What is the treatment for tenosynovitis?

Treatment of Tenosynovitis

The treatment of tenosynovitis should begin with conservative measures including rest, ice, NSAIDs, and physical therapy, progressing to corticosteroid injections if symptoms persist, with surgery reserved for refractory cases. 1, 2

Initial Conservative Management

Rest and Activity Modification

• Limit activities that aggravate symptoms to prevent ongoing damage
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1
• Continue activities that do not worsen pain 1

Ice Therapy

• Apply ice through a wet towel for 10-minute periods
• Most effective for acute inflammatory tenosynovitis by blunting the inflammatory response 1
• Helps reduce swelling and provides short-term pain relief 1

Medications

• NSAIDs: First-line pharmacological treatment
  • Naproxen 500mg initially, followed by 500mg every 12 hours or 250mg every 6-8 hours as needed 3
  • Total daily dose should not exceed 1000mg after the first day 3
  • Topical NSAIDs can be used for localized pain with fewer systemic side effects 1, 2
• Acetaminophen: Alternative for those who cannot tolerate NSAIDs 2

Physical Therapy

• Range of motion exercises to prevent stiffness 2
• Eccentric strengthening exercises to stimulate collagen production and promote healing 1, 2
• Gentle stretching and mobilization techniques 2

Splinting/Orthoses

• Used to reinforce, unload, and protect tendons during activity 1
• Can help correct biomechanical problems 1
• Should be used in conjunction with other therapies, not as sole treatment 1, 2

Second-Line Treatment

Corticosteroid Injections

• Consider if symptoms persist after 4-6 weeks of conservative management
• Effective for short-term relief in acute phase of tendon pain 1
• Success rates of approximately 90% for De Quervain's tenosynovitis with methylprednisolone acetate injections 4
• For trigger finger (flexor tenosynovitis), corticosteroid injections resolve symptoms in 61% after a single injection 5
• Important caution: Avoid injecting directly into the tendon substance as this may:
  • Inhibit healing
  • Reduce tensile strength
  • Predispose to spontaneous rupture 1, 2

Surgical Management

Indications for Surgery

• Failure of conservative treatment (including injections)
• Persistent pain and dysfunction affecting quality of life
• Evidence of tendon damage or impending rupture

Surgical Options

• Tenosynovectomy (removal of inflamed synovium) 6
• Release of constricting retinaculum or pulley
• Repair of damaged tendons if present

Post-Surgical Rehabilitation

• Splinting initially to protect the surgical site
• Progressive range of motion exercises
• Gradual strengthening program
• Edema and scar management 7

Special Considerations

Inflammatory Arthritis

• In rheumatoid arthritis, early surgical tenosynovectomy may be indicated to prevent tendon rupture 6
• More aggressive medical management may be needed in inflammatory conditions

Infectious Tenosynovitis

• Requires prompt antibiotic therapy
• May require surgical drainage and debridement
• Different from mechanical or inflammatory tenosynovitis

Prognosis

• Most patients (approximately 80%) with overuse tenosynovitis fully recover within 3-6 months with appropriate conservative treatment 2
• Regular assessment of pain, range of motion, and function should guide progression of treatment 2

Common Pitfalls

1. Returning to full activities too quickly before adequate healing
2. Over-reliance on corticosteroid injections without addressing underlying biomechanical issues
3. Delaying surgical intervention when conservative measures clearly fail
4. Failing to distinguish between inflammatory, infectious, and mechanical causes of tenosynovitis

Remember that tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers, making controlled activity an important part of the healing process 1.