What is the treatment for De Quervain's tenosynovitis?

Treatment of De Quervain's Tenosynovitis

Begin with conservative management including thumb spica splinting, NSAIDs, and activity modification, reserving corticosteroid injection for cases that fail initial therapy, as this multimodal conservative approach is highly effective especially in the acute phase. 1

Initial Conservative Management (First-Line Treatment)

• Thumb spica splinting to immobilize the first dorsal compartment and prevent ongoing tendon damage while promoting healing 2
• NSAIDs (oral or topical) for pain relief, with topical formulations eliminating gastrointestinal hemorrhage risk while maintaining efficacy 2
• Activity modification to eliminate repetitive thumb and wrist movements that perpetuate the condition 1
• Cryotherapy applied through a wet towel for 10-minute periods provides effective short-term pain relief 2
• Allow continuation of activities that do not worsen pain, but avoid complete immobilization to prevent muscular atrophy 2

Corticosteroid Injection (Second-Line Treatment)

If symptoms persist after 4-6 weeks of conservative management, proceed with corticosteroid injection into the first dorsal compartment. 3

• Inject a mixture of 1 ml (40mg) methylprednisolone acetate with 1 ml of 2% lidocaine into the first dorsal compartment 3
• 65% of patients become symptom-free within 2 weeks after the first injection 3
• If symptoms persist, administer a second injection 2 weeks after the first 3
• Up to 98.75% of patients achieve symptom resolution by 12 weeks with 2-3 injections 3
• Be aware that 25% of patients experience transient adverse steroid reactions that typically resolve within 20 weeks 3

Critical Caveat About Corticosteroid Injections

Use corticosteroid injections with caution, as they may inhibit tendon healing and reduce tensile strength, potentially predisposing to spontaneous rupture when injected into tendon substance. 2 Inject peritendinously rather than intratendinously.

Adjunctive Physical Modalities

• Low-level laser therapy is among the most effective physical therapies for De Quervain's tenosynovitis 4
• Therapeutic ultrasound shows effectiveness for pain control and functional improvement 4
• Phonophoresis may deliver topical medications to affected tissues, though high-quality evidence is limited 2

Surgical Intervention (Last Resort)

Reserve surgical release of the first dorsal compartment for the rare cases (approximately 1-2%) that fail conservative management after 3-6 months. 3, 5

• Surgery involves releasing the first dorsal compartment and any sub-compartments of the abductor pollicis longus and extensor pollicis brevis tendons 5
• Post-operative management includes splinting, edema control, scar management, and progressive therapeutic exercise 5
• Surgical techniques must account for tendon anomalies and protect the superficial branch of the radial nerve to avoid complications 6

Common Pitfalls to Avoid

• Do not misdiagnose this as simple "tendinitis" - De Quervain's involves stenosing tenosynovitis with thickening of the extensor retinaculum, not just inflammation 1
• Early recognition is critical because the condition is highly treatable in the acute phase but becomes more resistant with chronicity 1
• Failure to address underlying repetitive movements or occupational factors leads to recurrence 5
• Approximately 80% of tendinopathies fully recover with conservative management within 3-6 months, so patience with conservative therapy is warranted before considering surgery 7