What are the management options for De Quervain's tenosynovitis, especially in women during or after pregnancy and in individuals with repetitive strain injuries?

Management of De Quervain's Tenosynovitis

First-Line Treatment: Conservative Management

Start with relative rest, ice application, and corticosteroid injection—this approach successfully resolves symptoms in 80-98% of patients within 3-6 months. 1, 2

Initial Conservative Measures

• Relative rest of the affected thumb and wrist to prevent further tendon damage and promote healing 1
• Cryotherapy using melting ice water through a wet towel for 10-minute periods provides acute pain relief 1
• Thumb spica splinting to immobilize the first dorsal compartment 3

Corticosteroid Injection Protocol

Corticosteroid injection is the mainstay of treatment and should be offered early, particularly after NSAIDs have failed for approximately 6 weeks. 1, 2

• Inject a mixture of 1 ml (40mg) methylprednisolone acetate with 1 ml of 2% lidocaine into the first dorsal compartment 2
• 65% of patients are symptom-free at 2 weeks after the first injection 2
• If symptoms persist at 2 weeks, administer a second injection 2
• By 12 weeks, 98.75% of patients achieve symptom resolution with 1-3 injections 2

Ultrasound-Guided Injection Advantage

Use ultrasound guidance for corticosteroid injections to improve accuracy and identify anatomic variations. 3, 4

• 52% of patients have multiple subcompartments within the first dorsal compartment that require separate injection 4
• Ultrasound-guided injections achieve 97% partial or complete symptom resolution at 6 weeks 4
• Blind injections may miss subcompartments, leading to treatment failure 3, 4

Special Considerations for Pregnancy and Breastfeeding

Corticosteroid injection is safe and effective during the third trimester of pregnancy and while breastfeeding—there is no contraindication. 3

• Studies demonstrate optimal symptomatic relief for the mother without impact on the baby 3
• This is particularly important as De Quervain's tenosynovitis commonly affects women during or after pregnancy due to repetitive infant care activities 3
• Avoid NSAIDs during pregnancy, particularly in the third trimester, due to risk of premature ductus arteriosus closure 1

Role of NSAIDs

NSAIDs provide short-term pain relief but have no effect on long-term outcomes and should not be relied upon as primary treatment. 1

• Use NSAIDs for acute pain relief only 1
• Topical NSAIDs may have fewer systemic side effects 1
• NSAIDs are not recommended as monotherapy and should be combined with other conservative measures 1

Eccentric Strengthening Exercises

• Eccentric strengthening exercises are effective and may reverse degenerative tendon changes 1
• Implement these exercises once acute inflammation subsides 1

Surgical Management

Reserve surgical release of the first dorsal compartment for patients who fail 2-3 corticosteroid injections over 12 weeks. 3, 2

Surgical Technique Options

• Open release through a longitudinal incision allows better visualization of anatomy, resulting in fewer injuries to the superficial branch of the radial nerve and lower incidence of hypertrophic scarring compared to transverse incisions 3, 5
• Endoscopic release provides quicker symptom improvement, superior scar cosmesis, and lower incidence of radial sensory nerve injury for surgeons experienced in endoscopic techniques 3
• WALANT technique (wide-awake local anesthesia no tourniquet) can be safely used with potential cost savings 3

Surgical Success Rate

• Surgical release provides excellent symptom relief in patients who fail conservative management 3
• Only 1.25% of patients require surgery after appropriate conservative treatment 2

Emerging Alternative: Platelet-Rich Plasma

Platelet-rich plasma (PRP) injections show promise as a safe alternative to corticosteroid injections, but evidence remains insufficient for routine recommendation. 6

• PRP may provide regenerative stimulus to tendon healing through growth factors 6
• Current evidence suggests PRP is promising and safe but requires larger studies before definitive recommendation 6
• Consider PRP for patients who prefer to avoid corticosteroids or have contraindications 6

Critical Pitfalls to Avoid

• Do not rely on NSAIDs alone—they shift focus away from definitive treatment and have no long-term benefit 1
• Do not perform blind injections—52% of patients have anatomic variations requiring ultrasound guidance for complete treatment 4
• Do not delay corticosteroid injection in pregnant or breastfeeding women due to unfounded safety concerns—injection is safe and effective 3
• Do not use transverse incisions for surgical release—longitudinal incisions reduce nerve injury and hypertrophic scarring 3
• Recognize that 14% of patients with subcompartments may experience symptom recurrence even after successful initial treatment 4

Treatment Algorithm Summary

1. Weeks 0-6: Relative rest, ice, thumb spica splint, consider NSAIDs for acute pain
2. Week 6: First ultrasound-guided corticosteroid injection if conservative measures fail
3. Week 8: Second injection if symptoms persist
4. Week 12: Third injection if needed; 98.75% should be symptom-free by this point
5. After 12 weeks: Surgical consultation for the 1.25% who fail conservative management