What is the recommended treatment for a patient with tenosynovitis?

Treatment of Tenosynovitis

Begin with thumb spica splinting (for De Quervain's) or appropriate immobilization combined with NSAIDs and activity modification as first-line treatment, reserving corticosteroid injections for cases failing initial conservative management, and surgery only after 3-6 months of failed conservative therapy. 1

Initial Conservative Management (First 6 Weeks)

Relative rest and activity modification form the foundation of treatment—reduce repetitive loading activities while avoiding complete immobilization, which causes rapid muscle atrophy and deconditioning. 1, 2

Splinting/Immobilization:

• Thumb spica splinting for De Quervain's tenosynovitis to immobilize the first dorsal compartment 1
• Continue splinting throughout the treatment course, even after corticosteroid injection 1
• Pain should guide activity levels—continue activities that don't worsen symptoms 2

NSAIDs for pain relief:

• Topical NSAIDs provide equivalent pain relief with fewer gastrointestinal side effects compared to oral formulations 1, 2
• NSAIDs provide short-term pain relief but do not affect long-term outcomes 2, 3
• Cannot be recommended over other analgesics for superiority 2

Cryotherapy:

• Ice applied through a wet towel for 10-minute periods provides effective short-term pain relief by reducing tissue metabolism 2
• Local application of heat may provide symptomatic relief 1

Physical therapy modalities:

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence of consistent benefit is weak 1, 4
• Eccentric strengthening exercises should be initiated once acute pain subsides (primarily for tendinopathies like hamstring/biceps femoris) 2, 3

Second-Line Treatment: Corticosteroid Injection (If Conservative Management Fails)

Corticosteroid injection is highly effective when initial conservative measures fail, with approximately 90% of patients responding to single or multiple injections. 5, 6

Critical injection technique:

• Use ultrasound guidance to improve injection accuracy 1
• Never inject directly into the tendon substance—this inhibits healing, reduces tensile strength, and may predispose to rupture 2, 3
• Inject into the tendon sheath, not the tendon itself 5
• Maximum of 2-3 corticosteroid injections recommended 1

Expected outcomes:

• 58-61% of patients achieve complete symptom resolution after a single injection 5, 6
• 27-33% experience recurrence after prolonged pain-free intervals (mean 11.9 months) and respond effectively to re-injection 5, 6
• Local corticosteroid injections provide short-term pain relief but do not improve long-term outcomes 2, 3

Adverse reactions are self-limited:

• Pain at injection site, stiffness, ecchymosis, or subcutaneous fat atrophy may occur 5
• No serious complications (tendon rupture, infection) reported in prospective studies 5, 6

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

Surgery should be reserved for carefully selected patients who have failed 3-6 months of well-managed conservative therapy. 1, 2, 3

Surgical indications:

• Persistent symptoms despite appropriate conservative management including corticosteroid injections 1, 7
• 10-12% of cases require surgical release after injection failure or early recurrence 5, 6
• Surgical release of the first dorsal compartment (for De Quervain's), including any sub-compartments identified 7

Expected timeline:

• Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative management 1, 2, 3

Special Considerations and Pitfalls

Diagnostic accuracy matters:

• Most chronic cases represent degenerative tendinopathy ("tendinosis") rather than acute inflammation, despite the common misnomer "tendinitis" 1, 2
• If diffuse swelling extends beyond the expected anatomical compartment or multiple tendons are involved, evaluate for underlying inflammatory arthritis such as rheumatoid arthritis 1, 3
• Ultrasound is valuable for confirming diagnosis, detecting subcompartmentalization, and guiding injections 1

Critical pitfalls to avoid:

• Never inject corticosteroids directly into tendon substance 2, 3
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment 1, 2, 3
• Avoid complete immobilization for extended periods 2, 3
• Do not rely on NSAIDs alone for long-term management—they provide only short-term symptom relief 2, 3

Alternative physical modalities (limited evidence):

• Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathy but is expensive 2, 4
• Low-level laser therapy shows promise for De Quervain's tenosynovitis 4
• Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit 2