Treatment of Stenosing Tenosynovitis
Begin with relative rest, ice therapy, and NSAIDs for acute pain relief, followed by eccentric strengthening exercises once acute pain subsides; approximately 80% of patients fully recover within 3-6 months with conservative management alone. 1
First-Line Conservative Treatment
Relative rest is the cornerstone of initial management 1. This means reducing repetitive loading on the affected tendon sheath while maintaining some activity to prevent muscle atrophy and deconditioning 1. Complete immobilization for extended periods must be avoided as it leads to rapid muscle atrophy and loss of strength 1, 2.
Pain relief strategies include:
- Ice therapy applied through a wet towel for 10-minute periods provides effective short-term pain relief by reducing tissue metabolism 1, 2
- NSAIDs (oral or topical) effectively relieve acute pain, with topical formulations preferred due to elimination of gastrointestinal hemorrhage risk 1, 2
- Topical NSAIDs provide equivalent pain relief with fewer systemic side effects compared to oral formulations 2
Eccentric strengthening exercises should be initiated once acute pain subsides and are the cornerstone of rehabilitation 2.
Expected Timeline and Natural History
Approximately 80% of patients fully recover within 3-6 months with appropriate conservative treatment 3, 1. The condition typically presents with gradually increasing load-related localized pain coinciding with increased activity 3.
Corticosteroid Injection Therapy
When conservative measures fail, corticosteroid injection is the next step, but must be used with extreme caution 1, 2. Triamcinolone acetonide is FDA-approved for acute nonspecific tenosynovitis 4.
Critical injection technique requirements:
- Never inject directly into the tendon substance as this inhibits healing, reduces tensile strength, and predisposes to rupture 1, 2
- Injection must be made into the tendon sheath rather than the tendon itself 4
- Ultrasound guidance improves injection accuracy 5
Injection protocol based on symptom duration:
- Digits symptomatic for ≤3 months are more likely to resolve after one injection (OR 2.6) compared to those symptomatic >3 months 6
- For digits failing first injection, those symptomatic ≤5 months before first injection are more likely to respond to a second injection (OR 9.4) compared to those symptomatic >5 months 6
- A maximum of 2-3 corticosteroid injections is recommended 5
- Multiple injections are safe and effective, with no instances of tendon/pulley rupture, infection, or soft-tissue atrophy reported in large prospective studies 6
Important caveat: While corticosteroids provide short-term pain relief, they do not improve long-term outcomes and may have deleterious effects on tendon healing 2. A staged two-injection protocol does not improve overall failure rates and is associated with higher surgery rates (47% vs 27%) compared to single injection 7.
Surgical Management
Surgery is reserved for the 12% of cases where injection fails or early recurrence occurs 1. Surgical evaluation is warranted only after 3-6 months of well-managed conservative treatment has failed 3, 1, 2.
Surgical techniques involve excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1.
Prognostic Factors
Poor prognostic indicators include:
- Symptom duration >4 months before treatment (only 41% success rate with conservative therapy) 8
- Multiple-digit involvement (responds less favorably than single-digit involvement) 8
- Diabetes (associated with higher surgery rate at 1 year: 56% vs 37%) 7
- High baseline DASH score >40 (predicts higher chance of failure and need for surgery) 7
Common Pitfalls to Avoid
- Do not completely immobilize the affected area for extended periods—this causes rapid muscle atrophy and deconditioning 1, 2
- Avoid multiple corticosteroid injections beyond 2-3 total, as they may weaken tendon structure despite providing short-term symptom relief 5, 2
- Do not proceed to surgery without an adequate 3-6 month trial of well-managed conservative treatment 1, 2
- Avoid mislabeling chronic cases as "tendinitis" when they represent degenerative tendinopathy ("tendinosis"), as most patients in primary care have chronic degenerative conditions rather than acute inflammation 3, 5