What is the treatment for Dequervain tenosynovitis?

Treatment for De Quervain Tenosynovitis

The treatment for De Quervain tenosynovitis should begin with conservative measures including relative rest, ice therapy, NSAIDs, and splinting, followed by corticosteroid injection if these fail, with surgery reserved only for cases that do not respond to conservative management. 1, 2

Initial Conservative Management

• Relative Rest: Reduce activities that aggravate symptoms to decrease repetitive loading of the affected tendons (first dorsal compartment containing abductor pollicis longus and extensor pollicis brevis) 1

• Ice Therapy: Apply ice through a wet towel for 10-minute periods to provide short-term pain relief by reducing tissue metabolism and blunting inflammatory response 1

• NSAIDs: Both oral and topical NSAIDs effectively relieve pain in the acute phase, though topical formulations may have fewer systemic side effects 1

• Thumb Spica Splinting: Immobilization with a supportive thumb spica splint helps protect the affected tendons during healing 2

Second-Line Treatment

• Corticosteroid Injection: Local injection of corticosteroids (such as methylprednisolone acetate) into the first dorsal compartment is highly effective, with approximately 90% of patients responding either to a single injection (58%) or multiple injections (33%) 3

• Injection Technique: Care should be taken to identify any septum or subcompartmentalization within the first dorsal compartment using ultrasound guidance when available, as this may affect treatment outcomes 1

• Potential for Recurrence: Approximately 30% of patients may experience recurrence after initial injection (average 11.9 months later), but most respond well to repeat injections 3

Physical Modalities

• Therapeutic Ultrasound: Can be effective for pain relief and may increase the rate of collagen synthesis, though evidence for consistent benefit is limited 4

• Low-Level Laser Therapy: May provide pain relief and reduce inflammation in De Quervain's tenosynovitis 4

• Manual Therapy: Mobilization techniques targeting the first carpometacarpal, radiocarpal, and midcarpal joints may help address motion limitations that often accompany the condition 5

Surgical Management

• Surgical Release: Reserved for the approximately 10% of patients who fail conservative treatment, involving release of the first dorsal compartment while protecting the radial sensory nerve 3, 2

• Timing: Surgery should only be considered after a well-managed 3-6 month trial of conservative treatments 1

Treatment Algorithm

1. Initial 4-6 weeks: Relative rest, ice therapy, NSAIDs, and thumb spica splinting 1, 2
2. If no improvement: Corticosteroid injection into the first dorsal compartment 3
3. If recurrence after injection: Consider repeat injection (up to 3 injections may be attempted) 3
4. If persistent symptoms after 3-6 months of conservative care: Refer for surgical evaluation 1

Common Pitfalls and Caveats

• Injection Complications: Direct injection into the tendon substance should be avoided as it may inhibit healing and reduce tensile strength, potentially predisposing to rupture 1

• Anatomical Variations: Failure to identify anatomical variations such as multiple compartments or septa within the first dorsal compartment may lead to incomplete response to injection therapy 1

• Differential Diagnosis: Ensure proper diagnosis by ruling out other causes of radial-sided wrist pain such as osteoarthritis of the first carpometacarpal joint, which may require different treatment approaches 2

• Complete Immobilization: Avoid complete immobilization for extended periods as this may lead to muscular atrophy and deconditioning 1