DeQuervains Tendinopathy

What is it?

DeQuervain’s tenosynovitis is not a new medical condition, in fact, it has been around for quite some time. Back in 1895 Fritz de Quervain, a Swiss surgeon, studied hand pain cases where patients were experiencing pain in the area known as the “snuff box.” The “snuff box” is located at the back of the hand and base of the thumb.

He found the cause of pain in this area was related to the tendons that attach to the thumb. In the studied cases, he consistently found the tendon to be tender to touch and thicker in size when compared to normal, non-painful hands. All the cases were similar in that he determined the cause of the irritation in the tendons were due to overuse of the thumb and wrist.

Our hands have a complex design whose purpose is to feel, touch, pinch, grip, and firmly grasp. There is an intricate balance between the many arteries, nerves, tendons, ligaments, and bones that make up our hands. Collectively they work together, so our hands have sensation and movement.

Arteries are like channels which allow for blood to travel throughout our bodies, this includes to and from our hands. Blood is critical to helping keep tissue healthy. Like arteries, nerves are throughout our entire body communicating signals to and from our brains. Nerves are critical to sensation and movement.

The nerves within our hands help communicate what something feels like, how small to pinch something, or even how firm to grasp something. The loss of nerve function may affect sensation and movements of the hand which in some cases can be debilitating when performing simple daily activities.

Within our hands, we have 29 bones, 29 ligaments, and numerous tendons. Bones provide the structural framework of our hands. Ligaments are tough fibrous tissue attaching bone to bone. They help preserve the shape and function of a joint which is where the two bones meet.

Tendons attach muscle to bones. Our hand movements come from muscles within our forearms. When muscles contract or relax, this movement pulls on the tendon which in turn pulls on the bone allowing for movement. Each tendon has a protective covering called a sheath. Within the sheath, there is synovial fluid to allow for the tendon to glide through the sheath as it moves with muscle contraction and relaxation.

Tenosynovitis occurs when the tendon becomes chronically irritated. Once irritated, the tendon does not properly glide through the sheath. As this inflammation process develops, the irritation of the tendon worsens. Symptoms may worsen with repetitive thumb and lateral (radial or ulnar deviations) wrist movements.

There are two main tendons involved in De Quervain’s, the abductor pollicis longus (APL) and extensor pollicis brevis (EBP). When these two tendons become overly irritated from overuse (e.g. from texting on your phone too much), it is called De Quervain’s tenosynovitis. Today’s nickname for this condition is “texting thumb.”

What causes De Quervain’s?

The most common cause of De Quervain’s tenosynovitis is repetitive overuse of the thumb and wrist. Some of the more common repetitive activities affecting the APL and EPB tendons are:

  • Dental Hygiene work
  • Gardening
  • Hand Writing
  • Painting with a brush
  • Playing musical instruments (musicians)
  • Playing video games
  • Repetitive hammering
  • Texting on the phone
  • Typing on a keyboard

When there is trauma or an injury to soft tissue such as muscles and tendons, sometimes scar tissue develops. For those who have had a previous injury the backside of the hand and wrist area, scar tissue may form. This scar tissue can affect the APL and EPB tendons which over time may cause De Quervain’s tenosynovitis.

Finally, those who have rheumatoid arthritis are at higher risk of developing this condition. In severe cases, one may suffer from severe deformity and a breakdown of tissue, this disease often affects the hands which put some at higher risk for developing De Quervain’s.

Symptoms

De Quervain’s symptoms typically have a gradual onset, but not always. Usually, symptoms start out as a mild irritation at the base of the thumb when gripping, holding objects, or with repetitive thumb and wrist movements.

As the APL and EPB tendons become more irritated, pain worsens, and it can radiate up the thumb side of the forearm. (This is coming up as an incomplete comparison) In severe cases, some report hearing a sound with thumb movement, this sound is called crepitus.

Crepitus is when tendons, APL and EPB, become so irritated they rub against one another causing a noise with thumb movements. Along with crepitus, some also report a “catching” or “snapping” sensation which again relates to the inflamed and irritated tendons as they glide, and sometimes get stuck, within the sheath.

How is De Quervain’s diagnosed?

For a confirmed diagnosis, it is best to see your local health care provider such as your physical or occupational therapist (PT or OT) or your physician. Your health care provider will complete an exam of the hand and thumb by checking for swelling, redness, and tenderness. The most common test to confirm the diagnosis of De Quervain’s is called the Finkelstein test.

The Finkelstein test is when you bend your thumb towards your palm and wrap your fingers around your thumb to hold it gently in your palm. Then, bend your wrist towards your 5th digit, little finger. If you experience pain within the snuff box and forearm area, you most likely are suffering from De Quervain’s tenosynovitis.

It is highly unlikely your physician would order an MRI unless he or she would like to rule out another condition.

Treatment

De Quervain’s is a common condition which responds to conservative treatment like PT or OT. In most cases, medications, injections, and surgery are not needed. As a consumer of health care, you have a choice in deciding what the best path of treatment as well as where you go for treatment is.

In most states, you can be seen by a PT first, without a physician’s order. To determine if your state has direct access, please visit the American Physical Therapy Association’s website Physical Therapy Direct Access By State.

Direct access to occupational therapy services varies widely from state to state. Often an OT works collaboratively with your physician for a treatment referral. In some states, you can see an OT directly without a physician referral.

Whether you see a PT or OT, within each of these professions, there are specialists of the hand. You will want to seek out medical care from a PT or OT hand therapist. Often, they have advanced training and certification known as CHT (Certified Hand Therapist).

Your CHT will treat your hand with conservative measures such as splinting, soft tissue mobilization ( a form of massage) and strengthening when appropriate. He or she will also talk about biomechanical techniques with the use of your thumb and wrist. In other words, how to avoid irritating the tendons with activities.

In stubborn cases despite resting, splinting, changing activities, and therapy, some De Quervain’s cases require further medical intervention such as anti-inflammatory medications, injections or surgery.

If you need medications or an injection, these medical interventions will assist with the inflammation and irritation of the tendon; however, they do not fully resolve the mechanical issues that caused the problem in the first place. PT or OT services in conjunction with a medications or injections are found to have good long-term effects for resolving the symptoms.

In rare cases, surgical intervention is needed. For some, conservative care does not work. In these cases, a hand surgeon will perform a tendon release, which means the surgeon will make a small incision and cut the top part of the tendon sheath.

Cutting the sheath allows for the tendon to glide more freely and with less irritation. After surgery, and over time, the tendon sheath tissue will heal and close-up usually slightly looser than before surgery. It takes up to several months after surgery before the tendon is fully recovered and symptoms have subsided.

After surgery, you will be treated by a PT or OT hand therapist to guide you through a safe recovery. Your therapist will create a customized splint for your thumb and wrist to immobilize it during recovery. He or she will also work with you on decreasing swelling, pain, and when appropriate start gentle range of motion. Over time you will advance to strengthening exercises and eventually returning to functional activities.

Next Steps

Early intervention to hand pain is important. The sooner you address your symptoms, the more likely conservative care will work for you. As a consumer of health care, you have a choice in finding the right provider for you. Do your homework and search for a health care provider, like a physical therapist, with excellent outcomes, great customer reviews, and can provide you the care you need for a reasonable cost.

There are many qualified PTs and OTs, so to find one near you, please click on Find A Clinic. This link will help you find a PT or OT that has top national rankings for treating hand conditions such as De Quervain’s tenosynovitis.

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