What is the treatment for Dequervain's tenosynovitis?

Treatment of De Quervain's Tenosynovitis

Begin with thumb spica splinting and NSAIDs, but if symptoms persist beyond 4-6 weeks, proceed directly to corticosteroid injection into the tendon sheath, which achieves an 83% cure rate and is superior to all other conservative modalities. 1, 2

First-Line Conservative Management

Immediate Interventions

• Apply a thumb spica splint to immobilize the affected tendons and prevent ongoing damage to the abductor pollicis longus and extensor pollicis brevis 1, 3
• Use relative rest rather than complete immobilization to avoid muscle atrophy and deconditioning 1
• Prescribe topical NSAIDs preferentially over oral formulations to eliminate gastrointestinal hemorrhage risk while providing effective pain relief 4, 1
• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief 4, 1

Duration of Conservative Trial

• If symptoms persist after 4-6 weeks of NSAIDs and splinting, advance to corticosteroid injection rather than prolonging ineffective conservative care 5

Second-Line Treatment: Corticosteroid Injection

Injection Technique and Efficacy

• Inject a mixture of 1 mL (40mg) methylprednisolone acetate with 1 mL of 2% lidocaine into the first dorsal compartment sheath 5
• Critical: Inject into the tendon sheath, NOT into the tendon substance itself, as intratendinous injection causes deleterious effects, reduces tensile strength, and predisposes to spontaneous rupture 4, 1
• Injection alone achieves an 83% cure rate, dramatically superior to splinting alone (14%), rest (0%), or NSAIDs alone (0%) 2

Expected Timeline and Repeat Injections

• 65% of patients become symptom-free within 2 weeks after the first injection 5
• If symptoms persist at 2 weeks, administer a second injection 5
• 95% of patients achieve symptom resolution by 6 weeks, and 98.75% by 12 weeks with up to 2-3 injections 5
• Adverse steroid reactions occur in 25% of patients but typically subside within 20 weeks 5

Adjunctive Physical Modalities (Weak Evidence)

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 4, 1
• Extracorporeal shock wave therapy (ESWT) appears safe but requires further research to clarify optimal treatment strategies 4

Surgical Management

Indications for Surgery

• Refer for surgical evaluation if symptoms persist despite 2-3 corticosteroid injections over 3-6 months 4, 6
• Only 1-2% of patients require surgical intervention when injections are properly administered 5

Surgical Technique Considerations

• Use preoperative ultrasound to identify septations or subcompartments within the first dorsal compartment, as these affect surgical planning and outcomes 1, 7
• Surgical release involves opening the first dorsal compartment and any accessory subcompartments while protecting the radial sensory nerve 6, 3
• Ultrasound-guided percutaneous release is an emerging alternative that may improve visualization of neurovascular structures and reduce complications compared to open surgery 7

Critical Pitfalls to Avoid

• Never inject corticosteroid directly into the tendon substance—this is the most common technical error and leads to tendon weakening and potential rupture 4, 1
• Do not prolong ineffective conservative management beyond 4-6 weeks when injection has proven superior efficacy 5, 2
• Ensure complete release of all subcompartments during surgery, as incomplete release is a common cause of surgical failure 6, 3
• Protect the radial sensory nerve branches during any surgical approach to avoid iatrogenic nerve injury 6, 3