What is the management of De Quervain's (De Quervain's tenosynovitis) tenosynovitis?

Management of De Quervain's Tenosynovitis

Conservative management should be the first-line treatment for De Quervain's tenosynovitis, with surgery reserved for patients who have failed 3-6 months of appropriate non-surgical therapy. 1

Diagnostic Approach

• De Quervain's tenosynovitis presents as pain at the radial styloid due to stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendon compartment 1
• Diagnosis is primarily clinical with localized tenderness over the first dorsal compartment and pain that worsens with thumb and wrist movements 1
• Finkelstein's test (pain with ulnar deviation of the wrist with the thumb flexed across the palm) is typically positive 1
• Ultrasound can confirm the diagnosis by showing thickening of the tendon sheath and may identify the presence of a septum within the first dorsal compartment, which can affect surgical management 1

Treatment Algorithm

First-Line Management

1. Relative Rest and Activity Modification

   • Reduce activities that aggravate symptoms to decrease repetitive loading of the damaged tendons 1
   • Avoid complete immobilization to prevent muscle atrophy and deconditioning 1

2. Splinting/Bracing

   • Thumb spica splint to immobilize the wrist and thumb, reducing tension on affected tendons 1
   • Should be worn during activities that exacerbate symptoms 2

3. Ice Therapy

   • Apply ice through a wet towel for 10-minute periods to reduce pain and inflammation 1
   • Most effective when applied multiple times daily, especially after activity 1

4. Anti-inflammatory Medications

   • NSAIDs (oral or topical) for short-term pain relief 1
   • Topical NSAIDs may have fewer systemic side effects than oral formulations 1
   • Note that while effective for acute pain relief, NSAIDs do not alter long-term outcomes 1

Second-Line Management

1. Corticosteroid Injection

   • Locally injected corticosteroids can provide significant pain relief in the acute phase 1
   • May be more effective than oral NSAIDs for immediate symptom control 1
   • Caution: injections directly into the tendon substance should be avoided as they may weaken the tendon and predispose to rupture 1
   • Success rates of 62-93% have been reported with corticosteroid injections 3

2. Physical/Occupational Therapy

   • Eccentric strengthening exercises have proven beneficial in tendinopathies and may reverse degenerative changes 1
   • Stretching exercises for the thumb and wrist 2, 4
   • Manual therapy techniques including soft tissue mobilization 2

3. Therapeutic Modalities

   • Therapeutic ultrasound and low-level laser therapy have shown some efficacy 5
   • These modalities may help reduce inflammation and promote healing 5

Third-Line Management

1. Surgical Intervention
   • Should be reserved for patients who have failed 3-6 months of conservative therapy 1
   • Involves surgical release of the first dorsal compartment 3
   • Success rates of surgical intervention are high, with most patients returning to normal activities pain-free 3
   • Preoperative ultrasound to identify anatomical variations (such as a septum within the compartment) may improve surgical outcomes 1

Special Considerations

• Approximately 80% of patients with De Quervain's tenosynovitis will fully recover within 3-6 months with appropriate conservative management 1
• Patients should be educated about proper ergonomics and activity modification to prevent recurrence 2
• Newer treatments such as platelet-rich plasma injections are being investigated but are not yet part of standard care 6
• Pregnant and postpartum women are at higher risk for developing De Quervain's tenosynovitis and may require more aggressive initial management 3

Common Pitfalls to Avoid

• Misdiagnosis as osteoarthritis of the first carpometacarpal joint or intersection syndrome 1
• Overreliance on corticosteroid injections without addressing contributing mechanical factors 1
• Premature return to aggravating activities before adequate healing 1
• Delayed referral for surgical consultation when conservative measures have failed after 3-6 months 1
• Failure to identify and address occupational or recreational activities that contribute to the condition 2, 4