What is the medical management for De Quervain's tenosynovitis?

Medical Management of De Quervain's Tenosynovitis

Start with thumb spica splinting combined with NSAIDs (oral or topical) as first-line treatment, followed by corticosteroid injection if symptoms persist after 2-4 weeks of conservative therapy. 1, 2

First-Line Conservative Treatment (Weeks 0-4)

• Thumb spica splinting to immobilize the first dorsal compartment and rest the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons 1, 2
• NSAIDs for pain relief: Either oral or topical formulations are effective, with topical NSAIDs avoiding gastrointestinal side effects 1
• Relative rest: Maintain some activity level to prevent muscular atrophy while avoiding repetitive loading activities that worsen pain 2
• Cryotherapy: Apply through a wet towel for 10-minute periods for short-term pain relief 2
• Local heat application may provide symptomatic relief 1

Second-Line Treatment: Corticosteroid Injection (If Conservative Fails After 2-4 Weeks)

Corticosteroid injection is highly effective, with 78% of patients achieving treatment response versus 25% with placebo. 3

Injection Protocol

• Mixture: 1 ml (40mg) methylprednisolone acetate with 1 ml of 2% lidocaine, or 1 ml triamcinolone acetonide 10 mg/ml 4, 3
• Ultrasound guidance is recommended for injection accuracy and to identify anatomical variations like intercompartmental septum 1
• Maximum 2-3 injections total, spaced 2 weeks apart if first injection fails 1, 4
• Expected outcomes: 65% symptom-free at 2 weeks after first injection, 95% at 6 weeks, 98.75% at 12 weeks 4

Critical Injection Pitfall

Never inject into the tendon substance itself—only inject into the tendon sheath. Intratendinous injection causes deleterious effects and predisposes to tendon rupture. 2

Adjunctive Therapies

• Physical therapy with therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence of consistent benefit is weak 1, 2
• Extracorporeal shock wave therapy appears safe and effective but is expensive for chronic cases 1, 2
• Continue splinting and activity modification even after corticosteroid injection 1

Expected Timeline and Outcomes

The natural history shows most patients (about 80%) fully recover within 3-6 months with conservative treatment. 5 For steroid responders, beneficial effects are sustained at 12-month follow-up regarding pain severity and functional disability. 3

Surgical Referral (After 3-6 Months of Failed Conservative Treatment)

Reserve surgery for carefully selected patients who have failed 3-6 months of conservative therapy including corticosteroid injections. 1, 2 Surgical release of the first dorsal compartment should be considered only after exhausting medical management. 1

When to Consider Surgery Earlier

• Presence of intercompartmental septum detected on ultrasound (affects surgical planning) 1
• Persistent symptoms despite 2-3 corticosteroid injections 1

Common Management Pitfalls to Avoid

• Avoid complete immobilization: This leads to muscular atrophy and deconditioning 2
• Avoid injecting tendon substance: Only inject the tendon sheath 2
• Don't delay injection too long: If conservative measures fail after 2-4 weeks, proceed to injection rather than prolonging ineffective treatment 4, 3
• Monitor for steroid side effects: 25% of patients experience adverse reactions that typically subside within 20 weeks 4