DeQuervain’s Tenosynovitis

Question 1

Characteristics

Answer 1

1. Abductor pollicis longus (APL) and Extensor pollicis brevis (EPB) tendons are surrounded by a synovial sheath
2. they course under the extensor retinaculum on the radial side of the wrist (anatomical snuff box*)
3. repetitive or overuse activities involving the thumb can lead to tendon irritation
4. subsequent inflammation can cause thickening and adhesions between the tendons and their synovial sheath

Question 2

Anatomical Snuff Box

Answer 2

• medial (ulnar) border: Extensor pollicis longus
• lateral (radial) border: Extensor pollicis brevis & Abductor pollicis longus

-medial and lateral are used in the context of the anatomical position, where the forearm is supinated

-when observing a patient’s anatomical snuffbox, the forearm is usually pronated

Question 3

Causes

Answer 3

• may result from anatomical anomalies:
  -septum or fascial wall between APL and EPB tendons
• occurs in occupations where the hands are used extensively:
  -golfing, playing piano, fly fishing, carpentry, office work, musicians
• parents of newborns repeated lifting with thumbs radially abducted and wrists moving from ulnar to radial deviation
• if local inflammation presses on radial nerve, may cause paresthesia along thumb dorsum of hand or index finger

Question 4

History

Answer 4

• localized pain in distal radial forearm near wrist
• pain: constant aching, burning, pulling sensation
• may refer proximally into forearm
• pain during activities where something is pinched between thumb and fingers (tendons stabilize base of thumb)
• may cause reflex muscular inhibition and muscle weakness in thumb or hand
• gradual onset of symptoms

Question 5

Observation

Answer 5

• no significant visible factors

-attributed to myxoid degeneration (the process in which the connective tissues are replaced by a gelatinous substance)

• fibrous tissue deposits and increased vascularity rather than acute inflammation of the synovial lining
• thought to be a tendinosis rather than a tendonitis

Question 6

Palpation

Answer 6

• tenderness in anatomical snuff box
• proximal and distal may also be tender
• pain may be present at proximal attachments of APL and EPB on radius due to enthesopathy
• palpable edema is possible around retinaculum near styloid process of radius
• fibrous thickening of tendons possible

Question 7

Range of Motion

Answer 7

• AROM:
• painful at end of thumb extension as tendons pulled against retinaculum
• pain/discomfort may occur at end of ulnar deviation of wrist or flexion of thumb as tendons stretched
• PROM:
• painful at end of thumb extension as tendons pulled against retinaculum
• pain/discomfort may occur at end of ulnar deviation of wrist or flexion of thumb as tendons stretched

Question 8

Resistance Testing

Answer 8

Manual Muscle Test:

• test thumb extension and abduction
• pain and/or weakness due to reflex muscular inhibition apparent in thumb gripping and extension or abduction of thumb

Question 9

Special Test

Finkelstein Test

Answer 9

• patient pulls thumb into full flexion across anterior face of palm
• fingers wrap over thumb to hold in position
• either actively/passively move wrist into ulnar deviation
• positive or likely if pain reproduced near styloid process of radius at end ROM
• bringing thumb across anterior surface of palm stretches affected tendon
• ulnar deviation extends the stretch

Question 10

Differential Evaluation:

Other pathologies

Answer 10

1. carpal tunnel syndrome
2. rheumatoid arthritis
3. distal radial
4. entrapments
5. myofascial trigger point referrals
6. tendinitis
7. osteoarthritis
8. enthesitis of affected tendons
9. carpal bone or ligamentous injury
10. distal radial styloid injury

Question 11

Treatment Suggestions:

Answer 11

1. Massage Therapy:

• deep frictions to address fibrous adhesions between tendon and sheath (transverse to fibre direction)
• reduce tension in affected muscles APL and EPB with deep longitudinal stripping and active engagement
• ice post frictions and if inflammation present

2. Non-massage:

• splinting
• ultrasound
• multimodal hand therapy
• activity modification
• corticosteroid injection
• surgery

Question 12

Self-care

Answer 12

• patient education regarding avoidance of repetitive or aggravating movements
• ice/heat packs (heat to muscle belly, ice to tendons)
• use brace if suggested by doctor
• other modalities (physiotherapy for ultrasound)
• strengthening: isometric, eccentric

a. resistance with opposite hand (extension, abduction of thumb, radial deviation)

b. resistance with elastic band - resistance band (extension, abduction of thumb, radial deviation)

c. resistance with weight (wrist extension, flexion, ulnar/radial deviation)
( mm setting (resistance isometric), stretch small part of the mm),