What is the initial treatment for tenosynovitis?

Initial Treatment for Tenosynovitis

The initial treatment for tenosynovitis should follow the RICE protocol (rest, ice, compression, elevation) combined with NSAIDs as first-line medication to manage pain and inflammation. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Imaging: Radiography is usually appropriate as the initial imaging study for chronic hand or wrist pain 2
• Advanced imaging: If symptoms persist or diagnosis is unclear, ultrasound or MRI without IV contrast are equally appropriate for evaluating tendon pathology 2
• Clinical assessment: Evaluate for localized pain, swelling, and limited range of motion along tendon sheaths

Initial Treatment Protocol

First-Line Treatment

1. RICE Protocol:

   • Rest: Avoid activities that exacerbate pain
   • Ice: Apply for 15-20 minutes every 2-3 hours
   • Compression: Use elastic bandage to reduce swelling
   • Elevation: Keep affected area elevated when possible 1

2. Medication:

   • NSAIDs are strongly recommended as first-line treatment
   • Ibuprofen 1.2g daily (can be increased to 2.4g if needed)
   • Can be combined with acetaminophen (up to 4g daily) for inadequate relief 1

3. Immobilization:

   • Splinting to restrict movement of the affected tendon
   • Functional treatment rather than complete immobilization is preferred 1
   • For de Quervain's tenosynovitis, thumb spica splint is commonly used 3

Physical Therapy

• Begin with gentle, pain-free range of motion exercises
• Progress to low-load strengthening exercises as tolerated
• Include proprioceptive training and activity modification 1

Treatment Based on Etiology

Mechanical/Overuse Tenosynovitis

• Activity modification and ergonomic adjustments
• NSAIDs and splinting for 4-6 weeks
• Physical therapy focusing on proper biomechanics 4

Inflammatory/Rheumatoid Tenosynovitis

• Coordinate with rheumatology for systemic management
• More aggressive anti-inflammatory approach may be needed 2, 4

Infectious Tenosynovitis

• Requires immediate referral for potential surgical intervention
• Intravenous antibiotics are essential
• Nearly 50% of clinicians proceed to surgical decompression and washout even in early diagnosis 5

When to Consider Advanced Interventions

If symptoms persist despite 4-6 weeks of conservative management:

1. Corticosteroid Injections:

   • Limited to 2-3 injections with 4-6 weeks between injections 1
   • Particularly effective for de Quervain's tenosynovitis 3

2. Surgical Consultation:

   • Consider if pain persists despite 3-6 months of well-managed conservative treatment
   • Indicated for significant functional limitations impacting quality of life 1
   • Surgical synovial débridement may be performed early (6 weeks) in patients with enthesopathies, but can be delayed 3 months in mechanical cases 4

Monitoring and Follow-up

• Regular reassessment of pain, function, and range of motion
• Ultrasound or MRI may be used to monitor treatment response 2
• Return to full activity permitted when patient demonstrates complete resolution of pain during and after activity, full range of motion, and strength symmetry >90% compared to uninjured side 1

Common Pitfalls to Avoid

• Delaying treatment of infectious tenosynovitis, which requires urgent intervention
• Overuse of corticosteroid injections, which can lead to tendon weakening
• Failing to address underlying biomechanical issues or systemic conditions
• Returning to full activity too quickly before adequate healing

Remember that early intervention with appropriate conservative measures is key to preventing progression and complications of tenosynovitis.