What are the treatment options for a patient diagnosed with De Quervain's Tendinitis?

De Quervain's Tendinitis: Diagnosis and Treatment

Diagnostic Testing

The Finkelstein test is the primary diagnostic maneuver for De Quervain's tenosynovitis, where the patient makes a fist with the thumb tucked inside and the wrist is deviated ulnarly—reproduction of pain confirms the diagnosis. 1

Clinical Examination Findings

• Palpation elicits well-localized tenderness over the first dorsal compartment (radial styloid) that reproduces the patient's activity-related pain 1
• Look for swelling and asymmetry over the radial wrist, which are commonly present 1
• Assess for muscle atrophy, which indicates chronicity of the condition 1
• Range of motion testing is often limited on the symptomatic side 1

Imaging Studies

• Plain radiographs are appropriate as initial imaging to rule out bony pathology, though they typically cannot demonstrate the soft-tissue changes of tendinopathy 1
• Ultrasound is useful for preoperative planning to identify a septum or subcompartmentalization within the first dorsal compartment, which affects surgical management 1
• Advanced imaging (MRI or ultrasound) should be reserved for unclear diagnoses, recalcitrant pain despite adequate conservative management, or preoperative evaluation 1

Treatment Algorithm

First-Line Conservative Management (3-6 Months)

Begin with a multimodal conservative approach combining relative rest, NSAIDs, thumb spica splinting, and corticosteroid injection, as this is highly effective especially in the acute phase. 2, 3, 4

Immediate Interventions

• Thumb spica splinting to immobilize the affected tendons 4
• Relative rest by reducing repetitive thumb and wrist movements while avoiding complete immobilization to prevent muscle atrophy 2, 5
• Cryotherapy through a wet towel for 10-minute periods provides effective short-term pain relief 2

Pharmacologic Management

• NSAIDs (oral or topical) for short-term pain relief—topical formulations eliminate gastrointestinal hemorrhage risk 2
• Corticosteroid injection into the first dorsal compartment (NOT into the tendon substance itself) is usually successful and may be more effective than oral NSAIDs for acute pain 5, 4
  • Critical pitfall: Never inject directly into the tendon substance as this inhibits healing, reduces tensile strength, and may predispose to rupture 5

Active Rehabilitation

• Eccentric strengthening exercises are the cornerstone of treatment and can reverse degenerative tendon changes 5, 6
• Deep friction massage and myofascial release therapy may provide additional benefit 6
• Kinesiology taping can be used as an adjunct 6

Second-Line Options for Persistent Symptoms

If symptoms persist beyond initial conservative management:

• Extracorporeal shock wave therapy is a safe, noninvasive option for chronic cases, though expensive 2
• Consider ultrasound-guided therapeutic injections 1
• Tool-assisted fascial stripping techniques may be beneficial 6

Surgical Management

Surgery is indicated only after failure of 3-6 months of well-managed conservative treatment. 5, 7

Surgical Technique Considerations

• Release of the first dorsal compartment with careful identification of all accessory compartments (present in 50% of cases) 7
• Protect the superficial branch of the radial nerve during surgery to avoid neuroma formation 4, 8
• Subcutaneous fixation of the retinaculum flap prevents tendon instability 7
• Note that multiple slips of the abductor pollicis longus tendon are present in approximately 44% of cases 7

Surgical Outcomes

• Long-term surgical results show 85% complete resolution of functional impairment with 97.5% satisfaction rates and no recurrences when proper technique is used 7
• No cases of tendon dislocation or neuroma when nerve-sparing techniques are employed 7, 8

Critical Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance—only into the tendon sheath 5
• Avoid multiple corticosteroid injections as they may weaken tendon structure despite providing short-term relief 5
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 5, 7
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 1, 5
• Avoid complete immobilization as it leads to muscle atrophy and deconditioning 2, 5

Expected Outcomes

Approximately 80% of patients with De Quervain's tenosynovitis recover completely within 3-6 months with appropriate conservative treatment. 5 Early recognition and treatment in the acute phase yields the best results 3