What is the treatment for Dequervain tenosynovitis?

Treatment of De Quervain Tenosynovitis

Begin with conservative management including thumb spica splinting, NSAIDs, and relative rest for 3-6 months, reserving corticosteroid injection for cases that fail initial therapy and surgery only for those who fail all conservative measures. 1, 2

First-Line Conservative Treatment

The initial approach should focus on reducing repetitive loading while maintaining some activity to prevent muscular atrophy and deconditioning 3, 1:

• Thumb spica splinting to immobilize the first dorsal compartment (containing abductor pollicis longus and extensor pollicis brevis tendons) 2
• Relative rest by avoiding activities that reproduce pain, but not complete immobilization which leads to muscle atrophy 3, 1
• NSAIDs (oral or topical) for acute pain relief—topical formulations eliminate gastrointestinal hemorrhage risk while providing equivalent pain control 3, 1
• Cryotherapy applied through a wet towel for 10-minute periods provides effective short-term pain relief by reducing tissue metabolism 3, 2

Most patients (approximately 80%) fully recover within 3-6 months with this conservative approach 3, 4.

Second-Line: Corticosteroid Injection

If symptoms persist after initial conservative measures, corticosteroid injection is highly effective 1:

• Inject into the tendon sheath, NOT the tendon substance—intratendinous injection inhibits healing, reduces tensile strength, and predisposes to rupture 3, 1, 2
• Use ultrasound guidance when available to identify anatomical variations such as septations or subcompartments within the first dorsal compartment, which if missed lead to treatment failure 1
• A mixture of methylprednisolone acetate (40mg) with local anesthetic is effective, with 58-90% of patients responding to a single injection 5, 6
• If initial injection fails, a second injection 2 weeks later achieves symptom resolution in an additional 25-35% of patients 5

Recent evidence from 2025 shows platelet-rich plasma (PRP) is equivalent to corticosteroids for pain reduction at 12 weeks, though corticosteroids provide faster improvement in hand function at 1-4 weeks 7. Given the faster functional recovery and established track record, corticosteroids remain the preferred injectable treatment.

Adjunctive Therapies (Weak Evidence)

These modalities have limited supporting data but are safe and may provide benefit 3, 2:

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence is weak 3, 2
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but is expensive and requires further research 2
• Eccentric strengthening exercises have proven beneficial in other tendinopathies and may help 3

Surgical Management

Reserve surgery for carefully selected patients who fail 3-6 months of well-managed conservative therapy 3, 1, 2:

• Surgical release of the first dorsal compartment (and any sub-compartments) is effective for refractory cases 8
• Only 10% of patients require surgical intervention when conservative management is properly implemented 6
• Post-operative rehabilitation includes splinting, edema management, scar management, and therapeutic exercise 8

Critical Pitfalls to Avoid

• Never inject directly into the tendon substance—this causes deleterious effects including potential rupture 3, 1, 2
• Avoid complete immobilization—maintain some activity level to prevent muscular atrophy and deconditioning 3, 2
• Identify anatomical variations—failure to recognize multiple compartments or septa leads to incomplete response to injection 1
• Don't rush to surgery—most patients respond to conservative measures within 3-6 months 3, 4