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

Management of De Quervain's Tenosynovitis

Start with thumb spica splinting, NSAIDs, and relative rest as first-line treatment; reserve corticosteroid injections for cases that fail initial conservative measures, and only consider surgery after 3-6 months of failed conservative therapy. 1

Initial Conservative Management (First-Line Treatment)

• Apply a thumb spica splint immediately to immobilize the abductor pollicis longus and extensor pollicis brevis tendons, preventing ongoing tendon damage 1
• Prescribe NSAIDs for pain relief and anti-inflammatory benefit; topical NSAIDs are preferred over oral formulations to eliminate gastrointestinal bleeding risk 2
• Implement relative rest by avoiding activities that worsen pain, but avoid complete immobilization as this leads to muscular atrophy and deconditioning 1
• Apply cryotherapy through a wet towel for 10-minute periods to provide effective short-term pain relief 1, 2
• Maintain some activity level to prevent muscular atrophy while reducing repetitive loading of the damaged tendon 1

Physical Therapy Modalities (Adjunctive Treatment)

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence of consistent benefit is weak 1
• Low-level laser therapy has shown effectiveness in multiple studies for De Quervain tenosynovitis 3
• Extracorporeal shock wave therapy (ESWT) appears safe, noninvasive, and effective but is expensive for chronic tendinopathies 1

Corticosteroid Injection (Second-Line Treatment)

Critical Safety Considerations:

• Never inject corticosteroid into the tendon substance itself—this causes deleterious effects and predisposes to tendon rupture 1, 2
• The injection must be administered carefully into the tendon sheath, not the tendon 2
• Consider ultrasound guidance to identify anatomical variations such as septa or subcompartmentalization within the first dorsal compartment, which may affect treatment success 2

Surgical Management (Reserved for Treatment Failures)

• Reserve surgery only for carefully selected patients who have failed 3-6 months of conservative therapy 1
• Surgical release should be considered after 6 months of conservative management for persistent symptoms 1
• Preoperative ultrasound identification of septa or subcompartmentalization within the first dorsal compartment can affect surgical planning 2
• Surgical intervention is usually not necessary, as De Quervain tenosynovitis is very well treatable with conservative measures, especially in the acute phase 4

Common Pitfalls to Avoid

• Do not inject corticosteroids into the tendon substance—only inject into the tendon sheath to avoid rupture risk 1, 2
• Do not completely immobilize the thumb and wrist—this causes muscular atrophy; relative rest with maintained activity is preferred 1, 2
• Do not rush to surgery—a multimodal conservative approach is most effective, particularly when initiated early 4