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

Treatment of De Quervain's Tenosynovitis

Begin with conservative management including thumb spica splinting, activity modification, and ice therapy for 3-6 months, as approximately 80% of patients will fully recover with this approach alone. 1

Initial Conservative Management (First-Line)

Activity Modification and Rest

• Allow continuation of activities that do not worsen pain, but avoid complete immobilization to prevent muscle atrophy. 2
• Relative rest and reduced activity prevent further tendon damage while promoting healing. 1
• Tensile loading through controlled activity stimulates collagen production and guides proper alignment of newly formed collagen fibers. 2

Thumb Spica Splinting

• Immobilize the wrist and thumb with a thumb spica splint to reduce tension on the affected tendons in the first dorsal compartment. 1
• This is a cornerstone of first-line treatment recommended by the American Academy of Family Physicians. 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods to reduce pain and inflammation. 2, 1
• Ice reduces tissue metabolism and blunts the inflammatory response in acute presentations. 2

NSAIDs

• Topical or oral NSAIDs provide effective short-term pain relief but do not alter long-term outcomes. 2, 1
• Topical NSAIDs eliminate the gastrointestinal hemorrhage risk associated with systemic NSAIDs. 2

Second-Line Management: Corticosteroid Injections

If conservative measures fail after 6 weeks, proceed to corticosteroid injection, which provides superior acute pain relief compared to oral NSAIDs. 1

Injection Technique Considerations

• Ultrasound-guided injection is superior to blind injection, with 97% of patients showing at least partial symptom resolution at 6 weeks. 3
• Ultrasound guidance ensures proper compartment penetration, particularly important since 52% of patients have multiple subcompartments within the first dorsal compartment. 3
• Inject peritendinously rather than into the tendon substance itself to avoid weakening the tendon and predisposing to rupture. 2, 1

Expected Outcomes

• Corticosteroid injections are more effective than NSAIDs in the acute phase but do not change long-term outcomes. 2, 1
• Success rates are high with ultrasound guidance, though 14% of patients experience symptom recurrence, particularly those with subcompartments. 3

Adjunctive Physical Modalities

Evidence-Based Options

• Low-level laser therapy and therapeutic ultrasound are the most effective physical therapies for De Quervain's tenosynovitis. 4
• These modalities may decrease pain and increase collagen synthesis rates. 2
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies. 2

Emerging Therapies

• Neural therapy with local anesthetics shows promise, with significantly lower pain scores at 1 and 12 months compared to splinting alone. 5
• No adverse effects were reported with neural therapy interventions. 5

Third-Line Management: Surgical Intervention

Reserve surgical release of the first dorsal compartment for patients who fail 3-6 months of conservative therapy. 1, 6

Preoperative Considerations

• Obtain preoperative ultrasound to identify anatomical variations, particularly septations within the compartment, as this affects surgical planning. 2, 1
• Identification of subcompartments improves surgical outcomes by ensuring complete release. 2

Surgical Outcomes

• Surgical release provides high success rates, with most patients returning to normal activities pain-free. 1
• All patients who required surgery after failed injections in one study had anatomic variations noted. 3

Common Pitfalls to Avoid

• Do not misdiagnose as first carpometacarpal joint osteoarthritis or intersection syndrome—confirm diagnosis with Finkelstein's test and localized tenderness over the first dorsal compartment. 1
• Avoid overreliance on corticosteroid injections without addressing contributing mechanical factors such as repetitive thumb and wrist movements. 1
• Do not allow premature return to aggravating activities before adequate healing, as this leads to recurrence. 1
• Avoid delayed surgical referral—if conservative measures fail after 3-6 months, proceed to surgical consultation rather than continuing ineffective conservative treatment. 1
• Do not inject corticosteroids directly into the tendon substance, as this reduces tensile strength and predisposes to spontaneous rupture. 2, 1

Diagnostic Confirmation

• Diagnosis is primarily clinical with positive Finkelstein's test and localized tenderness over the radial styloid. 1
• Ultrasound confirms diagnosis by showing tendon sheath thickening and identifies septations that affect treatment planning. 2, 1