Physical Medicine and Rehabilitation for De Quervain Tenosynovitis

In the first dorsal compartment of the wrist, a tendon sheath encloses the abductor pollicis longus and the extensor pollicis brevis tendons at the lateral border of the anatomical snuffbox. Inflammation at this site commonly is seen in patients who use their hands and thumbs in a repetitive fashion. Thus, de Quervain tenosynovitis can result from cumulative (repetitive) microtrauma. Inflammation also may occur after an isolated episode of acute trauma to the site.[6]

The first dorsal compartment of the wrist often contains a septum, which can complicate treatment by making target structures more difficult to inject. Up to 50% of patients may have first dorsal compartments with septa. These septa have an average length of 5 mm.[12]

A randomized study of 300 undergraduate students showed that those who texted more mobile phone messages per day were more likely to have a positive Finkelstein test (indicative de Quervain tenosynovitis). The investigators concluded that students who use their mobile phones to send more than 50 texts per day have a higher probability of developing de Quervain tenosynovitis.[13]

A cross-sectional study by Baabdullah et al indicated that heavy smartphone use correlates with thumb/wrist pain. Using a self-administered patient-rated wrist and hand evaluation (PRWHE) questionnaire, the investigators found that smartphone “addicts” (as identified using the short version of the smartphone addiction scale) had a median total pain and disability score of 8.00, compared with 4.25 for non-addict smartphone users. However, the study did not find smartphone addiction to be significantly associated with a positive Finkelstein test.[14]

A cross-sectional study of 500 students, by Ma et al, showed that those who played mobile games frequently and for long periods of time were at higher risk of developing de Quervain tenosynovitis. The investigators recommended limiting mobile game play to less than 2.25 hours/day to limit the risk of developing the condition.[15]

A cross-sectional study by Warrender et al indicated that de Quervain tenosynovitis is less prevalent in regions with higher humidity and more prevalent in areas with higher average barometric pressure.[16]

Frequency

United States

De Quervain tenosynovitis is relatively prevalent, especially among individuals who perform repetitive activities using their hands (eg, certain assembly line workers, secretaries).[17]

Mortality/Morbidity

Mortality is not associated with de Quervain tenosynovitis. Some morbidity may result as the patient experiences progressive pain, with limitations occurring in activities requiring use of the affected hand.

Race

Traditionally, no race predilection has been reported for de Quervain tenosynovitis. However, recently the University of Colorado School of Medicine has described the black race as a risk factor for de Quervain tenosynovitis.[17]

Sex

Although this condition is commonly seen in females and males, the incidence of de Quervain tenosynovitis appears to be significantly greater in women.[6] Some sources even quote a female-to-male ratio as high as 8:1. Interestingly, many women suffer from de Quervain tenosynovitis during pregnancy or the postpartum period.[18]

Age

De Quervain tenosynovitis is much more common in adults than in children.

Genetics

Genomic research has revealed that rs35360670 on chromosome 8 has a significant association with de Quervain tenosynovitis.[19]

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.

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.[20]

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.[21]

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).[21]

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).[22]

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.

No laboratory studies support the diagnosis of de Quervain tenosynovitis. The clinician may consider serologic testing for rheumatoid arthritis (ie, checking serum rheumatoid factor) if the patient has no history of either acute or repetitive trauma or other risk factors.

Usually, no imaging studies are required for diagnosing de Quervain tenosynovitis.

If a sufficient history of acute trauma exists, radiographs of the wrist are indicated to assess for fracture.

If the radiographs are negative but there is nonetheless a suggestion of fracture or osteonecrosis, further imaging studies can be pursued (eg, 3-phase bone scan). Triple-phase scintigraphy includes the following:

• Phase 1 - Flow phase (radionuclide angiography)

• Phase 2 - Blood pool phase (soft-tissue scintigraphy)

• Phase 3 - Late phase (skeletal bone scintigraphy)

After a fracture, increased flow and pooling may be seen in phases 1 and 2, but these findings are due only to local inflammation, which is not specific for fracture. Thus, increased uptake in phase 3 is the most important feature for diagnosis of a fracture, and this indicator may remain positive for months.

For fracture at the scaphoid, the 3-phase bone scan is believed to have a sensitivity of 100%, and many research studies use this test as the criterion standard for diagnosis of de Quervain tenosynovitis; in clinical practice, however, bone scanning is needed only if the plain radiographs are negative.

Increased thickness of the extensor pollicus brevis and abductor pollicus longus are the most reliable indications on a MRI scan of the wrist that de Quervain tenosynovitis is present.[25]

Despite the inroads made with imaging in de Quervain tenosynovitis, the accuracy of imaging in diagnosing the disease is unclear. For example, a literature review by McBain et al was unable to determine the value of imaging in de Quervain tenosynovitis, owing to variation between studies. The investigators reported that the most common imaging findings in the disorder were sheath effusion, retinaculum thickening, tendon thickening, increased vascularity, periostitis, periosteal apposition, radial styloid osteopenia, and calcified lesions in the tendon sheath.[26]

A study showed that the presence of an intracompartmental septum, which divides the first extensor compartment, can negatively affect the outcomes of corticosteroid injections.[27] The septum may impair through spread of the injectate throughout the entire first dorsal compartment. The study suggests that the presence of this septum may be a risk factor for de Quervain tenosynovitis, and that ultrasonography can nonsurgically detect this septum. Further research may be necessary to elucidate whether visualization of the septum using ultrasonography can then be used as a predictor as to the prognosis of an injection as a treatment or whether ultrasonographic guidance can overcome any outcome obstacles posed by the septum. For example, a study used ultrasonographic guidance to determine the presence or absence of a septum within the first dorsal compartment. If a septum was present, half of the injectate was administered, then the septum was pierced by the needle and the other half of the injectate was then administered on the other side of the septum.[28]

No other diagnostic procedures are needed in most cases of de Quervain tenosynovitis.

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).[7]

Low-level laser therapy (3 J/cm2 in continuous mode, frequency 7-10 sessions on alternative days) and therapeutic ultrasound (0.8-1.5 W/cm2, 1 MHz in pulsed mode) have each proven successful in the treatment of de Quervain tenosynovitis, through reduction of tendon sheath diameter and tenderness, with ultrasound being slightly the more effective of the two modalities. However, both treatments have been found to be less effective than steroid injections in reducing pain and improving grip strength.[8]

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.[29]

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 in the treatment of de Quervain tenosynovitis, sometimes a custom-made thumb spica can be fabricated by a trained occupational therapist.[9]

Greater muscle loads tend to be exerted by individuals with de Quervain tenosynovitis when executing the same power grasp as healthy controls. However, electromyographic analysis has demonstrated that for individuals with the disorder, utensils with thicker handle diameters (45 or 55 mm) require less muscle activity during a power grasp than do those with thinner handle diameters (33 mm).[30]

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

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, 10, 11]

Park and Smith described a volar approach to surgical release that allows for clear visualization of the retinaculum, allowing the surgeon to do a midline retinacular release. The benefit of this approach is that the patient may have a decreased risk of iatrogenic nerve injury, with no greater likelihood of volar tendon subluxation.[31]

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.[32] The outcome was successful in all patients, as demonstrated by a negative Finkelstein test. See the image below.

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

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

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

Unlike a typical wrist splint, a thumb 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.

In the acute and chronic phases of de Quervain tenosynovitis, the standard brace prescribed is a long thumb orthosis (a thumb spica splint that extends proximally along the forearm). However, a study by Liu et al revealed, on electromyography (EMG), no significant difference in forearm muscle activity between long and short thumb orthoses.[30]

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.[33]

A 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.[34, 35]

Corticosteroid injection for de Quervain tenosynovitis[36, 37] 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).[38] 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 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.[39]

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.[40]

Ultrasonographically 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.[41, 42]

Ultrasonography also helps practitioners to identify target structures, such as the extensor pollicis brevis (EPB) tendon sheath, during injections. In patients with septate first extensor compartments, practitioners can much more reliably inject the appropriate compartment when using ultrasonography. A cadaveric study by Kang et al reported that with ultrasonographic guidance, injection into septate wrists targeting the EPB tendon sheath was 85.7% accurate, compared with 16.7% accuracy in septate wrists when ultrasonography was not used.[43]

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.[44]

• 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.[45]

A study of 30 patients with de Quervain tenosynovitis compared treatment outcomes for 15 patients undergoing acupuncture versus 15 patients undergoing corticosteroid injections. At 6-week follow-up, there was a 90% decrease in disability for the injection group, versus an 85% decrease for the acupuncture patients, as evaluated via the Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score. The visual analogue scale (VAS) pain score showed an 82% decrease in pain for the injection group, versus a 71% decrease for the acupuncture group. Although corticosteroid injection is a mainstay of tendinopathy management, the benefit may be only short-term, and there is some risk for side effects in steroid use. Acupuncture may have an advantage in treating de Quervain tenosynovitis, since patients can undergo multiple sessions with very low risk for side effects.[46]

A study by Akhtar et al found treatment of de Quervain tenosynovitis with a combination of thumb spica cast and methylprednisolone acetate injection to be more effective than therapy with the cast alone. The rate of successful treatment with the combined therapy was 85.1%, while the success rate with the cast by itself was 37.4%.[47]

Medications for de Quervain 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.

Class Summary

Oral NSAIDs may decrease pain and inflammation in de Quervain 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.[48]

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.

Diclofenac topical

Inhibits inflammatory reactions and pain, possibly by decreasing prostaglandin synthesis.

Class Summary

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.

Have the patient return for reevaluation approximately 2-4 weeks after corticosteroid injection.

At the time of the follow-up visit, assess for therapeutic response to the injection and evaluate for any complication or further treatment needs.

Instruct the patient to contact his/her physician sooner if a significant progression of symptoms is noted or if local signs of infection are present at the injection site.

Please see Medication.

A patient with de Quervain tenosynovitis may need to avoid certain repetitive activities of the wrist or thumb until adequate rehabilitation has been achieved.

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

Most patients with de Quervain tenosynovitis respond very well to nonsurgical treatment (eg, corticosteroid injection, splinting, physical therapy, occupational therapy).

For severe cases that are unresponsive to injections, refer the patient for surgical treatment to decompress the first dorsal compartment.

A literature review by Cavaleri et al indicated that the combined use of orthoses and corticosteroid injections for de Quervain tenosynovitis is more effective at improving pain and function than the use of either treatment by itself.[49]

As with any injection, educate the patient to watch for signs or symptoms of local infection at the injection site.

Instruct diabetic patients that they may experience a transient increase in blood glucose levels with corticosteroid injection.

Educate patients that symptomatic improvement from corticosteroid injection usually is observed a few days after injection. Patients should understand that they may experience a mild, transient increase in symptoms during the period in which the local anesthetic has worn off but the steroids have not yet begun to demonstrate a noticeable therapeutic effect.