What is the treatment for tenosinovitis?

Treatment of Tenosynovitis

The treatment of tenosynovitis should begin with NSAIDs as first-line therapy, followed by corticosteroid injections if symptoms persist, and surgical intervention only after 3-6 months of failed conservative management. 1

First-Line Treatment

Medications

• NSAIDs: Recommended as first-line treatment for tendon pain 1, 2
  • Naproxen is FDA-approved specifically for tenosynovitis 2
  • Recommended dosage: 500mg initially, followed by 500mg every 12 hours or 250mg every 6-8 hours as needed 2
  • Initial total daily dose should not exceed 1250mg, with subsequent daily doses not exceeding 1000mg 2
  • Use the lowest effective dose for the shortest duration to minimize side effects 2

Conservative Measures (RICE Protocol)

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

Second-Line Treatment

Corticosteroid Injections

• Effective for short-term pain control when NSAIDs fail 1
• Limitations:
  • Limited to 2-3 injections with 4-6 weeks between injections
  • Does not change long-term outcomes 1
• Success rate: Approximately 90% of cases respond to either single (58%) or multiple (33%) injections 3, 4
• Potential side effects include pain at injection site, stiffness, ecchymosis, or subcutaneous fat atrophy, but these are typically self-limited 3

Rehabilitation Approach

The American Physical Therapy Association recommends a phased rehabilitation approach 1:

1. Initial Phase (0-4 weeks):

   • Focus on pain control
   • Protected range of motion exercises

2. Intermediate Phase (4-8 weeks):

   • Progressive strengthening exercises

3. Advanced Phase (8-12 weeks):

   • Sport-specific or occupation-specific training

Imaging and Diagnosis

• Initial imaging: Plain radiographs (X-rays) if symptoms persist beyond 4-6 weeks 1
• Advanced imaging: If symptoms persist despite conservative management for 6-8 weeks:
  • MRI without contrast or ultrasound to evaluate for tendon tears 1
  • Both ultrasound and MRI are equally appropriate for evaluating tendon pathology 1

Surgical Intervention

Consider surgical referral when:

• Symptoms persist despite 3-6 months of well-managed conservative treatment
• Significant functional limitations impact quality of life
• Recurrent episodes despite appropriate conservative management 1, 5

Surgical options may include tenosynovectomy, which can provide successful long-term relief from synovitis and prevent tendon ruptures 5

Special Considerations

Elderly Patients

• Consider lower doses of NSAIDs
• Use the lowest effective dose as prudent practice 2

Patients with Renal Impairment

• Naproxen-containing products are not recommended for patients with moderate to severe renal impairment (creatinine clearance <30 mL/min) 2

Rheumatoid Arthritis

• Early rheumatology referral if multiple joints are involved or systemic symptoms are present 1
• Tenosynovitis in rheumatoid arthritis may require more aggressive management to prevent tendon ruptures 5

Common Pitfalls to Avoid

1. Delayed diagnosis: Tenosynovitis can lead to tendon rupture if left untreated, particularly in inflammatory conditions like rheumatoid arthritis
2. Overuse of corticosteroid injections: Limit to 2-3 injections with 4-6 weeks between injections to prevent tendon weakening
3. Inadequate rest: Continuing activities that exacerbate symptoms can prolong recovery
4. Missing underlying causes: Some cases of tenosynovitis may be due to infections or systemic conditions like syphilis that require specific treatment 6

By following this treatment algorithm, most cases of tenosynovitis can be effectively managed without the need for surgical intervention.