Treatment of Tenosynovitis
Initial management of tenosynovitis should begin with relative rest, NSAIDs for pain relief, and thumb spica splinting (for de Quervain's), with corticosteroid injection reserved for cases failing conservative therapy after 4-6 weeks. 1, 2
Initial Conservative Management (First 4-6 Weeks)
Activity Modification and Rest
- Reduce repetitive loading activities that stress the affected tendon to prevent ongoing damage and promote healing 1
- Avoid complete immobilization to prevent muscular atrophy; allow activities that do not worsen pain 1
- For de Quervain's tenosynovitis specifically, thumb spica splinting is first-line treatment to immobilize the first dorsal compartment 2
Pain Management
- NSAIDs are recommended for short-term pain relief (oral or topical formulations) 1
- Topical NSAIDs are equally effective and avoid gastrointestinal side effects 1, 2
- Cryotherapy with melting ice water through a wet towel for 10-minute periods provides acute pain relief 1
Physical Therapy Modalities
- Eccentric strengthening exercises are effective and may reverse degenerative tendon changes 1
- Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence of consistent benefit is weak 1, 2
- Stretching exercises are widely accepted and generally helpful 1
Corticosteroid Injection (After 4-6 Weeks of Failed Conservative Therapy)
When to Consider
- Locally injected corticosteroids are more effective than oral NSAIDs for acute-phase pain relief but do not alter long-term outcomes 1
- For de Quervain's tenosynovitis, approximately 90% of patients respond to corticosteroid injection (58% with single injection, 33% with multiple injections) 3
- Ultrasound guidance improves injection accuracy and confirms appropriate needle placement 2, 4
Important Caveats
- Maximum of 2-3 corticosteroid injections recommended 2
- Inject peritendinously, not into the tendon substance, as intratendinous injection may reduce tensile strength and predispose to rupture 1
- For inflammatory arthritis-associated tenosynovitis, US-guided peritendinous corticosteroid injections show significant reduction in clinical and sonographic findings at 2 weeks 4
Surgical Intervention
Indications
- Surgery is reserved for carefully selected patients who have failed 3-6 months of conservative therapy 1, 2
- For seronegative spondyloarthropathies causing posterior tibial tendon tenosynovitis, surgical synovial débridement may be performed earlier (6 weeks) 5
- Approximately 10% of de Quervain's cases cannot be controlled with injection and require surgical release 3
Surgical Considerations
- For de Quervain's, surgical release of the first dorsal compartment is the definitive procedure 2
- During surgery for posterior tibial tendon tenosynovitis, inspect the undersurface for longitudinal split tears and repair with nonabsorbable suture 5
Special Considerations by Location
De Quervain's Tenosynovitis
- Ultrasound can detect subcompartmentalization within the first dorsal compartment, which may affect surgical management 2
- Most patients (approximately 80%) fully recover within 3-6 months with conservative treatment 2
Inflammatory Arthritis-Associated Tenosynovitis
- Consider NSAIDs for mild forms; intra-articular corticosteroids for mono- or oligoarthritis 1
- Most patients require systemic corticosteroids (10-20 mg prednisone) 1
- Early referral to rheumatology for grade 2 symptoms or insufficient response to corticosteroids 1
Infectious Tenosynovitis
- For gonococcal arthritis with tenosynovitis, ceftriaxone 1g IV or IM daily is first-line treatment, followed by oral therapy to complete 7 days 6
Common Pitfalls to Avoid
- Do not inject corticosteroids directly into the tendon substance—this weakens the tendon and increases rupture risk 1
- Do not use complete immobilization for extended periods—this causes atrophy and deconditioning 1
- Do not give multiple repeated courses of corticosteroid injections beyond 2-3 attempts—refer for surgery instead 2
- Extracorporeal shock wave therapy is effective but expensive and should be reserved for chronic cases 1