What is the treatment for extensor tenosynovitis?

Treatment of Extensor Tenosynovitis

Begin with 3-6 months of conservative management including relative rest, NSAIDs, cryotherapy, and eccentric strengthening exercises before considering invasive interventions. 1

Initial Conservative Treatment (First-Line)

Activity Modification and Rest

• Reduce repetitive strain on the affected tendon while maintaining some activity to prevent muscle atrophy 1
• Avoid complete immobilization as it leads to muscular atrophy and deconditioning 2, 1
• Allow patients to continue activities that do not worsen pain 2

NSAIDs for Pain Relief

• Topical NSAIDs are preferable to oral formulations as they provide equivalent pain relief while eliminating the gastrointestinal hemorrhage risk associated with systemic NSAIDs 2, 1
• Oral NSAIDs (such as ibuprofen or naproxen) effectively relieve tendinopathy pain but do not affect long-term outcomes 2, 1
• For naproxen specifically: start with 500 mg followed by 500 mg every 12 hours or 250 mg every 6-8 hours for acute tendonitis, with initial daily dose not exceeding 1250 mg 3

Cryotherapy

• Apply ice through a wet towel for 10-minute periods for effective short-term pain relief 2, 1
• Ice reduces tissue metabolism and may slow the release of blood and proteins from surrounding vasculature 2

Eccentric Strengthening Exercises

• Eccentric exercises are the cornerstone of treatment and have proven beneficial in multiple tendinopathies including Achilles and patellar tendinosis 2, 1
• Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 2
• These exercises can reverse degenerative changes in the tendon 1

Secondary Treatment Options (If Conservative Measures Fail)

Corticosteroid Injections - Use With Caution

• May be more effective than oral NSAIDs for acute phase pain relief, but do not alter long-term outcomes 2, 1
• Critical pitfall: Never inject directly into the tendon substance as this inhibits healing, reduces tensile strength, and may predispose to spontaneous rupture 2, 1, 4
• Peritendinous injections should be used with caution as they may inhibit healing 2
• For de Quervain's tenosynovitis specifically, approximately 90% of patients respond to corticosteroid injection (58% with single injection, 33% with multiple injections) 5
• Avoid multiple injections as they may weaken tendon structure despite short-term symptom relief 1, 4

Advanced Conservative Modalities

• Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathies, though costly 2, 1
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, though evidence is weak 2
• Orthotics and braces are safe adjuncts that may help correct biomechanical problems, though definitive evidence is limited 2

Surgical Management

Indications for Surgery

• Surgery is justified only if pain persists despite 3-6 months of well-managed conservative treatment 1, 4
• In rheumatoid arthritis patients with extensor tenosynovitis, preventative tenosynovectomy is indicated if symptoms do not resolve with medical management to prevent tendon rupture 6

Surgical Techniques

• Excision of abnormal tendinous tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
• For stenosing tenosynovitis (such as ECU), ultrasound-guided retinaculum release of the affected dorsal compartment may be effective 7
• When tendon rupture has occurred, reconstruction with either transfer or graft has reasonable success if the number of tendons involved is limited 6

Expected Outcomes

• Approximately 80% of patients with overuse tendinopathies recover completely within 3-6 months with appropriate conservative treatment 1
• For de Quervain's tenosynovitis treated with corticosteroid injection, recurrence occurs in some patients at a mean of 11.9 months after initial injection 5

Critical Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance 2, 1, 4
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1, 4
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease such as rheumatoid arthritis 1, 6
• In immunosuppressed patients, consider infectious etiologies (including fungal) that may require surgical debridement and antimicrobial therapy 8