Management of Flexor Tenosynovitis of the Thumb
For non-infectious flexor tenosynovitis of the thumb present for 2 months, the recommended initial management includes NSAIDs, immobilization, and corticosteroid injection, followed by progressive rehabilitation exercises.
Initial Assessment and Conservative Management
First-line Treatment
- NSAIDs: Recommended as first-line pharmacological treatment 1
- Ibuprofen 1.2g daily (can be increased to 2.4g daily if needed)
- Can be combined with acetaminophen (up to 4g daily) for inadequate relief
Immobilization and Rest
- Thumb splinting to limit movement and reduce inflammation
- Rest from aggravating activities
- Application of local heat (e.g., paraffin wax, hot pack) may provide symptomatic relief 2
Corticosteroid Injection
- Local corticosteroid injection is highly effective for tenosynovitis 3, 4
- Studies show approximately 60% resolution after a single injection and up to 90% success rate with multiple injections if needed 3
- Limit to 2-3 injections with 4-6 weeks between injections 1
- Technique: Inject along the tendon sheath, avoiding direct injection into the tendon
Rehabilitation Protocol
Phase 1 (Weeks 0-4)
- Pain control and protected range of motion
- Gentle stretching exercises
- Avoid activities that exacerbate symptoms
Phase 2 (Weeks 4-8)
- Progressive strengthening exercises
- Gradual return to normal activities
- Continue with pain management as needed
Phase 3 (Weeks 8-12)
- Occupation-specific or sport-specific training
- Full return to activities when:
- Complete resolution of pain during and after activity
- Full range of motion compared to uninjured side
- Strength symmetry >90% compared to uninjured side 1
When to Consider Advanced Interventions
Indications for Surgical Consultation
- Persistent symptoms despite 3-6 months of well-managed conservative treatment
- Functional limitations significantly impacting quality of life
- Evidence of progression on follow-up evaluation 1
Surgical Options
- For severe thumb base involvement, surgical options include:
- Trapeziectomy
- Interposition arthroplasty
- Arthrodesis 2
- Single surgical procedures appear to have fewer complications than combined approaches 2
Special Considerations
Infectious Tenosynovitis
- It's critical to rule out infectious flexor tenosynovitis, which presents with:
- Kanavel signs: symmetrical finger swelling, flexed posture, pain on passive extension, and tenderness along tendon sheath
- May have systemic symptoms (fever, chills) 5
- If infection is suspected, immediate IV antibiotics and surgical consultation are required 5
- Early infectious cases may sometimes be managed non-surgically with antibiotics, immobilization, and elevation 6
Follow-up Recommendations
- Regular follow-up at 2,6, and 12 weeks to assess healing and function
- Consider MRI for persistent symptoms to evaluate for additional soft tissue injuries 1
- Monitor for complications such as tendon adhesions or rupture
Common Pitfalls to Avoid
- Failing to distinguish between infectious and non-infectious tenosynovitis
- Overuse of corticosteroid injections (>3 injections), which can lead to tendon weakening or rupture
- Inadequate immobilization during the acute phase
- Premature return to aggravating activities before adequate healing
By following this structured approach, most cases of non-infectious flexor tenosynovitis of the thumb can be successfully managed without requiring surgical intervention.