Symptoms and Treatment of Tenosynovitis
Tenosynovitis is characterized by pain, swelling, and limited range of motion in the affected tendon area, with treatment primarily consisting of rest, NSAIDs, and physical therapy, progressing to steroid injections or surgery only when conservative measures fail.
Clinical Presentation
Tenosynovitis presents with several characteristic symptoms:
- Pain and tenderness along the affected tendon and its sheath
- Swelling of the tendon area, often visible or palpable
- Limited range of motion due to pain and inflammation
- Crepitus (crackling sensation) when moving the affected tendon
- Stiffness, particularly after periods of inactivity
- Warmth and possible redness over the affected area
- Functional limitation in activities involving the affected tendon
In the hands, tenosynovitis commonly affects the flexor digitorum tendons (trigger finger), extensor carpi ulnaris, extensor carpi radialis, or extensor communis tendons 1. In the lower extremities, the posterior tibial tendon and peroneal tendons are frequently involved 2.
Diagnostic Approach
Diagnosis is primarily clinical, but imaging may be helpful:
- Ultrasound is an inexpensive and accurate method to assist in diagnosis 2
- MRI may be necessary for suspected complex anatomical variations 3
- Standard radiographs (anteroposterior and lateral views) can identify calcifications or underlying bone abnormalities 3
Treatment Options
First-Line Treatment (0-4 weeks)
Rest and activity modification
- Avoid activities that exacerbate symptoms
- Protected range of motion exercises
Medication management
Bracing and support
- Appropriate bracing can provide symptomatic relief 3
- Should support rather than replace active rehabilitation
Second-Line Treatment (4-8 weeks)
Physical therapy
- Progressive strengthening exercises
- Eccentric training
- Manual therapy combined with supervised exercise 3
Bracing reassessment
- Adjust bracing as symptoms improve
- Gradually decrease reliance on external support
Advanced Treatment (8-12 weeks)
Occupation-specific training
- Functional exercises tailored to daily activities
- Gradual return to normal activities
Injection therapy (if no improvement with conservative measures)
- Corticosteroid injections using proper aseptic technique 3
- Post-injection care includes avoiding overuse of the injected area for 24 hours
Surgical Intervention
Consider surgical intervention when:
- Conservative measures fail after 3-6 months of well-managed treatment
- Significant functional limitation persists 3
Surgical options include:
- Tenosynovectomy - removal of inflamed synovium
- Repair of tendon tears if present
- Release of stenotic pulley in cases of stenosing tenosynovitis
Special Considerations
Rheumatoid Arthritis
Tenosynovitis is a common manifestation in rheumatoid arthritis:
- May require earlier surgical intervention (tenosynovectomy) to prevent tendon ruptures 4
- More aggressive immunomodulatory therapy may be necessary
Infectious Tenosynovitis
- Requires urgent irrigation, debridement, and appropriate antibiotic therapy 5
- Consider infectious etiology in cases with rapid onset, severe pain, or systemic symptoms
Follow-up and Monitoring
Regular assessment at 2,6, and 12 weeks is necessary to evaluate:
- Pain levels
- Range of motion
- Functional improvement
- Signs of recurrent inflammation 3
Consider referral to a specialist if no improvement occurs after 6-8 weeks of conservative treatment.
Common Pitfalls
- Misdiagnosis - Tenosynovitis may be confused with other conditions like sprains or arthritis
- Delayed treatment - Can lead to tendon rupture or chronic inflammation
- Overreliance on bracing - Should not replace active rehabilitation
- Inadequate follow-up - Regular assessment is crucial to monitor progress and adjust treatment
Return to full activity is permitted when the patient demonstrates complete resolution of pain, full range of motion, strength symmetry >90% compared to the uninjured side, and successful completion of occupation-specific functional tests 3.