What is the appropriate treatment for de Quervain’s tenosynovitis in an otherwise healthy adult?

Treatment of De Quervain's Tenosynovitis

Begin with thumb spica splinting and NSAIDs, followed by ultrasound-guided corticosteroid injection if symptoms persist beyond 2-4 weeks; reserve surgery only for patients who fail 2-3 properly administered injections over 3-6 months. 1

First-Line Conservative Management

Initial treatment should combine thumb spica splinting with NSAIDs (oral or topical) to immobilize the first dorsal compartment and reduce pain. 1 The splinting immobilizes the affected abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, allowing the degenerative tendinopathy to heal. 1

• Thumb spica splinting is the cornerstone of initial therapy, providing rest to the inflamed first dorsal compartment 1
• NSAIDs (topical formulations avoid gastrointestinal side effects while providing equivalent pain relief) 1, 2
• Local heat application may provide additional symptomatic relief 1
• Physical therapy with therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit remains weak 1

Most patients (approximately 80%) achieve full recovery within 3-6 months with conservative treatment alone. 1

Corticosteroid Injection Protocol

If symptoms persist after initial conservative measures, proceed to ultrasound-guided corticosteroid injection with methylprednisolone—this achieves complete pain relief in 58-90% of patients with a single injection. 2 Research confirms that 65% of patients become symptom-free at 2 weeks after first injection, with 98.75% symptom-free by 12 weeks after 1-3 injections. 3

Critical Technical Requirements

• Always use ultrasound guidance to ensure accurate placement within the first dorsal compartment and identify subcompartmentalization (which affects treatment success) 1, 2
• Inject peritendinously only—never into the tendon substance itself, as intratendinous injection reduces tensile strength and predisposes to spontaneous tendon rupture 2
• Use methylprednisolone 40mg mixed with 1ml of 2% lidocaine for the injection 3
• Continue thumb spica splinting alongside injection therapy 2

Important Caveat on Immobilization

Recent evidence suggests that immobilization following injection does not improve outcomes and may actually be inferior. A 2020 randomized trial found that patients receiving injection alone had superior resolution of radial-sided wrist pain (100% vs 64%) compared to those who received injection plus 3 weeks of immobilization. 4 However, the American Academy of Family Physicians guidelines still recommend continuing splinting. 1, 2 In practice, offer splinting as optional rather than mandatory post-injection, particularly for patients whose activities of daily living would be significantly impaired. 4

Injection Frequency

• Maximum of 2-3 corticosteroid injections should be administered before considering surgical referral 1, 2
• Space injections 2-4 weeks apart if repeat injection is needed 3
• Adverse reactions occur in approximately 25% of patients but typically subside within 20 weeks 3

Surgical Management

Refer for surgical release of the first dorsal compartment only after failure of 2-3 properly administered ultrasound-guided injections over 3-6 months. 1, 2 Surgery involves excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 1

Surgical Considerations

• Ultrasound can detect subcompartmentalization within the first dorsal compartment, which affects surgical outcomes and must be addressed intraoperatively 1
• Protect the superficial branch of the radial nerve during surgical release to avoid iatrogenic injury 5, 6
• Identify all accessory compartments to prevent incomplete release 6
• Ultrasound-guided percutaneous release is an emerging alternative that may reduce recovery time and nerve injury risk 7

Diagnostic Confirmation When Needed

Plain radiographs are not necessary for typical presentations but may be obtained to exclude first carpometacarpal joint osteoarthritis, scaphoid fracture, or other bony pathology. 1

• Ultrasound is the most useful imaging modality when confirmation is needed, showing thickened hypoechoic tenosynovial sheath surrounding the APL and EPB tendons 1
• MRI is not routinely indicated for straightforward cases but may be appropriate when diagnosis remains unclear 8, 1

Common Pitfalls to Avoid

• Premature surgical referral before attempting 2-3 properly guided injections 2
• Injecting into tendon substance rather than peritendinous space (causes tendon rupture risk) 2
• Mislabeling chronic cases as "tendinitis" when the underlying pathology is degenerative tendinopathy ("tendinosis"), which explains why anti-inflammatory treatments eventually fail 1
• Missing subcompartmentalization by not using ultrasound guidance, leading to treatment failure 1, 2
• Failing to consider inflammatory arthritis when multiple tendons are symptomatic simultaneously or when diffuse wrist swelling extends beyond the first dorsal compartment 1, 9

Alternative Therapy for Refractory Cases

Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathies refractory to injections and may be considered as a noninvasive option before proceeding to surgery, though it is expensive and evidence for optimal protocols is still evolving. 1