What is the treatment for De Quervain's (De Quervain's tenosynovitis) tenosynovitis?

Treatment for De Quervain's Tenosynovitis

The most effective treatment for De Quervain's tenosynovitis is a multimodal conservative approach, with corticosteroid injections providing the best short-term relief while a comprehensive rehabilitation program offers sustained improvement. 1, 2

Initial Conservative Management

Pain Management

• First-line treatment:
  • NSAIDs for pain relief (e.g., naproxen 500mg twice daily or ibuprofen 1.2g daily, which can be increased to 2.4g daily if needed) 1
  • Consider combining with paracetamol (up to 4g daily) for enhanced pain control 1
  • Activity modification to reduce repetitive wrist movements 2, 3

Splinting

• Thumb spica splint to immobilize the first dorsal compartment while allowing other wrist functions 3
• Should be worn during activities that exacerbate symptoms and at night 3
• Duration: 4-6 weeks as part of initial management 1, 3

Corticosteroid Injections

• Most effective short-term intervention with 78% response rate compared to 25% for placebo 4
• Number needed to treat: 2 (95% CI: 1,3) 4
• Injection protocol:
  • 1ml of triamcinolonacetonide 10mg/ml into the first dorsal compartment 4
  • Maximum 2-3 injections with 4-6 weeks between injections 1
  • Use proper aseptic technique with skin preparation 1
  • Monitor diabetic patients for transient hyperglycemia 1

Physical Therapy Interventions

Therapeutic Modalities

• Laser therapy and therapeutic ultrasound have shown effectiveness 5
• Phased rehabilitation approach:
  1. Initial phase (0-4 weeks): Pain control and protected range of motion 1
  2. Intermediate phase (4-8 weeks): Progressive strengthening exercises and eccentric training 1, 6
  3. Advanced phase (8-12 weeks): Occupation-specific training and functional exercises 1

Manual Therapy

• Graston Technique® (instrument-assisted soft tissue mobilization) may be beneficial 6
• Eccentric training for the affected tendons 6

Follow-up and Progression

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement 1
• Return to full activity when patient demonstrates:
  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to uninjured side 1

When to Consider Surgery

• Surgical intervention should only be considered when:
  • Conservative measures fail after 3-6 months of well-managed treatment 1, 3
  • Significant functional limitation persists 1
• Surgical procedure involves release of the first dorsal compartment 3

Important Considerations and Pitfalls

• Early recognition and treatment is crucial for better outcomes, especially in the acute phase 2
• Avoid complete immobilization of the wrist as it may lead to stiffness 1
• The beneficial effects of steroid injections can be maintained for up to 12 months in responders 4
• Patients should be educated about activity modification to prevent recurrence 3
• Caution: Limit corticosteroid injections to 2-3 to avoid tendon weakening and potential rupture 1