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De Quervain’s Tenosynovitis

What is De Quervain's tenosynovitis?

  • De Quervain’s tenosynovitis is a condition caused by inflammation of two tendons that control the movement of the thumb and their tendon sheath.

How common is De Quervain's's tenosynovitis?

  • It affects approximately 0.5% of males and 1.3% of females (1).
  • It affects manual professions and office-based work equally (11).

Should I worry?

  • No.
  • With early detection and appropriate rehabilitation symptoms generally recover well.
  • This condition is not related to any other serious conditions.

Who is most likely to suffer from De Quervain's tenosynovitis?

  • Women are 6 to 10 times more likely to develop this condition than men (2).
  • Those aged 40-60 (2).
  • Pregnant women.
  • People who frequently overuse their thumb by completing repetitive hand/wrist movements.

What are the common symptoms?

  • Spasms and tenderness over the thumb/wrist and maybe a burning sensation in the affected hand (3).
  • Aggravated by tasks that load the affected tendon, e.g. lifting and gripping.
  • Abduction (thumbs up position) also increases pain.
  • Inflammation and swelling in the same area as pain.
  • Reduced movement of the thumb and a possible ‘catching’ feeling in certain positions.

What can I do?

  • Physiotherapy can significantly improve symptoms (12).
  • Thumb splint – can help to take the pressure off the tendons (easily purchased at low cost).
  • Activity modification – limit aggravating movements whilst in the painful stage.

How long will it take to recover?

  • This is dependent upon several variables. If symptoms are addressed early, you could expect improvements within 4-6 weeks.
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1. Introduction

De Quervain’s tenosynovitis (DQT) is an overuse condition affecting the membrane (tendon sheath) that surrounds two of the tendons responsible for the movements of the thumb. Tendons are strong tissues that connect muscle to bone and those involved in De Quervain’s tenosynovitis are the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) tendons. These tendons help with movements of the thumb (4). De Quervain’s tenosynovitis is characterised by pain, inflammation and tenderness in the area where the wrist and thumb articulate (meet). You may find that certain tasks involving the affected hand or thumb are troublesome. An appropriately qualified healthcare professional can help you find ways to modify your activities and best manage your symptoms.

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2. Signs & Symptoms

3. Causes

This condition can develop from a gradual or sudden overload of the tendon sheath which surrounds two tendons that move the thumb. Over time, this can irritate the sheath that surrounds the tendons of the thumb. Repeated loading is often a significant factor in the development of this condition. Continuous gripping, pinching, grasping and wringing actions may cause a scar-like formation with an associated worsening of symptoms. Research suggests that the tendon sheath thickens due to degeneration, which can cause the space around the affected tendons to narrow. This means the tendons cannot move as freely, creating friction, inflammation and pain (2,5,6,7,8). Whilst De Quervain’s tenosynovitis is heavily associated with overuse, it can arise from direct trauma.

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4. Risk Factors

This is not an exhaustive list. These factors could increase the likelihood of someone developing De Quervain’s tenosynovitis. It does not mean everyone with these risk factors will develop symptoms.

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5. Prevalence

The prevalence of De Quervain’s tenosynovitis is approximately 0.5% in males and 1.3% in females in the general population (1). It affects women 6 to 10 times more than men (2).

 

6. Assessment & Diagnosis

Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.

Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies such as magnetic resonance imaging (MRI) or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.

7. Self-Management

As part of your treatment, your treating clinician may suggest relative rest to offload the tendon sheath to help reduce irritation. A thumb and wrist ‘spica’ splint is often helpful. It has been suggested that splinting reduces how much the affected tendons glide through the narrowed compartment/canal so there is less friction and hopefully less inflammation/pain (4). It may also help you carry out gripping actions more easily.

Please note it is important to keep the thumb and tendon moving as immobilisation may lead to reduced function and restricted movement. Your clinician will provide advice regarding modifications of any tasks that are currently painful which will allow the tendon sheath to settle and begin to recover.

The use of exercise and splinting as management of De Quervain’s tenosynovitis is recommended and supported by evidence (1).

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8. Rehabilitation

The affected tendons often benefit from strengthening which encourages regeneration, making previously irritable tasks manageable. A musculoskeletal physiotherapist will often guide you through a tailored strengthening programme.

For example, eccentric exercises (where the muscle lengthens during an exercise) have been linked with positive results (9). It is reported that these types of exercises promote remodelling in the affected tendons.

Below are some recommended exercises, split into three stages. The exercises should not reproduce significant pain and balancing them with resting and offloading the tissues is important to let the inflammation settle. We also have a general thumb strengthening programme. We advise consulting with a musculoskeletal physiotherapist prior to trying any of these exercises. Regular reassessment will ensure you are making progress and that your management and exercise plan remains optimal for producing favourable outcomes.

9. De Quervain's Tenosynovitis Rehabilitation Plan

Treatment Plan

Pain should not exceed 2/10 on your perceived pain scale whilst completing this exercise programme.

Treatment Plan  - Rating
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11. Return to Sport/Normal Life

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. These exercises will progressively and carefully load the hands more to continue to build strength.

As part of a multi-modal treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.

11. Other Treatment Options

Physiotherapy alone can significantly improve symptoms (12). However, in persistent and irritable cases more invasive treatment such as those detailed below might be required.

Corticosteroid injections: if your symptoms are not improving with time or if they are more severe, you may benefit from a steroid injection into the affected area as a mode of short-term pain relief (10). It can be used as an adjunct to other management interventions.

Medications: your GP can discuss pain relief and anti-inflammatory medications with you as another adjunct to physiotherapy management. It may be useful to help get the hand or thumb moving more.

Surgery: in more severe cases where conservative treatment has not been effective and symptoms are persistent, surgical intervention is available to free the restricted tendons, but this is rarely necessary (1).

References

  1. Young, S.W., Young, T.W. and MacDonald, C.W. (2020). Conservative management of De Quervain’s tendinopathy with an orthopedic manual physical therapy approach emphasizing first CMC manipulation: a retrospective case series. Physiotherapy Theory and Practice.1-10.
  2. Ferrara, P.E., Codazza, S., Cerulli, S., Maccauro, G., Ferriero, G. and Ronconi, G. (2020). December. Physical modalities for the conservative treatment of wrist and hand’s tenosynovitis: A systematic review. In Seminars in Arthritis and Rheumatism (50)6, pp. 1280-1290.
  3.  Babaji, G.A. and Shinde, S.B. (2017). Effect of the Mckenzie’s Method of Mechanical Diagnosis and Therapy and Pain Releasing Phenomenon in Subjects with Dequervain’s Tenosynovitis. IJPOT. 11(3), 162.
  4.  Liu, C.H., Yip, K.S. and Chiang, H.Y. (2020). Investigating the optimal handle diameters and thumb orthoses for individuals with chronic de Quervain’s tenosynovitis–a pilot study. Disability and rehabilitation, 42(9), 1247-1253.
  5. Wai-si, T.E., Joanne, Y., Yu, L.K., Lun, Y.K., Christian, F. and Pui, N.S. (2020). De Quervain’s Tenosynovitis-A Systematic and Citation Network Analysis Review. Biomedical Journal of Scientific & Technical Research, 24(5), 18674-18684.
  6.  Nemati, Z., Javanshir, M.A., Saeedi, H., Farmani, F. and Aghajani Fesharaki, S. (2017). The effect of new dynamic splint in pinch strength in De Quervain syndrome: a comparative study. Disability and Rehabilitation: Assistive Technology, 12(5), 457-461.
  7.  Ahmad, I., Khan, A., Khan, Z., Kashif, S., Saeed, M. and Arif, M. (2020). Seasonal variations and occupational risk factors: Analysis of 460 patients of de Quervain’s tenosynovitis. Pak J Surg, 36(3), 251-254.
  8.  Garçon, J.J., Charruau, B., Marteau, E., Laulan, J. and Bacle, G. (2018). Results of surgical treatment of De Quervain’s tenosynovitis: 80 cases with a mean follow-up of 9.5 years. Orthopaedics & Traumatology: Surgery & Research, 104(6), 893-896.
  9.  Rabin, A., Israeli, T. and Kozol, Z. (2015). Physiotherapy Management of People Diagnosed with de Quervain’s Disease: A Case Series. Physiotherapy Canada, 67(3), 263-267.
  10.  Huisstede, B.M., Gladdines, S., Randsdorp, M.S. and Koes, B.W. (2018). Effectiveness of conservative, surgical, and postsurgical interventions for trigger finger, Dupuytren disease, and De Quervain disease: a systematic review. Archives of physical medicine and rehabilitation, 99(8), 1635-1649.
  11.  Stahl, S., Vida, D., Meisner, C., Lotter, O., Rothenberger, J., Schaller, H.E. and Stahl, A.S. (2013). Systematic review and meta-analysis on the work-related cause of de Quervain tenosynovitis: a critical appraisal of its recognition as an occupational disease. Plastic and Reconstructive Surgery, 132(6), 1479-1491.
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