What is the appropriate next‑step treatment for a 69‑year‑old woman with bilateral de Quervain tenosynovitis that persists despite rest, thumb splinting, and over‑the‑counter analgesics?

Treatment of Persistent Bilateral De Quervain Tenosynovitis After Failed Conservative Management

The next step is ultrasound-guided corticosteroid injection into the first dorsal compartment (tendon sheath, NOT the tendon substance itself), which provides effective relief in the acute phase and is more effective than oral NSAIDs alone. 1, 2

Immediate Next Steps

Corticosteroid Injection Protocol

• Inject 4-10 mg of methylprednisolone acetate into the tendon sheath of the first dorsal compartment for small joints like the metacarpophalangeal joints, which includes the thumb base 3
• Use ultrasound guidance to improve injection accuracy and identify any subcompartmentalization within the first dorsal compartment, which affects treatment success 1, 2, 4
• Critical: Inject into the tendon sheath, never into the tendon substance itself, as intratendinous injection inhibits healing, reduces tensile strength, and can cause tendon rupture 1, 5
• The injection may be repeated if needed, but limit to a maximum of 2-3 total injections to avoid tendon weakening 2

Concurrent Management

• Continue thumb spica splinting for both thumbs to maintain relative rest 2, 5
• Switch to topical NSAIDs if not already using them, as they provide equivalent pain relief without gastrointestinal hemorrhage risk 6, 5
• Initiate eccentric strengthening exercises once acute pain subsides after injection, as these stimulate collagen production and reverse degenerative tendon changes 1, 5
• Apply ice for 10 minutes through a wet towel for acute pain relief 6, 5

Expected Outcomes and Timeline

• Approximately 80% of patients fully recover within 3-6 months with appropriate conservative treatment including corticosteroid injection 2, 5
• Most patients with corticosteroid injection alone experience complete resolution of at least 2 out of 3 pretreatment symptoms (88% success rate) 7
• Relief from corticosteroid injection typically occurs within hours to days and can persist for weeks 3

When to Consider Surgical Referral

Refer for surgical release of the first dorsal compartment if pain persists despite 3-6 months of well-managed conservative treatment including at least one properly administered corticosteroid injection 1, 2, 5, 4

Surgical Considerations

• Open surgical release through a longitudinal incision allows better visualization and results in fewer nerve injuries and less hypertrophic scarring 4
• Preoperative ultrasound should identify septations or subcompartments, as these affect surgical outcomes 1, 5
• Surgery involves excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 2

Critical Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance—only into the tendon sheath surrounding the tendons 1, 5
• Avoid multiple corticosteroid injections (more than 2-3), as they may weaken tendon structure despite providing short-term relief 2
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment including proper injection technique 1, 2, 5
• Evaluate for underlying rheumatic disease if multiple tendons beyond the first dorsal compartment are symptomatic, as this suggests systemic inflammatory arthritis rather than isolated mechanical overuse 6, 1, 2
• Avoid complete immobilization—thumb spica splinting is appropriate, but prolonged rigid immobilization causes muscle atrophy and deconditioning 6, 1

Alternative Considerations

• Extracorporeal shock wave therapy is a safe, noninvasive option for chronic cases refractory to injection, though it is expensive 1, 2
• Platelet-rich plasma (PRP) injection shows equivalent pain reduction to corticosteroids at 12 weeks, though corticosteroids provide faster improvement in hand function at 1 and 4 weeks 8
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence of consistent benefit is weak 2, 5

Why Conservative Treatment May Have Failed

• The underlying pathology is degenerative tendinopathy (tendinosis), not acute inflammation (tendinitis), which explains why anti-inflammatory treatments alone eventually fail 6, 2
• Inadequate rest or continued repetitive loading of the damaged tendons prevents healing 6, 5
• Subcompartmentalization within the first dorsal compartment can prevent adequate distribution of injected medication and requires ultrasound identification 1, 2, 5