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De Quervain's Tenosynovitis

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Woman experiencing acute pain in wrist or thumb

De Quervain’s Tenosynovitis is a condition that causes  inflammation of the tendon sheath or tunnel on the thumb side of the hand. This sheath houses the two tendons that control the movement of the thumb. The cause of this condition has not been clearly established.  Another name for it is De quervain’s syndrome.

The principal symptom of De quervain’s is pain when attempting to turn the wrist, to grasp an object or to make a fist. The onset of this painful condition is usually gradual. De quervain’s tenosynovitis usually becomes worse if the patient performs activities that involve repetitive hand or wrist movements. This includes activities such as gardening or playing racquet sports, to take two examples.

Cause

De quervain’s pain normally originates from the two tendons that pass through a small tunnel in the wrist and lower thumb.  The muscles involved are the extensor pollicis brevis and the abductor pollicis longus. These tendons also connect to the base of the thumb. De quervain’s syndrome causes irritation of the sheath around these tendons. This irritation results in thickening of the sheath, which then restricts their ability to move smoothly through the tunnel.

As we have stated above, doctors are uncertain as to the exact cause of De Quervain’s tenosynovitis. However, the condition tends to appear when an individual uses the wrist or thumb in a repetitive movement of some kind.

De quervain’s tenosynovitis is also associated with the following:

  • A direct injury to the wrist or to the tendons controlling the movement of the thumb. When this happens, scar tissue can develop around the tendons. This will then make it difficult for the tendons to move smoothly through the sheath in which they are housed;
  • Rheumatoid arthritis can also cause De quervain’s as a secondary effect.

Demographic risk factors for this condition include:

  • Age – it tends to have the highest prevalence among adults between the ages of 30 and 50;
  • Gender – it is more common among women than men;
  • Pregnancy and/or childbearing appears to increase the risk of developing the condition.

Symptoms

Symptoms of De Quervain’s tenosynovitis includes some or all of the following:

  • Pain and/or swelling near the base of the thumb;
  • Difficulty moving the thumb and wrist when the patient needs to do something that requires pinching or grasping movements. The patient also experiences difficulty when trying to bend the wrist , resulting in reduced range of motion of that joint
  • A feeling that the thumb is “sticking” when the patient tries to move it.

Left untreated, the severity of De Quervain’s increases. The pain usually spreads further into the thumb or it may spread along the forearm. In some cases, it may spread in both directions.

Diagnosis & Treatment

Diagnosis

To make a formal diagnosis of De quervain’s tenosynovitis, a doctor will normally perform a physical examination of the wrist. A key question will be if the patient feels pain when pressure is applied to the thumb side of the wrist (tenderness). This tenderness is most acute over the tip of the radial styloid. Swelling along the course of the two affected tendons may be present.

Abduction of the thumb against resistance will usually cause pain.

Another important test to perform during the diagnosis stage is the “Finkelstein test”. To perform this test, the doctor will ask the patient to:

  • Bend the thumb across the palm of the hand;
  • Then bend the fingers down over the thumb, and finally;
  • Bend the wrist in the direction of the little finger.

If this causes pain on the thumb side of the wrist, the patient is likely suffering from De quervain’s tenosynovitis.

In most cases, imaging tests are not required to make a diagnosis.

Treatment

The first step in trying to treat this condition is usually home based. If the diagnosis is made early and treatment is started promptly, conservative (home-based) measures may be all that is required to bring about resolution of symptoms.The patient can try:

  • Avoiding activities that make use of the affected thumb for a period (if this is not inconvenient);
  • Applying ice or a cold compress to the affected wrist and/or thumb;
  • Taking an anti inflammatory medication such as ibuprofen.

If these measures are not successful, doctors may consider further steps such as:

  • Corticosteroid injections into the tendon sheath. The doctor will  hope that this will reduce swelling and facilitate movement of the tendons through the sheath;
  • Immobilizing the thumb and wrist and trying to keep them in a straight position. This will allow the injured tendons an opportunity to rest and recover naturally. To do this, doctors may recommend wearing a thumb brace (sometimes called a thumb spica). Alternatively, they may recommend wearing a wrist/thumb brace that immobilizes both the wrist and thumb.

Sometimes, avoidance of activities involving the affected thumb, ice and anti-inflammatory medication are tried initially, with splints being used later on if these initial interventions do not improve symptoms. However, alternatively, a thumb spica can be used at the same time as the other measures.

Surgery

If the above conservative treatments fail to eliminate the symptoms of De quervain’s tenosynovitis, the doctor may suggest surgical correction. The surgery will attempt to widen the sheath housing the injured tendons. If successful, the tendons will again be able to move through the tunnel with ease. Regular wrist/thumb movement would then return.

Physical Therapy

An important part of the treatment will be physical therapy. A physical therapist can prescribe an exercise program to strengthen the wrist, hand and thumb.

It is important that the patient adheres to this part of the treatment. If not, there is a risk that the De quervain’s tenosynovitis will return in the future. If so, the patient will have to go through the above treatments all over again.

In addition to the physical therapy, an occupational therapist can review how the patient uses the wrist to perform tasks requiring repetitive movements. The occupational therapist can then recommend changes to the equipment the patient uses, or to how the movements are performed. These changes will help to reduce the irritation of the tendons due to these movements.

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