What is the recommended treatment for a patient with De Quervain's tendinitis?

Treatment of De Quervain's Tendinitis

Begin with relative rest, thumb spica splinting, and NSAIDs for short-term pain relief, followed by corticosteroid injection if symptoms persist beyond 2-4 weeks, reserving surgery only for cases that fail 3-6 months of conservative management. 1

Initial Conservative Management (First 2-4 Weeks)

Relative rest is the foundation of treatment by reducing repetitive loading of the abductor pollicis longus and extensor pollicis brevis tendons in the first dorsal compartment. 2, 1 Patients should avoid activities that worsen pain while maintaining activities that don't aggravate symptoms—complete immobilization must be avoided as it causes muscular atrophy and deconditioning. 2, 1

Thumb spica splinting provides mechanical support and unloading of the affected tendons, though evidence for specific protocols is limited. 2 Clinical experience supports its use as a safe adjunct to other therapies. 2

NSAIDs for acute pain relief:

• Both oral and topical NSAIDs effectively relieve tendinopathy pain in the acute phase. 2, 1
• Topical formulations are preferable as they eliminate the gastrointestinal hemorrhage risk associated with oral NSAIDs while providing equivalent pain relief. 2, 1
• For oral therapy, naproxen 500 mg twice daily is FDA-approved for acute tendonitis and bursitis, with initial doses not exceeding 1250 mg/day. 3
• Critical limitation: NSAIDs provide only short-term symptom relief and do not alter long-term outcomes. 2, 1

Cryotherapy through a wet towel for 10-minute periods provides effective acute pain relief by reducing tissue metabolism and blunting inflammatory response. 2, 1

Second-Line Treatment: Corticosteroid Injection

If symptoms persist beyond 2-4 weeks of conservative management, corticosteroid injection is indicated. 1, 4 Injections may be more effective than oral NSAIDs for acute-phase pain relief, though they do not improve long-term outcomes. 2

Critical technical considerations:

• Use ultrasound guidance when available to identify any septum or subcompartmentalization within the first dorsal compartment. 1, 4 This is essential because anatomical variations with multiple compartments are common and may lead to incomplete response if not identified. 1
• Never inject directly into the tendon substance—only peritendinous injection is appropriate, as intratendinous injection inhibits healing, reduces tensile strength, and may predispose to spontaneous rupture. 2, 1

Special population note: For patients in the third trimester of pregnancy or breastfeeding, corticosteroid injection is not contraindicated and can provide optimal symptomatic relief without impacting the baby. 4

Surgical Management

Surgery should only be considered after 3-6 months of well-managed conservative treatment failure. 2, 1 Open release of the first dorsal compartment through a longitudinal incision is the standard approach, allowing better visualization of underlying anatomy and resulting in fewer injuries to structures and lower incidence of hypertrophic scarring compared with transverse incisions. 4

Surgical technique considerations:

• Protect the radial sensory nerve during release. 5, 4
• Identify all accessory compartments, as failure to release separate subcompartments is a common cause of persistent symptoms. 5
• Endoscopic release is an alternative for experienced surgeons, potentially offering quicker symptom improvement and superior scar cosmesis. 4

Emerging Modalities (Limited Evidence)

While laser therapy and therapeutic ultrasound have been studied for De Quervain's, the evidence remains insufficient to make definitive recommendations. 6 Extracorporeal shock wave therapy appears safe and effective for chronic tendinopathies but is expensive and requires further research to clarify optimal treatment strategies. 2

Common Pitfalls to Avoid

• Do not perform multiple corticosteroid injections as they may weaken tendon structure despite providing short-term symptom relief. 2
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment. 2, 1
• Avoid complete immobilization for extended periods as this leads to muscular atrophy and deconditioning. 2, 1
• Failure to use ultrasound guidance may result in missed anatomical variations and incomplete treatment response. 1