De Quervain tendonitis

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 patient try to grip or during rotation of wrist.

Pathophysiology

In De Quervain syndrome involves non inflammatory thickening of the tendons and synovial sheaths.

There are two tendons present first is extensor pollicis brevis and the second is abductor pollicis longus.

• extensor pollicis brevis (EPB)
  • Origin: ½ dorsal side of the radius, the membrane interossea
  • Insertion: base of the proximal phalanx of the thumb
  • Function: - wrist joint: radial abduction
                 - thumb: extension
  • Innervations: N. radialis
  • Artery: A. interossea posterior
• abductor pollicis longus (APL)
  • Origin: dorsal side of the radius and the ulna, the membrana interossea
  • Insertion: base of ossis metacarpi I
  • Function: - wrist joint: radial abduction
                 - thumb: abduction
  • Innervations: N. radialis
  • Artery: A. interossea posterior

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 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 cause irritation and pain. One common movement that causes it is lifting a child into a car seat. Another is lifting a heavy grocery bags by include a direct injury to the wrist or inflammatory arthritis.

• Scar tissue can restrict the movement of your tendons.
• Pregnancy can cause it because of the hormonal changes during pregnancy can cause.
• Arthritis can also cause.
• Sometime degenerative changes.

• Pain at the radial side of the wrist.
• Spasm at that side
• Tenderness will be present.
• Burning sensation may feel occasionally.
• Swelling is present over the thumb side of the wrist.
• Pain may radiate to the thumb or the forearm.

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 special test present for the De Quervain syndrome which 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.)

De Quervain syndrome is likely.

While a positive Finkelstein’s test is often considered pathogenesis for De Quervain syndrome.

Neurological test

• Upper Limb Tension Test B (ULTT B)

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.

• Tinel’s Sign

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 patient's thumb position while performing this maneuver.

• Intercarpal Instabilities
  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 disassociation, scapho-trapezio-trapezoidal joint degeneratioin, and lunatotriquetral dissociation could all present with radial sided wrist pain.
• Scaphoid Fracture
  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.
• Superficial Radial Neuritis (Wartenberg’s Syndrome)
  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.
• C6 Cervical Radiculopathy
  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 a radiculopathy can present much like De Quervain’s a thorough screen of the cervical spine is necessary.
• Osteoarthritis of the 1st carpometacarpal joint (CMC)
  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
  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

Ice/Heat Packs

Heat can help relax and loosen tight musculature, and ice can be used to help relieve inflammation of the extensor sheath.

Massage

Deep tissue massage at the thenar eminence can help relax tight musculature that causes pain.

Stretching

Stretching the thenar eminence muscles into thumb extension and abduction can relax and lengthen this tight musculature that causes pain. 

Decreasing Swelling

To decrease swelling you can use:

• Thumb splinting
• Corticosteroid injections
• NSAIDs
• Ice/heat packs
• Massage
• Stretching

Improving Range of Motion

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.

Increasing Strength

• Resisted finger and thumb extension
• Palm up position - for thumb extension and abduction strength
• Thumb up position - for thumb extension and abduction strength
• Resisted radial deviation
• In thumb up position
• Resisted supination
• In thumb up position
• Resisted thumb opposition
• In thumb up position

Any of 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 with the conventional and traditional treatments which are available with most of the therapist, 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 patter. We are working on the faulty biomechanics by releasing these trigger points. Releasing the trigger points results restoring the normal biomechanics, with normal ROM and joint function.

These techniques include:

• Soft tissue release: This helps in restoring the length of the muscle, by releasing the trigger points with various techniques like myofascial release, IASTM, Ischemic compression, Active release technique, passive release technique, Positional release technique and muscle energy technique.
• Dry Needling: In this technique, we insert thin filament needles in the trigger points of the muscles to break them resulting in muscle relaxation, only after having a thorough knowledge of anatomical structures.
• Deep tissue Release: there are many advanced techniques, which includes massage strokes, and are modifies to address specific conditions like cramps, strains, light, muscular and joint stiffness or breakdown of adhesions and bad scars. This stand alone in the form of tissue treatment, if therapist wants to target deeper muscles or to increase range of motion at any joint using basic but very specific techniques of compression and stretching of the muscles. This is applied by the therapist to treat patients.
• Joint mobilizations: These techniques help in restoring the normal joint ROM by giving graded oscillations to the joints. We use the latest 3-d mobilization technique known as KKMT which gives very fast results to restore the movement by correcting the altered biomechanics.
• Lymphatic Drainage: Our body tends to accumulate extracellular fluid, in cause tissue trauma and lymphoedema is a common condition when the lymph nodes are excised due to which the lymphatic fluid accumulates. This can be drained by lymphatic drainage to release the pressure in the tissues and also helps in increasing the blood circulation.
• Taping: We use various tapes and techniques to apply it. We use Kinesio tape, rigid tape, semi- elastic etc. Taping helps in restoring the function of the muscle, supporting the structure involved, and restricting the joint or the muscle movement.