De Quervain's Tenosynovitis: Diagnosis and Treatment
This is De Quervain's tenosynovitis (stenosing tenosynovitis of the first dorsal compartment), and you should start with conservative management including thumb spica splinting, NSAIDs, activity modification, and consider corticosteroid injection if symptoms persist beyond 2-4 weeks. 1, 2
Clinical Diagnosis
The repetitive wrist and thumb motion from scooping ice cream causes mechanical irritation and thickening of the tendon sheath containing the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in the first dorsal compartment at the radial side of the wrist base 3, 2.
Key diagnostic features:
- Well-localized tenderness over the radial styloid at the base of the thumb on the dorsal wrist 1
- Positive Finkelstein's test (pathognomonic): pain reproduced when the thumb is flexed into the palm and the wrist is ulnarly deviated 4, 2
- Pain with resisted thumb extension and abduction 2
- Swelling may be visible over the first dorsal compartment 1, 3
Demographics support this diagnosis: De Quervain's is most common in women aged 30-50 years and is associated with repetitive motion activities 3, 2.
Initial Imaging
Plain radiographs of the wrist should be obtained to rule out bony pathology such as osteoarthritis, fractures, or osteophyte formation, though they typically do not show the soft tissue changes of tendinopathy 1, 2.
Ultrasound is appropriate if the diagnosis is uncertain as it can demonstrate tendon thickening, decreased echogenicity, and identify septations within the first dorsal compartment that may affect surgical planning 1.
Conservative Treatment Algorithm (First 3-6 Months)
Immediate Interventions
Relative rest is essential: The patient must reduce or eliminate ice cream scooping activities to decrease repetitive loading of the damaged tendons 1, 5. This does not mean complete immobilization, which can cause muscle atrophy 5.
Thumb spica splinting: Immobilize the thumb and wrist to prevent aggravating movements 6, 2.
Cryotherapy: Apply ice for acute pain relief and to reduce swelling 1, 5.
NSAIDs:
- Naproxen 500 mg initially, then 500 mg every 12 hours or 250 mg every 6-8 hours for acute tendonitis (maximum 1250 mg first day, then 1000 mg daily thereafter) 7
- Topical NSAIDs are preferable to oral formulations as they eliminate gastrointestinal hemorrhage risk while providing equivalent pain relief 1, 8
Progressive Rehabilitation (After Acute Phase)
Eccentric strengthening exercises should be initiated once acute pain subsides, as they stimulate collagen production and guide proper alignment of healing collagen fibers 1, 8, 6.
Stretching exercises are widely accepted for tendon rehabilitation 1.
Activity modification: The patient needs ergonomic assessment of ice cream scooping technique to minimize repetitive wrist extension and radial deviation 1, 8.
Second-Line Treatment (If No Improvement After 2-4 Weeks)
Corticosteroid injection into the first dorsal compartment is more effective than NSAIDs for acute phase relief, though it does not alter long-term outcomes 1, 8, 2.
Critical caveat: Avoid injecting directly into the tendon substance, as this inhibits healing and reduces tensile strength, potentially causing rupture 1, 8. Inject into the tendon sheath only 2.
Surgical Referral Criteria
Refer for surgical evaluation if pain persists despite 3-6 months of well-managed conservative treatment 1, 8, 5.
Surgery involves release of the first dorsal compartment with careful identification of all accessory compartments and protection of the radial sensory nerve 3, 9, 2.
Prognosis
Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 8, 5. Many cases are self-limiting, though treatment accelerates recovery 3.
Common Pitfalls
Do not continue the same repetitive activity during treatment - this is the most common reason for treatment failure 6. The patient must either stop scooping ice cream temporarily or modify technique significantly 1, 8.
Do not use prolonged complete immobilization beyond what thumb spica splinting provides, as this causes deconditioning 5.
Preoperative ultrasound may be valuable to identify septations or subcompartments within the first dorsal compartment, as these affect surgical outcomes 1.