What is the initial treatment for tenosynovitis?

Initial Treatment for Tenosynovitis

The initial treatment for tenosynovitis should consist of relative rest, cryotherapy (ice applications through a wet towel for 10-minute periods), and NSAIDs for pain relief, with corticosteroid injection reserved for cases that fail to respond to these conservative measures within 6 weeks. 1

First-Line Conservative Management

Relative Rest

• Reduce activity to decrease repetitive loading of the affected tendon, but avoid complete immobilization to prevent muscular atrophy and deconditioning 1
• Allow patients to continue activities that do not worsen pain 1
• Most patients (approximately 80%) fully recover within 3-6 months with conservative treatment 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods, which is the most effective method 1
• Cryotherapy provides acute pain relief by reducing tissue metabolism and blunting the inflammatory response 1
• Particularly effective for reducing swelling and pain in acute inflammatory tenosynovitis 1

NSAIDs

• Use NSAIDs for short-term pain relief, though they do not alter long-term outcomes 1
• Topical NSAIDs are effective and eliminate the increased risk of gastrointestinal hemorrhage associated with systemic NSAIDs 1
• NSAIDs may offer additional benefit in acute inflammatory tendonitis due to anti-inflammatory properties 1

Second-Line Treatment: Corticosteroid Injection

When to Consider Injection

• If symptoms persist despite rest, NSAIDs, and physical therapy for 6 weeks in mechanical/overuse cases 2
• Earlier intervention (within 6 weeks) may be appropriate for enthesopathies or seronegative disease 2
• Injected corticosteroids may be more effective than oral NSAIDs for acute-phase pain relief 1

Efficacy and Safety

• For flexor tenosynovitis (trigger finger), corticosteroid injection resolves symptoms in 61% after a single injection, with recurrent episodes responding to re-treatment in 27% of cases 3
• For De Quervain's tenosynovitis, approximately 90% of patients are effectively managed with either single (58%) or multiple injections (33%) 4
• Local adverse reactions (pain at injection site, stiffness, ecchymosis, subcutaneous fat atrophy) are self-limited 3, 4

Important Cautions

• Avoid injecting corticosteroids directly into the tendon substance, as this may cause deleterious effects including reduced tensile strength and predisposition to spontaneous rupture 1
• Peritendinous injections should be used with caution, as corticosteroids may inhibit healing 1
• Corticosteroids do not alter long-term outcomes despite providing acute pain relief 1

Adjunctive Therapies

Physical Therapy and Eccentric Exercises

• Eccentric strengthening exercises are effective and may reverse degenerative changes 1
• Stretching exercises are widely accepted and generally thought to be helpful 1
• Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 1

Orthotics and Braces

• Safe and widely used to reinforce, unload, and protect tendons during activity 1
• Helpful in correcting biomechanical problems 1
• Clinical experience and patient preference should guide therapy, as definitive evidence is limited 1

Diagnostic Imaging Considerations

• Ultrasound is the first-line imaging modality for wrist tenosynovitis due to excellent visualization of superficial structures, dynamic assessment capability, and high specificity 5
• MRI is an alternative when ultrasound findings are inconclusive or deeper structures need evaluation 5
• Begin with plain radiographs to exclude other pathology before proceeding to advanced imaging 1, 5

When to Consider Surgical Referral

• Reserve surgery for patients who fail conservative therapy after 3-6 months 1
• Earlier surgical synovial débridement (6 weeks) may be indicated for enthesopathies or seronegative disease 2
• Surgery is effective, with tenosynovectomy providing successful long-term relief and preventing tendon ruptures in rheumatoid arthritis 6