What is de Quervain’s Tenosynovitis?
Tendons are rope like structures that connect muscle to bone. In the thumb joint there are two tendons: The Abductor Pollicis Longus (APL) and the Extensor Pollicis Brevis (EPB) that are responsible for the “thumbs up” movement. The EPB brings the thumb outwards and the APL brings the thumb forward, coming away from the palmar surface of the hand. These tendons pass through a tunnel (the first dorsal compartment) on their way to the radius, the forearm bone on the thumb side of the arm.
With wrist and thumb movement the tendons usually glide smoothly through the tunnel however with chronic overuse, the tendons can become inflamed and swollen making it more difficult for them to slide and decreasing the space in the compartment.
De Quervain’s was first described in 1895 by Fritz de Quervain, a Swiss surgeon who was a leading expert in thyroid disease. It is characterised by pain on grasping objects, turning the wrist over or making a fist. The pain is due to a break down in collagen which leads to a thickening in the tendon sheaths, or a narrowing of the dorsal tunnel. The onset of symptoms in de Quervain’s is usually gradual.
Other symptoms can include swelling at the base of the thumb, decreased range of movement in the thumb joint and a “catching” at various points. If left untreated the pain can radiate further down into the thumb or up into the forearm.
Diagnosis is confirmed by a clinical assessment of symptoms, sometimes accompanied by ultrasound imaging. An objective assessment may involve the Finkelstein test, where the the patient grasps their thumb into a fist and then the examiner moves the wrist in an inwards direction, towards the little finger side. If this test is provocative of pain it is a strong indicator for de Quervain’s. However, Finkelstein’s test can also be positive in those suffering from osteoarthritis, so further assessment may be necessary.
Who suffers from de Quervain’s?
The exact cause of de Quervain’s is unknown but it can be due to repetitive movements of strain and chronic overuse of the wrist e.g. playing racquet sports such as tennis, holding/carrying a baby and manual labour. Traditionally, it has commonly been called Washerwoman’s Sprain due to the high incidence amongst housewives. De Quervain’s can also be caused by scar tissue that forms as a result of an injury, making tendon gliding more difficult as well as inflammatory conditions such as rheumatoid arthritis.
It is more prevalent in women, especially during pregnancy and with breast feeding mothers. The most common age of incidence is between 30-50 years.
With the increase use in smart phones and tablets in today’s society, as well as computer games gaining popularity amongst children and adults alike, a higher incidence of de Quervain’s is being seen in the population. As a result, the condition is sometimes known as Texter’s Thumb, Gamer’s Thumb or Nintenditis.
Treatment of de Quervain’s
Initial treatment should concentrate on anti-inflammatory measures such as icing the area, avoiding aggravating activities and using anti-inflammatories or other analgesia for pain relief. It is recommended to begin with conservative management first. Swelling can be reduced by such measures as compression and elevation, or perhaps massage. Any massage should be gentle and pain free as if it is too vigorous it can cause more inflammation. At the right pressure, it can help to reduce pain over the base of thumb, wrist and forearm.
Patients should consider any required activity modification:
- Using aids or different techniques to peel and chop vegetables or open jars
- Using the unaffected hand wherever possible.
- Using your whole hand instead of just your thumb to grasp and grip objects.
- Using built up grips for cutlery and tooth brushes.
- Use electrical items such as a dishwasher or food processor to reduce the amount of chopping, washing you have to do.
- Choose bras that have front fastenings and clothes for you and baby that have minimal fastenings and buttons.
- Try not to use your thumb to text
- Consider using an ergonomic computer mouse
During recovery, try to keep the thumb moving as pain allows to prevent stiffening in the joints and weakness in the muscles. Your Physio will be able to advise you on suitable exercises.
Splints or braces may be required to immobilise the joint, a physiotherapist can advise on these or an occupational therapist may be involved. It is important to wear a brace only as necessary as long-term immobilisation can lead to weakness and stiffness of the joints.
TENS and acupuncture may be considered as adjunct treatments, however, the inflammation in de Quervain’s is thought to be secondary to friction so these modalities won’t treat the underlying cause.
For a further anti-inflammatory solution, a corticosteroid injection may be performed into the joint. This is done by a doctor and has been found to be effective in 50% of patients. (*) De Quervain’s was initially treated purely by surgery until the first corticosteroid injection in 1955 by Jarrod Ismond.
Surgery should be used only when conservative treatment or injections have been unsuccessful. If conservative treatments have proven to be unsuccessful then you may require a consultation with an orthopaedic surgeon. Surgical intervention usually involves opening up the first dorsal compartment sheath longitudinally, the main risk of this procedure being damage to the radial nerve.
(*) Ashraf, MO; Devadoss, VG (22 January 2013). “Systematic review and meta-analysis on steroid injection therapy for de Quervain’s tenosynovitis in adults”. European Journal of Orthopaedic Surgery & Traumatology: Orthopedie Traumatologie. 24 (2): 149–57.