From the Guidelines
Secondary stenosis caused by tenosynovitis is primarily driven by the inflammatory process leading to thickening of the tendon sheath, accumulation of synovial fluid, and fibrosis, which collectively reduce the available space in anatomical tunnels or compartments, as seen in conditions like carpal tunnel syndrome, De Quervain's tenosynovitis, trigger finger, and posterior tibial tendon dysfunction 1.
Causes and Risk Factors
The causes of secondary stenosis by tenosynovitis include:
- Inflammation of the tendon sheath
- Thickening of the tendon sheath
- Accumulation of synovial fluid
- Fibrosis Risk factors for developing tenosynovitis and subsequent secondary stenosis include:
- Repetitive movements
- Rheumatoid arthritis
- Diabetes
- Pregnancy
- Hypothyroidism
Diagnosis and Treatment
Diagnosis of tenosynovitis and secondary stenosis involves:
- Physical examination to assess for swelling, asymmetry, and erythema of involved tendons
- Range-of-motion testing
- Palpation for tenderness
- Examination maneuvers that simulate tendon loading and reproduce pain
- Imaging studies such as plain radiography, ultrasonography, and magnetic resonance imaging (MRI) may be helpful if the diagnosis remains unclear 1 Treatment typically begins with:
- Rest
- NSAIDs like ibuprofen (400-800mg three times daily)
- Corticosteroid injections
- Physical therapy focusing on stretching and strengthening exercises
- Splinting to reduce movement and inflammation In severe cases unresponsive to conservative measures, surgical release of the affected compartment may be necessary to decompress the area and restore normal function 1.
From the Research
Causes of Secondary Stenosis by Tenosynovitis
- Tenosynovitis refers to an inflammatory condition involving the synovial sheath of a tendon, which can lead to secondary stenosis 2
- The main forms of stenosing tenosynovitis include de Quervain tendinopathy, trigger finger, and stenosing tenosynovitis of the extensor carpi ulnaris, extensor carpi radialis, or extensor comunis tendons 2
- Local anatomy, mechanical factors, and hormonal factors can contribute to the development of stenosing tenosynovitis 2
- The cardinal finding on ultrasonography is the presence of a thickened retinaculum or pulley that constricts the osseofibrous tunnel through which the tendon runs 2
Factors Contributing to Stenosis
- Radial styloid stenosing tenosynovitis is a common chronic motor system injury that can lead to joint pain and aggravate with activity 3
- Pyogenic flexor tenosynovitis is a potentially devastating closed-space infection of the flexor tendon sheath of the hand that can result in considerable morbidity 4
- Stenosis of the tendon sheath can be overcome by release of the tendon sheath or deepening of the retromalleolar groove, which can be performed endoscopically 5
Treatment and Rehabilitation
- Conservative treatment can effectively relieve pain and improve wrist motion in the acute phase, but may have little effect on long-term outcomes and can lead to recurrence 3
- Surgical treatment is often chosen for recalcitrant cases with many complications due to its high cure rate 3
- The use of closed-catheter irrigation systems, such as the On-Q delivery system, can allow for simultaneous in situ antibiotic and pain control for outpatient treatment of flexor tenosynovitis, improving rehabilitation 6