What is the treatment for flexor tenosynovitis?

Treatment of Flexor Tenosynovitis

For non-infectious (stenosing) flexor tenosynovitis, initiate conservative management with relative rest, ice therapy, NSAIDs, and splinting for 3-6 months, followed by corticosteroid injection if symptoms persist; for pyogenic (infectious) flexor tenosynovitis, immediately start IV antibiotics combined with urgent surgical drainage and consider adding local corticosteroids to minimize loss of motion.

Non-Infectious (Stenosing) Flexor Tenosynovitis

Initial Conservative Management (First 3-6 Months)

• Relative rest is the cornerstone of initial treatment, reducing repetitive loading on the affected flexor tendon sheath while maintaining some activity to prevent muscle atrophy and deconditioning 1

• Ice therapy provides short-term pain relief by reducing tissue metabolism and blunting the inflammatory response 1

• NSAIDs (oral or topical) effectively relieve acute pain, with topical formulations preferred due to elimination of gastrointestinal hemorrhage risk associated with systemic NSAIDs 1

• Splinting helps immobilize the affected digit and reduce mechanical stress on the inflamed tendon sheath 2

• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment 1

Corticosteroid Injection (Second-Line Treatment)

• Local corticosteroid injection is indicated when symptoms persist despite conservative management with rest, NSAIDs, and splinting 2

• Single injection with depo-methylprednisolone acetate or triamcinolone acetonide resolves symptoms in 61% of cases 2

• Recurrent episodes after prolonged pain-free intervals occur in 27% of cases and respond effectively to repeat injection 2

• Combined success rate approaches 90% when including patients who respond to single or multiple injections 2

• Prednisone is FDA-approved for acute nonspecific tenosynovitis as adjunctive therapy for short-term administration 3

• Critical caveat: Direct injection into the tendon substance must be avoided as it inhibits healing, reduces tensile strength, and predisposes to rupture 1

• Local adverse reactions (injection site pain, stiffness, ecchymosis, subcutaneous fat atrophy) are self-limited with no serious complications like infection or tendon rupture reported 2

Surgical Management

• Surgery is reserved for the 12% of cases where injection fails or early recurrence occurs after conservative management 2

• Surgical evaluation is warranted only after 3-6 months of well-managed conservative treatment has failed 1

• Surgical techniques involve excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1

• For flexor carpi radialis tenosynovitis specifically, surgical decompression of the trapezium canal allows good functional recovery with resolution of painful symptoms 4

Pyogenic (Infectious) Flexor Tenosynovitis

Immediate Management

• Prompt administration of empirical IV antibiotics is mandatory regardless of the pathogen 5

• Urgent surgical decompression with sheath irrigation is the current standard of care, typically performed within 24 hours of diagnosis 5, 6

Adjunctive Corticosteroid Therapy

• Local corticosteroid injections combined with antibiotics and surgical drainage significantly decrease loss of motion compared to antibiotics and surgery alone 6

• Corticosteroid-treated groups regain significantly more active flexion at all post-treatment time points (7,14, and 28 days) 6

• This approach is supported by similar success with corticosteroids in other closed-space infections like septic arthritis 6

Alternative Approach for Select Cases

• Intrasynovial antibiotics alone (without surgery) may be effective in certain cases, with outcomes comparable to or better than systemic antibiotics with surgical drainage 6

• This represents a potential paradigm shift, though further research is needed to establish standardized protocols 5

Important Considerations

• Despite prompt treatment, complication rates remain high with potential for impaired function and digit amputation 5

• Currently no standardized treatment algorithm exists regarding timing or type of surgical intervention 5

• The undersurface of the tendon must be inspected intraoperatively for longitudinal split tears, which require repair with nonabsorbable suture 7

Common Pitfalls

• Avoid complete immobilization for extended periods as this leads to muscle atrophy and deconditioning 1

• Do not inject directly into tendon substance as this inhibits healing and increases rupture risk 1

• Do not delay surgical treatment in pyogenic cases, as this closed-space infection can rapidly progress to devastating outcomes 5

• For posterior tibial tendon tenosynovitis in seronegative spondyloarthropathies, surgical synovial débridement should be performed early at 6 weeks rather than waiting 3 months 7