What is the treatment for mild de Quervain's tenosynovitis?

Treatment for Mild De Quervain's Tenosynovitis

For mild De Quervain's tenosynovitis, a multimodal conservative approach is the most effective treatment and should be initiated before considering surgical intervention. 1

First-line Treatment Options

Pain Management

• NSAIDs are strongly recommended as first-line treatment for tendon pain
  • Ibuprofen at 1.2g daily is the safest option
  • Can be increased to 2.4g daily if needed
  • Can be combined with paracetamol (up to 4g daily) for inadequate relief 2

Immobilization

• Thumb spica splinting to immobilize the affected tendons 3
• Splinting should be used during painful activities and at night
• Goal is to rest the first dorsal compartment tendons while maintaining function

Activity Modification

• Avoid repetitive movements that exacerbate symptoms
• Modify activities that involve repetitive thumb and wrist movements
• Early recognition and treatment is crucial for better outcomes 1

Second-line Treatment

Corticosteroid Injections

• If symptoms persist after 2-4 weeks of conservative treatment, consider corticosteroid injection
• Highly effective with 65% of patients becoming symptom-free after first injection
• Up to 98.75% of patients become symptom-free after multiple injections (typically 2-3) 4
• Injection technique:
  • Mixture of methylprednisolone acetate (40mg) and 2% lignocaine hydrochloride 4
  • Injected into the first dorsal compartment of the wrist

Physical Therapy

• Should focus on:
  • Range of motion exercises
  • Gentle stretching
  • Progressive strengthening exercises
  • Proprioception training 2

Physical Modalities

• Laser therapy and therapeutic ultrasound have shown effectiveness 5
• Can be used as adjuncts to other conservative treatments

Treatment Algorithm

1. Initial phase (0-4 weeks):

   • NSAIDs for pain control
   • Thumb spica splinting
   • Activity modification
   • Rest, ice, compression, and elevation (RICE protocol) 2

2. Intermediate phase (4-8 weeks):

   • If symptoms persist, corticosteroid injection
   • Progressive strengthening exercises
   • Continue splinting during activities that cause pain

3. Advanced phase (8-12 weeks):

   • Return to normal activities as tolerated
   • Occupation-specific training
   • Consider second corticosteroid injection if needed

Surgical Intervention

• Reserved for cases that fail conservative treatment (typically after 3-6 months)
• Surgical release of the first dorsal compartment may be necessary in resistant cases 3
• Only about 1% of patients require surgical intervention when proper conservative treatment is applied 4

Common Pitfalls and Caveats

• Delayed diagnosis can lead to chronic symptoms and poorer outcomes
• Overuse of corticosteroid injections (more than 2-3) can lead to adverse effects including skin atrophy and depigmentation 4
• Failure to identify anatomical variations such as accessory compartments during surgical release can lead to treatment failure 3
• Inadequate protection of the radial sensory nerve during surgical release can lead to complications 3

De Quervain's tenosynovitis is highly treatable, especially in the acute phase, and surgical intervention is usually not necessary when conservative management is properly implemented 1.