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). [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]
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 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.
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.
Consultations
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.
Other Treatment
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:
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Bleeding or bruising can occur, especially in individuals with bleeding disorders or in patients taking anticoagulants.
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Infection at the injection site is rare but possible. Minimize risk through the use of sterile technique for the procedure.
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In patients with diabetes, a transient elevation of the blood glucose level may occur after corticosteroid injection.
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Allergic reactions to injected medications are rare, but possible.
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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).
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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]
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Tendon weakening and rupture is rare, but possible.
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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]
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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.
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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.
