What is the treatment for tenosinovitis?

Treatment of Tenosynovitis

The first-line treatment for tenosynovitis is NSAIDs, with naproxen specifically indicated for the relief of signs and symptoms of tendonitis, followed by corticosteroid injections if symptoms persist. 1, 2

Initial Management

First-Line Treatments

• NSAIDs:

  • Recommended as first-line pharmacological treatment 1
  • Naproxen is FDA-approved specifically for tendonitis 2
  • Initial dose: 500mg followed by 500mg every 12 hours or 250mg every 6-8 hours
  • Maximum initial daily dose: 1250mg, then no more than 1000mg daily thereafter 2
  • Use the lowest effective dose for the shortest duration to minimize side effects 2

• 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

Second-Line Treatment

• Corticosteroid Injections:
  • Recommended for moderate to severe cases that don't respond to NSAIDs 1
  • Limited to 2-3 injections with 4-6 weeks between injections 1
  • Effective in up to 61% of cases after a single injection 1, 3
  • Studies show approximately 90% of de Quervain's tenosynovitis cases can be effectively managed with either single (58%) or multiple (33%) corticosteroid injections 4

Rehabilitation Approach

Progressive Rehabilitation Protocol

1. Initial Phase (0-4 weeks):

   • Pain control and protected range of motion
   • Immediate functional treatment rather than immobilization
   • Splinting may be beneficial to rest the affected tendon 1, 5

2. Intermediate Phase (4-8 weeks):

   • Progressive strengthening exercises
   • Low-load strengthening exercises
   • Pool-based exercises if appropriate 1

3. Advanced Phase (8-12 weeks):

   • Sport-specific or occupation-specific training
   • Gradual return to full activity 1

When to Consider Referral

Orthopedic/Surgical Consultation

• Pain persists despite 3-6 months of well-managed conservative treatment
• Significant functional limitations impacting quality of life
• Suspicion of more serious pathology 1
• Approximately 10-12% of cases may require surgical intervention when injections fail or early recurrence occurs 3, 4

Rheumatology Referral

• Multiple joints are involved
• Presence of systemic symptoms
• Suspicion of underlying rheumatological condition 1

Important Considerations and Pitfalls

• Diagnostic Pitfalls: Tenosynovitis can be a manifestation of underlying conditions such as rheumatoid arthritis or even infectious diseases like syphilis 1, 6

• Treatment Pitfalls:

  • Overuse of corticosteroid injections can lead to tendon weakening or rupture
  • Inadequate rest during initial treatment can prolong recovery
  • Failure to identify and address underlying causes 1

• Special Populations:

  • Elderly patients may require dose adjustments for NSAIDs
  • Patients with renal or hepatic impairment should use lower doses of NSAIDs
  • Naproxen is not recommended for patients with moderate to severe renal impairment 2

• Return to Activity Criteria:

  • Complete resolution of pain during and after activity
  • Full range of motion compared to uninjured side
  • Strength symmetry >90% compared to uninjured side
  • Successful completion of activity-specific functional tests 1

By following this structured approach to tenosynovitis management, most patients can achieve symptom relief and return to normal function without requiring surgical intervention.