Management of De Quervain's Tenosynovitis
Begin with thumb spica splinting combined with NSAIDs and relative rest, followed by corticosteroid injection if symptoms persist, reserving surgical release for patients who fail 3-6 months of conservative therapy. 1, 2
First-Line Conservative Management
Thumb spica splinting is the cornerstone of initial treatment, immobilizing the first dorsal compartment to rest the affected abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons and prevent ongoing damage. 1, 2 The key is relative rest—maintain some activity level to prevent muscular atrophy while reducing repetitive loading of the damaged tendon. 1 Complete immobilization should be avoided as it leads to muscular atrophy and deconditioning. 1
NSAIDs provide pain relief and potential anti-inflammatory benefit:
- Topical NSAIDs are preferable over oral formulations when possible, as they avoid gastrointestinal side effects including bleeding risk. 2, 3
- Oral NSAIDs remain an effective alternative if topical preparations are insufficient. 2
Cryotherapy applied through a wet towel for 10-minute periods provides effective short-term pain relief. 1, 3 Local heat application may also provide symptomatic relief. 2
Physical Therapy Modalities
Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence of consistent benefit is weak. 4, 1, 2 Laser therapy has shown effectiveness in research studies for De Quervain's tenosynovitis. 5
Extracorporeal shock wave therapy appears safe, noninvasive, and effective but expensive for chronic tendinopathies. 4, 1
Second-Line Treatment: Corticosteroid Injection
When conservative measures fail after several weeks, corticosteroid injection into the tendon sheath is indicated. 6
Critical injection technique to avoid complications:
- Inject into the tendon sheath, NOT the tendon substance itself—injecting corticosteroid into the tendon substance causes deleterious effects and predisposes to rupture. 1, 3
- Ultrasound guidance improves injection accuracy and is recommended. 2
- Ultrasound can identify subcompartmentalization within the first dorsal compartment, which may affect treatment success. 2, 3
- Limit to a maximum of 2-3 corticosteroid injections. 2
- Continue splinting and activity modification after injection. 2
Surgical Management
Surgery is reserved for carefully selected patients who have failed 3-6 months of conservative therapy. 4, 1 Surgical release of the first dorsal compartment provides excellent symptom relief when nonoperative treatment is unsuccessful. 6
Surgical considerations:
- Open release through a longitudinal incision allows better visualization of underlying anatomy, resulting in fewer injuries to underlying structures and lower incidence of hypertrophic scarring compared with transverse incision. 6
- Preoperative ultrasound identification of a septum or subcompartmentalization within the first dorsal compartment can affect surgical management. 3
- Endoscopic release can result in quicker symptom improvement, superior scar cosmesis, and lower incidence of radial sensory nerve injury for surgeons comfortable with the technique. 6
- Long-term surgical outcomes are excellent with simple decompression of both tendons and partial resection of the extensor ligament. 7
Common Pitfalls to Avoid
- Never inject corticosteroid into the tendon substance—this is the most critical error, causing tendon damage and rupture risk. 1, 3
- Avoid complete immobilization—leads to muscular atrophy and deconditioning; relative rest is preferable. 1, 3
- Do not rush to surgery—most cases respond to conservative management, particularly when diagnosed in the acute phase. 8
Differential Diagnosis Considerations
When evaluating suspected De Quervain's tenosynovitis, consider: