A painful condition affecting the tendons on the thumb side of the wrist. It is inflammation of two tendons that control movement of the thumb and their tendon sheath. This results in pain at the outside of the wrist. Repetitive hand or wrist movements can make the condition worse. Pain will typically increase when a patient try to grip or during rotation of the wrist.
De Quervain syndrome involves non-inflammatory thickening of the tendons and synovial sheaths.
There are two tendons present: the first is extensor pollicis brevis and the second is abductor pollicis longus.
These two muscles run side by side and function to bring the thumb away from the hand. The thumb outwards radially, and abductor pollicis longus brings the thumb forward away from the palm.
De Quervain tendinopathy affects the tendon of these muscles as they pass from the forearm into hand via a fibro-osseous tunnel which is the first dorsal compartment.
The cause of De Quervain syndrome is not established.
The most common cause of De Quervain tendinopathy is chronic overuse of the wrist. Repetitive movement day after day causes irritation and pain. One common movement that causes it is lifting a child into a car seat. Another is lifting heavy grocery bags by including a direct injury to the wrist or inflammatory arthritis.
De Quervain syndrome is diagnosed clinically based on history and physical examination, though diagnostic imaging such as X-ray to rule out fracture, arthritis or other causes.
There is a special test present for the De Quervain syndrome which is called Finkelstein’s test. It’s a physical examination test. To perform the test, the examiner grasps and ulnar deviates the hand when the person has their thumb held within their fist. If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist.)
While a positive Finkelstein’s test is often considered pathogenesis for De Quervain syndrome.
Neurological test
This test is in supine lying. The first step is shoulder depression, followed by elbow extension, then medial rotation of the whole arm, and finally adding the last component which is wrist, finger and thumb flexion. If there is pain or tingling sensation or numbness at any stage during the movement at any step, confirms the muscle involvement.
This is performed by lightly tapping the nerve over the nerve to elicit a sensation of tingling or pins and needles in the distribution of the nerve. Be aware of the patient’s thumb position while performing this maneuver.
Differential Diagnosis
The wrist has many small bones and ligaments and is a complex structure. Injury to these structures through trauma or degeneration can cause instability between the articulating bones. This can lead to altered biomechanics of the wrist accompanied by pain. Scapholunate dissociation, scapho-trapezio-trapezoid joint degeneration, and lunotriquetral dissociation could all present with radial sided wrist pain.
A scaphoid fracture most commonly occurs by a fall on an outstretched hand (FOOSH) in wrist extension and will present with radial sided wrist pain, tenderness and possible swelling in the anatomical snuff box, and limited range of motion (ROM) with pain, especially at the end range. If the patient presents with radial side wrist pain after a traumatic injury a scaphoid fracture must be ruled out.
The superficial radial nerve supplies sensation to the dorsal surfaces of digits 1-2 and the first web space. The nerve can become compressed between the tendons of the extensor carpi radialis brevis and the brachioradialis, in developing scar tissue after trauma or by tight jewelry. Compression will cause ischemia resulting in numbness and tingling in this distribution.
Compression on a spinal nerve root can cause sensory disturbances, myotome weakness, and diminished reflexes throughout the root’s distribution. The dermatomal key point for the C6 nerve root is the radial aspect of the 2nd metacarpal and index finger which is close to the area of pain experienced with De Quervain’s. Since radiculopathy can present much like De Quervain’s, a thorough screen of the cervical spine is necessary.
Osteoarthritis of the 1st CMC typically occurs in individuals greater than 50 years old, and will most frequently present with morning stiffness of the 1st CMC joint, a general decrease in ROM of the joint, tenderness along the joint line, and a positive grind test.
Intersection syndrome – pain will be more towards the middle of the back of the forearm and about 2-3 inches below the wrist.
The goal in treating De Quervain tendinitis is to relieve the pain caused by irritation and swelling.
Surgical treatment
Surgical is rare and is usually for those when non-surgical treatment has failed and the patient experiences persistent inflammation affecting his or her function. The goal of surgery is to open the dorsal compartment covering to make more room for the irritated tendons. The openings allow pressure relief of the tendons, to ultimately restore free tendon gliding.
Physiotherapy treatment
Heat can help relax and loosen tight musculature, and ice can be used to help relieve inflammation of the extensor sheath.
Deep tissue massage at the thenar eminence can help relax tight musculature that causes pain.
Stretching the thenar eminence muscles into thumb extension and abduction can relax and lengthen this tight musculature that causes pain.
To decrease swelling you can use:
Stretching as explained above can be used to improve range of motion. Ice/Heat packs can relax tight musculature so that you can attain a bigger range of motion.
Home care advice
Any of the above stretching and strengthening exercises can be done as a home exercise program (HEP). Patients can also use ice and heat packs at home. After education, patients can perform self-massage techniques at home, and if chosen as the preferred intervention.
Expert Treatment
There are various advanced techniques available these days which gives a better and complete recovery from the ailment. As compared to the conventional and traditional treatments which are available with most of the therapists, these new techniques give the best results in the long run.
In these treatments, we work on the muscles and fascia. Basically, whenever there is pain, inflammation, injury, postural imbalance, due to overstretching or over-contraction etc. result in taught band formation known as trigger points. These points are basically reducing the length of the muscle which impairs the joint function and ROM. Every muscle has a trigger point pattern. We are working on the faulty biomechanics by releasing these trigger points. Releasing the trigger points results in restoring the normal biomechanics, with normal ROM and joint function.
These techniques include:
