What are the diagnostic and treatment approaches for tenosynovitis?

From the Guidelines

Tenosynovitis diagnosis and treatment should prioritize a combination of clinical examination, imaging studies, and conservative management, with a focus on reducing pain and inflammation, and promoting tendon healing. Diagnosis typically begins with a physical examination where the healthcare provider looks for tenderness, swelling, and pain with movement along the affected tendon. Range of motion testing often reveals pain when the involved tendon is stretched or contracted. Imaging studies such as ultrasound or MRI may be ordered to confirm the diagnosis, visualize the extent of inflammation, and rule out other conditions 1.

Diagnostic Approaches

• Physical examination to assess tenderness, swelling, and pain with movement
• Range of motion testing to evaluate pain with tendon stretching or contraction
• Imaging studies, such as ultrasound or MRI, to confirm diagnosis and visualize inflammation
• Blood tests to check for underlying inflammatory or infectious causes

Treatment Approaches

• Initial treatment with rest, ice application, compression, and elevation (RICE protocol) of the affected area
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks to reduce pain and inflammation
• Physical therapy focusing on gentle stretching and strengthening exercises once acute pain subsides
• Corticosteroid injections (such as methylprednisolone 40mg or triamcinolone 10-40mg mixed with lidocaine) directly into the tendon sheath for more severe cases
• Splinting or bracing the affected area to rest the tendon and prevent further irritation
• Prompt antibiotic therapy for infectious tenosynovitis, often requiring intravenous antibiotics like cefazolin (1-2g every 8 hours) or vancomycin (15-20mg/kg every 12 hours) if MRSA is suspected 1

Key Considerations

• Addressing the underlying cause of tenosynovitis to prevent recurrence, whether it's modifying repetitive activities, treating an underlying inflammatory condition, or improving workplace ergonomics
• Reserving surgical intervention for cases that don't respond to conservative treatment, involve tendon rupture, or require drainage of infectious tenosynovitis
• Using imaging studies, such as ultrasound or MRI, to guide management decisions and prognosticate outcomes, particularly in cases of inflammatory tenosynovitis 1

From the Research

Diagnostic Approaches for Tenosynovitis

• Tenosynovitis can be diagnosed using various methods, including physical examination, ultrasound, and magnetic resonance imaging (MRI) 2.
• Ultrasound is an inexpensive and accurate method to assist in the diagnosis of tenosynovitis, particularly for peroneal tenosynovitis 2 and posterior tibial tendon tenosynovitis 3.
• Point-of-care ultrasonography can be used to promptly and accurately identify hyperemia, synovial thickening, and effusion within the tendon sheath 2.

Treatment Approaches for Tenosynovitis

• Conservative management is often the first line of treatment for tenosynovitis, including rest, nonsteroidal anti-inflammatory medication, and physical therapy 3, 2, 4.
• Corticosteroid injections can be effective in treating tenosynovitis, with success rates ranging from 61% to 90% 5, 6.
• Surgical intervention may be necessary in some cases, such as for patients with enthesopathies or those who do not respond to conservative management 3.
• A multimodal approach with conservative management is often the most effective treatment for De Quervain's tenosynovitis 4.

Specific Considerations for Different Types of Tenosynovitis

• Posterior tibial tendon tenosynovitis may require early surgical synovial débridement in patients with enthesopathies, while patients with true stage I disease may be treated conservatively for a longer period 3.
• Peroneal tenosynovitis can be treated with a walking boot and nonsteroidal anti-inflammatory drugs, and point-of-care ultrasonography can be used to expedite nonoperative management 2.
• De Quervain's tenosynovitis is typically treated with a multimodal approach, including conservative management, and surgical intervention is usually not necessary 4.