
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity, damaged skin, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; avoid coadministration of other NSAIDs to minimize side effects; special caution in patients on anticoagulants or systemic corticosteroids, with bleeding disorder, or with significant alcohol use; avoid during third trimester of pregnancy (potential risk of affecting closure of ductus arteriosus); caution in patients with history of GI bleed, hypertension, CHF, and in elderly patients; please see manufacturer's product information for further details
Corticosteroids
In contrast with the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. A variety of corticosteroid preparations are available. Mix the corticosteroid with a local anesthetic agent prior to injection.
Methylprednisolone (Depo-Medrol)
Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.
Adult
20-40 mg of methylprednisolone intralesionally, either 0.5 or 1 mL, respectively, of 40 mg/mL solution; may be mixed with a few mL of lidocaine or other local anesthetics
Pediatric
Not established
No medication interactions are reported for this route of administration
Documented hypersensitivity; never inject corticosteroids into or through a site of suspected infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Local injection of corticosteroids in a diabetic patient can sometimes cause transient elevation of blood glucose levels
More on De Quervain Tenosynovitis |
| Overview: De Quervain Tenosynovitis |
| Differential Diagnoses & Workup: De Quervain Tenosynovitis |
 Treatment & Medication: De Quervain Tenosynovitis |
| Follow-up: De Quervain Tenosynovitis |
| Multimedia: De Quervain Tenosynovitis |
| References |
| Further Reading |
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References
Breen TF. Wrist and hand. In: Steinberg GG, Akins CM, Baran DT. Orthopaedics in Primary Care. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:99-138.
Brinker MR, Miller MD. The adult wrist. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:179-95.
McGee DJ. Forearm, wrist, and hand. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:198-215.
Snider RK. Hand and wrist. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:160-263.
Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:756-82.
Ilyas AM, Ast M, Schaffer AA, et al. De quervain tenosynovitis of the wrist. J Am Acad Orthop Surg. Dec 2007;15(12):757-64. [Medline].
Wolf JM, Sturdivant RX, Owens BD. Incidence of de Quervain's tenosynovitis in a young, active population. J Hand Surg Am. Jan 2009;34(1):112-5. [Medline].
Schned ES. DeQuervain tenosynovitis in pregnant and postpartum women. Obstet Gynecol. Sep 1986;68(3):411-4. [Medline].
Forget N, Piotte F, Arsenault J, et al. Bilateral thumb's active range of motion and strength in de Quervain's disease: comparison with a normal sample. J Hand Ther. Jul-Sep 2008;21(3):276-84; quiz 285. [Medline].
Batteson R, Hammond A, Burke F, et al. The de Quervain's screening tool: validity and reliability of a measure to support clinical diagnosis and management. Musculoskeletal Care. Sep 2008;6(3):168-80. [Medline].
Hanlon DP, Luellen JR. Intersection syndrome: a case report and review of the literature. J Emerg Med. Nov-Dec 1999;17(6):969-71. [Medline].
Glajchen N, Schweitzer M. MRI features in de Quervain's tenosynovitis of the wrist. Skeletal Radiol. Jan 1996;25(1):63-5. [Medline].
Diop AN, Ba-Diop S, Sane JC, et al. [Role of US in the management of de Quervain's tenosynovitis: review of 22 cases]. J Radiol. Sep 2008;89(9 Pt 1):1081-4. [Medline].
Lennard TA. Fundamentals of procedural care. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:1-13.
Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of the radial nerve. Clin Anat. Jan 2008;21(1):38-45. [Medline].
Scheller A, Schuh R, Honle W, et al. Long-term results of surgical release of de Quervain's stenosing tenosynovitis. Int Orthop. Oct 2009;33(5):1301-3. [Medline].
Richie CA 3rd, Briner WW Jr. Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooled quantitative literature evaluation. J Am Board Fam Pract. Mar-Apr 2003;16(2):102-6. [Medline]. [Full Text].
Geiringer SR. Tendon sheath and insertion injections. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:44-8.
Goldfarb CA, Gelberman RH, McKeon K, et al. Extra-articular steroid injection: early patient response and the incidence of flare reaction. J Hand Surg [Am]. Dec 2007;32(10):1513-20. [Medline].
Sawaizumi T, Nanno M, Ito H. De Quervain's disease: efficacy of intra-sheath triamcinolone injection. Int Orthop. Apr 2007;31(2):265-8. [Medline]. [Full Text].
Apimonbutr P, Budhraja N. Suprafibrous injection with corticosteroid in de Quervain's disease. J Med Assoc Thai. Mar 2003;86(3):232-7. [Medline].
Chodoroff G, Honet JC. Cheiralgia paresthetica and linear atrophy as a complication of local steroid injection. Arch Phys Med Rehabil. Sep 1985;66(9):637-9. [Medline].
Green SM. Nonsteroidal anti-inflammatories. In: Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Pub; 2000:2000:11-2.
Further Reading
Clinical guidelines:
Diagnostic imaging guideline for musculoskeletal complaints in adults - an evidence-based approach. Part 2: upper extremity disorders. Canadian Protective Chiropractic Association - Professional Association
l'Université du Québec à Trois-Rivières - Academic Institution. 2008 Jan. 31 pages. NGC:006702
Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Work Loss Data Institute - Public For Profit Organization. 2004 (revised 2008 May 29). 128 pages. NGC:006557
Clinical trials:
A Clinical Trial of Splinting for DeQuervain's Tenosynovitis
Keywords
de Quervain tenosynovitis, tenosynovitis, de Quervain's tenosynovitis, Quervain's tenosynovitis, quervain tenosynovitis, stenosing tenosynovitis, de Quervain's disease, Quervain disease, de Quervain disease, abductor pollicis, extensor pollicis, abductor pollicis longus, extensor pollicis brevis, pollicis longus, pollicis brevis
