What is the treatment for Quervain tenosynovitis?

Treatment for De Quervain Tenosynovitis

Begin with a multimodal conservative approach combining thumb spica splinting, NSAIDs, and corticosteroid injection into the first dorsal compartment—this successfully manages approximately 90% of cases without surgery. 1, 2, 3

Initial Conservative Management (First-Line Treatment)

• Relative rest is essential to decrease repetitive loading of the abductor pollicis longus and extensor pollicis brevis tendons in the first dorsal compartment, while avoiding complete immobilization that leads to muscle atrophy. 1, 2

• Thumb spica splinting should be applied to immobilize the affected tendons while maintaining some functional activity. 2

• NSAIDs (both oral and topical formulations) effectively relieve acute phase pain, with topical preparations preferred due to elimination of gastrointestinal hemorrhage risk. 1, 2

• Ice therapy provides short-term pain relief by reducing tissue metabolism and blunting the inflammatory response. 1, 2

Corticosteroid Injection (Highly Effective Second-Line)

• Corticosteroid injection into the first dorsal compartment is the mainstay of treatment and achieves symptom resolution in approximately 90% of patients, either with a single injection (58%) or multiple injections (33%). 4, 3

• Use ultrasound guidance when available to identify any septum or subcompartmentalization within the first dorsal compartment—this anatomical variation occurs frequently and failure to identify it leads to incomplete response to injection therapy. 5, 1, 2

• Critical injection technique: Inject methylprednisolone acetate (10 mg) mixed with 1% lidocaine (1 mL) into the tendon sheath—never inject directly into the tendon substance as this inhibits healing, reduces tensile strength, and predisposes to rupture. 1, 2, 6

• Insert a 24- or 26-gauge needle at the point of maximum tenderness, directed proximally toward the radial styloid process, parallel to the tendons—observe swelling of the synovial sheath from the volume effect to confirm proper placement. 6

• Recurrence occurs in approximately 30% of patients at a mean of 11.9 months after initial injection, but these cases respond well to repeat injection. 3

• Avoid multiple repeated injections as they may weaken tendon structure despite providing short-term relief. 2

Physical Modalities (Adjunctive Options)

• Low-level laser therapy and therapeutic ultrasound are the most effective physical therapy modalities for De Quervain tenosynovitis based on available evidence. 7

• Extracorporeal shock wave therapy (ESWT) is a safe, noninvasive option for chronic cases, though it is expensive and requires further research. 2, 7

• Eccentric strengthening exercises stimulate collagen production and guide normal alignment of newly formed collagen fibers—these are the cornerstone of long-term tendon rehabilitation. 2

Surgical Management (Last Resort)

• Surgery should only be considered after 3-6 months of well-managed conservative treatment fails. 1, 2, 4

• Open surgical release of the first dorsal compartment through a longitudinal incision provides better visualization of underlying anatomy, resulting in fewer injuries to structures and lower incidence of hypertrophic scarring compared to transverse incisions. 4

• Endoscopic first dorsal compartment release results in quicker symptom improvement, superior scar cosmesis, and lower incidence of radial sensory nerve injury for surgeons comfortable with the technique. 4

• The WALANT (wide-awake local anesthesia no tourniquet) technique can be safely and effectively used for first dorsal compartment release with potential cost savings. 4

• Surgical release achieves approximately 91% efficacy in resistant cases. 6

Common Pitfalls to Avoid

• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment—most cases resolve with nonoperative management. 1, 2, 8

• Avoid complete immobilization for extended periods as this causes muscular atrophy and deconditioning. 1, 2

• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease as this may indicate systemic inflammatory arthritis rather than isolated tenosynovitis. 2

• Failure to use ultrasound guidance may miss anatomical variations (septa or multiple compartments) that require targeted injection or surgical planning. 5, 1

Special Population Considerations

• For pregnant patients in the third trimester or breastfeeding mothers, corticosteroid injection is not contraindicated and provides optimal symptomatic relief without impacting the baby. 4