De Quervain’s Tenosynovitis: Clinical Features, Diagnosis, and Management

Introduction

De Quervain’s tenosynovitis is a common overuse injury affecting the tendons on the thumb side of the wrist. This blog post explores the clinical features, diagnosis, and management options for de Quervain’s tenosynovitis, incorporating insights from key research articles and reviews.

Clinical Features

De Quervain’s tenosynovitis predominantly affects the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, which pass through the first dorsal compartment of the wrist. The condition is caused by repetitive or sustained strain, leading to thickening and swelling of the extensor retinaculum. Key clinical features include:

Pain and Swelling: Pain is typically localized to the radial side of the wrist and can radiate into the thumb or forearm. Swelling over the first dorsal compartment is common. The pain often worsens with thumb and wrist movements, such as grasping, wringing, or lifting. Activities that involve repetitive thumb motion, such as texting, gaming, or playing certain musical instruments, can exacerbate symptoms. The pain can be sharp or aching and is often described as a dull, constant ache that can become more intense with activity.
Provocative Tests: Finkelstein’s test is commonly used to diagnose de Quervain’s tenosynovitis. This involves the patient making a fist with the thumb enclosed by the fingers and then ulnarly deviating the wrist. Pain over the radial styloid process suggests a positive test. The Eichoff maneuver, a similar test, can also be used. Additionally, the Wrist Hyperflexion Abduction of the Thumb (WHAT) test can be performed, where pain is induced by hyperflexing the wrist while maintaining thumb abduction and extension.

Functional Limitations: Patients may report difficulty with activities that require grip strength and thumb movement, such as lifting objects or holding tools. The pain can also interfere with daily activities such as opening jars, turning doorknobs, or typing. In severe cases, patients might experience a weakened grip or find it challenging to perform tasks that involve pinching or grasping.

Risk Factors and Epidemiology

De Quervain’s tenosynovitis is more prevalent in women than men and often affects individuals aged 30-50 years. Common risk factors include:

Repetitive Activities: Occupations or hobbies that involve repetitive wrist and thumb movements, such as typing, gardening, or playing racquet sports, increase the risk. Hairdressers, musicians, and assembly line workers are particularly susceptible. Activities that involve repetitive ulnar deviation of the wrist or frequent use of the thumb can lead to overuse and strain of the tendons.
Pregnancy and Postpartum Period: Hormonal changes and repetitive lifting of infants contribute to a higher incidence in pregnant and postpartum women. De Quervain’s tenosynovitis is often referred to as "mommy thumb" due to its prevalence among new mothers. The hormonal changes during pregnancy can lead to increased fluid retention and swelling, exacerbating tendon sheath constriction.
Inflammatory Conditions: Conditions such as rheumatoid arthritis can predispose individuals to de Quervain’s tenosynovitis. The inflammatory process can lead to tenosynovitis, causing pain and swelling. Other systemic inflammatory diseases, such as lupus and psoriatic arthritis, may also increase the risk of developing de Quervain’s tenosynovitis.

Diagnosis

Diagnosis is primarily clinical, based on patient history and physical examination. Imaging studies are usually not required but may be used to rule out other conditions.

Physical Examination: Swelling and tenderness over the first dorsal compartment are typical findings. The Finkelstein and Eichoff maneuvers are key diagnostic tests. Palpation of the first dorsal compartment often reveals tenderness, and sometimes a crepitus can be felt as the tendons move. In addition to these tests, clinicians may observe for signs of visible swelling or nodules along the tendons.
Imaging: Ultrasound can visualize tendon thickening and fluid accumulation within the first dorsal compartment. Radiographs are generally not necessary unless there is a suspicion of bony pathology, such as fractures or arthritis. MRI may be considered in complex cases to evaluate soft tissue structures. Ultrasound is particularly useful for assessing dynamic changes in the tendons and can help identify partial tears or synovial hypertrophy.

Differential Diagnosis

When diagnosing de Quervain’s tenosynovitis, it is essential to consider other conditions that can cause similar symptoms:

Intersection Syndrome: Pain is located more proximally, where the APL and EPB cross over the extensor carpi radialis longus and brevis tendons. This condition often presents with a "squeaking" or creaking sensation over the distal forearm and is exacerbated by activities that involve wrist extension and flexion.
Radial Styloid Tenosynovitis: Inflammation of the tendons around the radial styloid can mimic de Quervain’s. This condition is characterized by tenderness and swelling localized to the radial styloid process.
Osteoarthritis of the Thumb Carpometacarpal Joint: This condition can cause pain in a similar location but is often associated with crepitus and joint stiffness. Patients with osteoarthritis may also report a "grinding" sensation during thumb movements and may have visible bony enlargements around the joint.
Carpal Tunnel Syndrome: While primarily causing numbness and tingling in the fingers, carpal tunnel syndrome can sometimes present with wrist pain. Differentiation can be made through nerve conduction studies and specific physical tests for carpal tunnel syndrome.
Ganglion Cysts: These benign cysts can develop near the tendons of the wrist and cause localized swelling and pain. They are often visible as a lump near the affected area and can be confirmed through ultrasound or MRI.

Management

Management of de Quervain’s tenosynovitis includes both conservative and surgical options, depending on the severity and duration of symptoms.

Conservative Treatment: Initial management focuses on reducing inflammation and modifying activities to relieve stress on the tendons.

Patient Education: Educating patients about activity modification and ergonomics to avoid repetitive wrist and thumb movements. Patients should be advised to take frequent breaks and use proper techniques when performing repetitive tasks. Ergonomic adjustments may include using tools with larger grips or altering workstations to minimize strain on the wrist and thumb.
Splinting: A thumb spica splint immobilizes the thumb and wrist, reducing movement and allowing the tendons to rest. The recommended splint position includes the wrist in neutral, 30° of carpometacarpal (CMC) joint flexion, and 30° of thumb abduction with the thumb interphalangeal (IP) joint free. Splinting for 4-6 weeks can significantly reduce symptoms. Night splinting is often recommended to prevent inadvertent wrist movements during sleep.
Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections are commonly used. Corticosteroid injections into the first dorsal compartment can provide significant symptom relief. Studies have shown prolonged relief in up to 80% of cases with corticosteroid injections. Ultrasonography-guided corticosteroid injections are associated with greater pain reduction than conventional injections. Oral NSAIDs can help manage pain and inflammation. In some cases, topical NSAIDs may be recommended to minimize systemic side effects.
Occupational Therapy: Techniques such as therapeutic ultrasound, iontophoresis, and manual therapy can help reduce pain and inflammation and improve function. Adaptive equipment and ergonomic modifications can help patients perform daily activities with less strain on the wrist. Occupational therapy can also include instruction in proper body mechanics and joint protection techniques to prevent recurrence.
Therapeutic Exercises: Tendon gliding exercises and gentle strengthening exercises are introduced as pain decreases. These exercises enhance the gliding of the APL and EPB tendons and restore function. Nerve glide exercises and soft tissue mobilization can also be beneficial. Stretching exercises for the wrist and thumb can help maintain flexibility and reduce the risk of further injury.
Laser Therapy: Low-level laser therapy can improve function, symptoms, and electrophysiological measures in the short term. Some studies suggest that laser therapy is more effective than placebo, particularly in patients with mild to moderate CTS. However, results are inconsistent, and further research is needed to confirm its efficacy. Laser therapy may work by reducing inflammation and promoting tissue healing at a cellular level.

Surgical Treatment: Surgery is considered when conservative treatments fail after 4-6 months.

Surgical Decompression: The procedure involves releasing the first dorsal compartment to allow the tendons to move freely. Postoperative care includes splinting, occupational therapy, and gradual return to activities. Surgery typically provides significant symptom relief, and most patients can return to normal activities within weeks. Addressing anatomical variations such as septated compartments during surgery can improve outcomes. The surgical approach may vary, with some surgeons opting for a mini-open or endoscopic technique to minimize scarring and recovery time.
Postoperative Care: Post-surgery, a thumb spica splint is worn for 1-2 weeks. Occupational therapy focuses on edema and scar management, range of motion exercises, and gradual strengthening. Desensitization techniques may be used if there is nerve involvement or scar hypersensitivity. Patients are typically encouraged to start gentle range of motion exercises soon after surgery to prevent stiffness and promote healing.
Long-term Outcomes: Surgical treatment is generally effective with high patient satisfaction. Addressing any anatomical variations, such as septated compartments during surgery, can improve outcomes. Long-term follow-up studies indicate that most patients experience lasting relief from symptoms, although a small percentage may require additional interventions if symptoms recur.

Evidence-Based Insights

Recent studies and systematic reviews provide valuable insights into the management of de Quervain’s tenosynovitis:

Combination Treatments: Adding thumb spica immobilization to corticosteroid injections has shown significant pain-relieving and functional benefits. Splinting combined with corticosteroid injections is effective for short-term relief. However, symptoms may recur when the splint is removed. A systematic review by Challoumas et al. (2023) found that combining these treatments can enhance overall outcomes, particularly in patients with severe symptoms.
Ultrasonography-Guided Injections: These injections are associated with greater pain reduction compared to conventional injections. This technique ensures accurate delivery of the corticosteroid into the affected compartment. Studies have demonstrated that ultrasound guidance can improve injection accuracy and reduce the risk of complications.
Surgical Outcomes: Surgical treatment is generally reserved for cases that do not respond to conservative measures. The success rate is high, particularly when anatomical variations such as septated compartments are addressed during surgery. A review by Ilyas et al. (2007) emphasized the importance of individualized surgical planning to address specific anatomical concerns and improve patient outcomes.

Conclusion

De Quervain’s tenosynovitis is a common condition that can significantly impact daily activities. Early diagnosis and appropriate management, including patient education, conservative treatments, and surgical options when necessary, can lead to successful outcomes and pain relief. By understanding the clinical features, risk factors, and evidence-based treatment options, healthcare providers can effectively manage this condition and improve patient quality of life.

References

Goel, Ritu, and Joshua M. Abzug. "de Quervain's tenosynovitis: a review of the rehabilitative options." Hand 10.1 (2015): 1-5.
Ilyas, Asif M., et al. "De quervain tenosynovitis of the wrist." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 15.12 (2007): 757-764.
Challoumas, Dimitris, et al. "Management of de Quervain Tenosynovitis: A Systematic Review and Network Meta-Analysis." JAMA Network Open 6.10 (2023): e2337001-e2337001.