De Quervain's Tenosynivitis

What is De Quervain's tenosynovitis?

De Quervain's tenosynovitis, also known as De Quervain's tendonitis, is a painful condition of the tendons located at the radial side of the wrist and at the base of the thumb. The pain, which is what primarily prompts the patient to go see a physican, gets worse with abduction or extension of the thumb, grasping action of the hand, and with ulnar deviation of the wrist. The pathology behind it can be described as a myxoid degeneration with fibrous tissue deposits and increased vascularity. This deposits at extensor retinaculum result in thickening of the tendon sheat, painfully entrapping the abductor pollicis longus tendon (APL) and the extensor pollicis brevis tendon (EPB).

Anatomy behind the condition:

The tendons that become entrapped include the abductor pollicis longus tendon (APL) and the extensor pollicis brevis tendon (EPB).

What can cause this condition?

Doctors often don't known exactly what can cause De Quervain's tendonitis, but it may result from:

Risk factors for developing the condition:

Even though physicians don't exactly know the cause for this condition, it is known that there are some risk factors associated with its development.

Some of the risk factors for De Quervain's tendonitis include:

Most common symptoms:

The primary symptom is radial sided wrist pain that radiates up the forearm with grasping movements of the hand, ulnar deviation of the wrist and thumb extension or abduction. The pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand such as opening a jar lid, holding the steering wheel or turning a door knob. Some patients report a "sticking" or "stop-and-go" sensation when moving the thumb. Other possible findings include weakness and swelling near the base of the thumb and paresthesia in the hand.

What to expect at the doctor's office?

First, an examination will begin by taking a thorough history followed by a physical examination. On palpation, some key significant finding will be tenderness over the base of the thumb and/or at the first dorsal compartment on the thumb side of the wrist, particularly over the radial styloid process. The provocative Finkelstein test in which the thumb is flexed and held inside a fist, and the patient actively ulnar deviates the wrist, causes a sharp pain along the radial wrist at the first dorsal compartment. This is a positive test result therefore confirming the diagnosis. Imaging tests, such as X-rays or MRIs, can help rule out other causes for the pain but these aren't needed to diagnose De Quervain's tendonitis. 

How can it be treated?

De Quervain's tendonitis can be self-limited and may resolve without intervation. Persistent symptoms can be treated with conservative management and if this fails then surgery is an option. Treatment will depend on the degree of severity of the condition. 

Most people notice improvement after 4 to 6 weeks of treatment and are able to use their hands and wrist without pain once the swelling is gone.

If symptoms fail to improve with conservative treatments or recur after two corticosteroid injections then operative management is an option. The goal of surgery is to open the dorsal compartment covering to make more room for the irritated tendons. The opening allows pressure relief of the tendons ultimately restoring free tendon gliding. After surgery, once the sutures are removed which is usually after the first or second week post-op, patients are typically released to resume normal activities. It is recommended that the patient do 6 to 8 weeks of physical therapy after the removal of stitches.

Why is Physical therapy important?

Physical therapy is targeted to increase motion and decrease stiffness. The therapists may review how the patient usually uses the hand and they may be able to give suggestions on how to make adjustments to relieve stress on the wrist. These therapists can also teach exercises for the wrist, hand and arm to strengthen the muscles reducing pain and limiting tendon irritation. Depending on what location the patient decides to do the physical therapy they may be able to provide other resources such as: massages, kinesio-taping and therapeutic ultrasound. Conservative treatment physical therapy can be 4 to 6 weeks. Surgical treatment physical therapy usually is 6 to 8 weeks. 

What is the recovery period?

Recovery times vary depending on age, general health and how long the symptoms have been present. If the patient didn't need surgery, recovery is expected in 4 to 6 weeks if the patient wears the splint, does exercises, and avoid movements that may cause tendon irritation. Recovery from surgery on the other hand may take longer. Pain and swelling should go away soon after the surgery but the area may still be tender for up to 3 months after. In the case that the patient needed surgery, after the stitches are removed, physical therapy should begin for a period of 6 to 8 weeks. This extends the recovery process to 2 to 3 months. 

Author
Endrina Mangual Valladares Third year Medical Student at University of Medicine and Health Sciences (UMHS)

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