What is the recommended treatment for tenosinovitis?

Treatment Recommendations for Tenosynovitis

The recommended first-line treatment for tenosynovitis is NSAIDs, with ibuprofen at 1.2g daily as the safest option, which can be increased to 2.4g daily or combined with paracetamol (up to 4g daily) if inadequate relief is achieved. 1

Initial Management

Pharmacological Treatment

• NSAIDs:

  • First-line treatment for pain and inflammation 1
  • Naproxen is an effective option at 500mg twice daily 2
  • For acute cases, naproxen can be started at 500mg, followed by 500mg every 12 hours or 250mg every 6-8 hours as required 2
  • Initial total daily dose should not exceed 1250mg, with subsequent doses not exceeding 1000mg daily 2
  • Lower doses should be considered in elderly patients and those with renal or hepatic impairment 2

• Corticosteroid Injections:

  • Recommended for moderate to severe cases that don't respond to NSAIDs 1
  • Can provide relief in up to 61% of cases after a single injection 1, 3
  • Should be limited to 2-3 injections with 4-6 weeks between injections 1
  • Particularly effective for flexor tenosynovitis ("trigger finger"), with nearly 90% success rate 3

Non-Pharmacological Approaches

• Rest and Activity Modification:

  • Avoid activities that exacerbate symptoms 1
  • RICE protocol (Rest, Ice, Compression, Elevation) for initial management 1

• Splinting:

  • Immobilizes the affected tendon to reduce inflammation 1, 4
  • Particularly useful for specific types like de Quervain's tenosynovitis 4

Rehabilitation Protocol

Progressive Rehabilitation

• Initial Phase (0-4 weeks):

  • Focus on pain control and protected range of motion 1
  • Low-load exercises within pain-free range

• Intermediate Phase (4-8 weeks):

  • Progressive strengthening exercises 1
  • Pool-based exercises may be beneficial

• Advanced Phase (8-12 weeks):

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

When to Consider Referral

Rheumatology Referral

• Multiple joints are involved 1
• Presence of systemic symptoms 1
• Suspicion of inflammatory arthritis as underlying cause 1

Surgical Consultation

• Pain persists despite 3-6 months of well-managed conservative treatment 1
• Significant functional limitations impacting quality of life 1
• For infectious tenosynovitis, urgent surgical consultation for irrigation and debridement 1, 5

Surgical Management

• Tenosynovectomy can provide long-term relief from synovitis and prevent tendon ruptures 6
• Early surgical synovial débridement (at 6 weeks) is recommended for patients with enthesopathies 7
• For mechanical causes (true stage I disease), surgery may be delayed for 3 months 7
• First dorsal compartment release may be necessary for persistent de Quervain's tenosynovitis 4

Special Considerations

Type-Specific Management

• Posterior Tibial Tendon Tenosynovitis:
  • Requires careful evaluation for structural deformity before surgery 7
  • Ultrasound may be an accurate and inexpensive diagnostic tool 7

Infectious Tenosynovitis

• Requires prompt diagnosis and treatment to prevent complications 5
• May require biopsy for accurate diagnosis of the causative organism 5
• Surgical debridement is often necessary 5

Follow-up Recommendations

• Arrange follow-up within 1-2 weeks of initial treatment 1
• Consider repeat imaging, specialist referral, or alternative diagnoses if no improvement after 3-4 weeks of conservative management 1

Common Pitfalls and Caveats

• Failure to identify underlying systemic conditions (e.g., rheumatoid arthritis, seronegative spondyloarthropathies) 1, 7
• Delaying appropriate referral for surgical intervention when conservative measures fail 1
• Not inspecting for longitudinal split tears during surgical intervention, which must be repaired with nonabsorbable suture 7
• Overlooking the need for post-surgical rehabilitation including edema management, scar management, and therapeutic exercise 4