Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

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Mobilization With Movement as an Adjunct

Intervention in a Patient With Complicated
De Quervains Tenosynovitis: A Case Report

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Name _______________________________________________________________________________________________
Study Design:
Case study.
tunnel. A shallow groove in the
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Objectives: To describe the use of conventional physical therapy interventions together with
radius makes up the floor, and the
Mobilization
With Movement (MWM) techniques in the treatment of an individual with a
dorsal retinaculum of the wrist
Address
_____________________________________________________________________________________________
complicated scenario of de Quervains tenosynovitis.
forms the ceiling, of this unyieldThe patient was a 61-year-old woman who presented with
signs and symptoms
CityBackground:
_______________________________State/Province
__________________Zip/Postal
Code _____________________
ing fibro-osseous
tunnel.14 As the
consistent with de Quervains tenosynovitis of the right hand. Range limitations in all motions of
tendons
exit the first dorsal tunPhone
_____________________________Fax____________________________Email
_____________________________
the right
wrist and first carpometacarpal joint complicated her presentation.
nel,
they
angulate acutely and
Methods and Measures: Physical therapy included conventional intervention with superficial heat,
reach
their
insertions on the first
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ice, iontophoresis, and transverse friction massage directed to the first dorsal tunnel. Conventional
metacarpal and proximal phajoint mobilization techniques addressed the motion limitations of the first carpometacarpal,
lanx.3 The greater incidence of de
radiocarpal, and midcarpal joints. In addition, MWM techniques were utilized to promote
Quervains tenosynovitis in women
pain-free wrist
and thumb mobility. The specific MWM techniques used with this patient involved
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active movements of the thumb and wrist superimposed on a passive radial glide of the proximal
is thought to be related to the fact
row of carpal
bones.(made payable to the JOSPT).
that this angulation against the

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Results: The described treatment regime, which involved conventional physical therapy
retinacular roof of the dorsal tuninterventions,
along with
MWM,MasterCard
aided in the complete
of this patients

Credit
Card (circle
one)
VISAresolution
American
Expressimpairments
nel is greater in females.3
and functional limitations.
Muckart16 described the mechaConclusion: The combination of conventional physical agents, exercise, and manual therapy, and
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nism by which this strong angulathe less conventional MWM techniques, proved successful with this patient. MWM involving the
tion results in a tearing stress to
correction
of minute joint malalignments, coupled with active motion of __________________________________________________
the wrist and first
Signature
______________________________________Date
the retinaculum. This aggravating
carpometacarpal joints, was an effective and efficient adjunct physical therapy intervention.
stress is greatest when radial deviaBecause subtle changes in joint alignment may contribute to painful syndromes in the tendon
tion of the wrist is combined with
complexes that cross a malaligned joint, use of MWM as a treatment technique warrants
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a gripping motion of the thumb.16
continued research. J Orthop Sports Phys Ther 2002;32:8697.
People who use their thumbs in
1111
Norththerapy,
Fairfax Street,
Suite 100, Alexandria, VA 22314-1436
Key Words: joint alignment,
manual
tendinitis
repetitive pinching, wringing, liftPhone 877-766-3450 Fax 703-836-2210 Email: subscriptions@jospt.org
ing, grasping, or extension activities of the wrist and hand are susThank you for subscribing!
ceptible to inflammation and
e Quervains tenosynovitis is a form of stenosing
progressive stenosis in the first
tenosynovitis affecting hand function in a wide range of
dorsal tunnel of the
patients, including mothers of young children, computer
wrist.3,7,10,12,14,16,23,25
keyboard operators, machinists, golfers, and mountain bikSurgical evidence implicates iners.10,12,26 De Quervains tenosynovitis involves inflammaflammation of the retinaculum,
tion of the abductor pollicis longus (APL), the extensor pollicis brevis
the synovial sheath, and the ten(EPB), and each of their synovial sheaths (Figure 1). At the level of the dons in de Quervains
radial styloid process, the APL and EPB tendons enter the first dorsal
tenosynovitis.3,7,14,16

Mobilization With Movement

1

Assistant professor, Physical Therapy Program, University of Colorado Health Sciences Center, Denver,
CO.
Send correspondence to Karen Maloney Backstrom, Physical Therapy Program, UCHSC, 4200 East Ninth
Avenue Box C-244, Denver, CO 80262. E-mail: Karen.Backstrom@UCHSC.edu

86

Mobilization With Movement

(MWM) is an intervention technique developed by Brian Mul-

Journal of Orthopaedic & Sports Physical Therapy

FIGURE 1. The region of the first dorsal tunnel.

Interview Data
The patient was a 61-year-old epidemiologist referred to physical therapy with the diagnosis of de
Quervains tenosynovitis in the right wrist. She attributed her current symptoms of radial wrist pain and
stiffness to an injury that occurred 2 months prior to
the first physical therapy visit, when she jammed her
hand against a table. The patient reported that the
force went through the web space of her right, dominant hand and was followed by noticeable bruising
on the radial side of the wrist and hand. She did not
seek medical intervention at the time. The symptoms
of pain with activities involving her thumb, stiffness,
and limited function, which caused her to seek physical therapy, began 3 weeks after this reported injury.
Radiographs taken 6 weeks following the initial injury ruled out scaphoid and other wrist fractures.
She came to physical therapy 2 months after the injury because pain was limiting her activities of daily
living and she could no longer ignore the symptoms.
She reported significant pain with grooming activities
such as brushing her teeth, fastening her bra strap,
and washing. She also had difficulty lifting even
small amounts of weight. Putting weight through the
right wrist during activities such as pushing up from
a chair was painful. She could no longer work in her
garden. Although she did not initially relate her pain
to the time she spent on the computer, she later
noted increased pain after using the computer for 2
to 3 hours. She described herself as a binge keyboard user, typing up to 14 hours on some days. The
patient was using ibuprofen on a regular basis for
pain relief related to this injury.

Physical Examination
Pain Description The patient complained of stiffness and sharp pain along the radial side of her
87

STUDY

J Orthop Sports Phys Ther Volume 32 Number 3 March 2002

METHODS AND CASE DESCRIPTION

CASE

ligan, a New Zealand physiotherapist. Dr. Mulligan17

has proposed that minor positional faults of joints
can occur following injuries or strains. He defines
positional faults as positions of joint surfaces whereby
they are no longer aligned in their natural, congruent position, but are subtly malaligned: These
[faults] are not readily palpable or visible on
X-ray . . .17 The proposed mechanism for the effectiveness of this intervention is the restoration of normal, pain-free, fluid movement through the correction of the joint malalignment. Mulligan17 suggests
that positional faults can occur in all extremity joints.
In comparison to other joint mobilization techniques
used by physical therapists, MWM emphasizes the
restoration of normal joint alignment to allow for
normal arthrokinematics, rather than the stretching
of tightened tissues to restore normal arthrokinematics.
MWM techniques involve the sustained correction
of subtle joint malalignment, which is accomplished
by passive mobilization. Active movement is then superimposed on the corrected joint position. The active movement chosen is one that previously produced pain, but when superimposed on a corrected
joint position, occurs without pain.1719
Determination of this techniques effectiveness
with a given patient requires some clinical trial and
error. The decision to use a particular joint glide is
determined by the patients response. If the involved
joint demonstrates an immediate increase in range of
motion, and there is no pain while the joint position
is maintained, this position is the one used for intervention.17 Often, the selected joint position requires
small adjustments by the clinician to achieve painfree movement, on which success of the technique
hinges.1721,28
Once the most effective joint position is determined and secured, repetitive movement of the involved joint is used as intervention. Although the
specific technique used in this case study has not
been described in the literature, Mulligan,17 and
Vicenzino and Wright,28 have used similar techniques, and describe positive results for other
musculotendinous conditions, such as tennis elbow
and rotator cuff tendinitis. Correcting minute joint
malalignments through the use of MWM may positively affect the function of a joint and the tissues

that cross the joint. MWM is used as part of a complete intervention program that may also include
modalities and exercise.
The purpose of this case report is to introduce
MWM as an adjunct intervention method for the
treatment of de Quervains tenosynovitis. This case
report also serves as an initial step in a research process that would explore MWM as a useful addition to
conventional physical therapy intervention, as there
is a paucity of clinical research studies that examine
the efficacy of this technique. Thus far, the evidence
supporting MWM is chiefly anecdotal. As with any
novel physical therapy intervention, research at all
levels is necessary to prove efficacy. In this case study,
one interesting conceptual question is raised: Can
subtle corrections in joint alignment positively influence tendon disorders?

right wrist. A verbal pain scale for which 0 indicated

no pain and 10 indicated excruciating pain was used
to quantify her pain.11 Prior to coming to physical
therapy, she reported that the pain was intermittent,
and ranged from 0/10 to 6/10 during the course of
a normal day. The activities that aggravated her pain
included radial abduction or adduction of the
thumb, forearm supination, twisting activities involving supination combined with wrist flexion, and
weight bearing through the right hand. The patient
did not report any proximal upper-extremity or
cervical pain.
Inspection The patient presented with a moderately slumped sitting posture, which included a forward head, rounded shoulders, and a slight increase
of high thoracic kyphosis. Swelling was evident in the
right wrist. Girth measurements revealed a 1-cm difference between the right and left wrists at the point
just distal to the ulnar and radial styloid processes.
The first dorsal tunnel on the right was tender at the
level of the snuffbox and at the base of the first
metacarpal.
Range of Motion All motions of the right wrist and
first carpometacarpal (CMC) joint were limited. Measurements were taken according to the American
Academy of Orthopaedic Surgeons guidelines.8
These goniometric measurements are listed in Table
1.
Isometric Resistive Testing Pain was elicited with
contraction of the right EPB and APL. Weakness was
noted, but could not be assessed accurately due to
pain.
Manual Muscle Testing Manual muscle testing was
deferred initially due to pain.
Accessory Motion and Positional Testing Accessory
motion was assessed according to the techniques of
Edmond.6 Accessory motions in the right radiocarpal
and midcarpal joints were limited when compared to
those of the left. Motions tested included distraction,
radial-ulnar glides, and volar-dorsal glides. The accessory motions (distraction, radial-ulnar glides, and
volar-dorsal glides) of the right first CMC joint were
also limited.
Upon palpation, it was noted that the right
capitate was positioned volarly when compared to the

left. The therapist determined this by bilaterally palpating the capitates with the thumbs on the dorsal
side and the index fingers on the volar side, just
proximal to the base of the third metacarpals, while
the patients wrists were held in a neutral position.
This subtle finding was based on palpation alone. It
should be noted that the validity and reliability of
this examination have not been determined.
Special Tests The Finklestein test was positive on
the right wrist.7 The patient was able to put her
thumb partially inside her right fist, but due to pain,
was unable to move into full range of thumb adduction or to perform any ulnar deviation of the wrist.
Significant Negative Findings The axial compression
or grind test for right first CMC joint arthrosis was
painless.27 The patient presented with full painless
range of motion with active movement and overpressure of the cervical spine. This assessment was used
to screen for referred pain from the C5C6 nerve
roots. To rule out entrapment of the superficial radial nerve, a neural provocation test with radial bias
of the upper limb was performed and was bilaterally
negative.1
Trial of Mobilization with Movement The therapist
provided a manual force to achieve a radial glide of
the proximal row of carpals, then asked the patient
to move her thumb into radial abduction-adduction.
The patient reported a significant decrease in pain
with active thumb movement while the wrist joint was
held in this position.

Physical Therapy Evaluation and Intervention

Planning
The patient presented with signs and symptoms
consistent with de Quervains tenosynovitis. These
included pain, swelling and tenderness in the area of
the first dorsal tunnel, pain with isometric activation
of the EPL and APB (hitchhikers sign),13 and a
positive Finklestein test.7 Additionally, the patient
presented with stiffness of the wrist and first CMC
joint, as indicated by range-of-motion limitations and
decreased accessory motion.

TABLE 1. Pre- and postintervention goniometric measurements.

Range of Motion
Joint Motion
Wrist flexion
Wrist extension
Wrist ulnar deviation
Wrist radial deviation
1st carpometacarpal palmar abduction
1st carpometacarpal radial abduction

88

Preintervention Left

Preintervention Right

Postintervention Right

94
94
46
22
60
60

86
52
33
20
48
58

108
90
48
30
58
62

J Orthop Sports Phys Ther Volume 32 Number 3 March 2002

89

STUDY

J Orthop Sports Phys Ther Volume 32 Number 3 March 2002

Intervention

CASE

The patient received 12 intervention sessions over

the course of 2 months. A summary of the patients
reported pain level, functional status, impairment
status, and intervention is given in Table 2.
The patient came to the first session with an elastic wrist support that firmly encircled the wrist alone
and fastened with Velcro. The patient reported that
this nonrestrictive support relieved her symptoms
somewhat, and so was used by the patient throughout the 2 months of treatment.
A manipulation as described by Cyriax5 was used
during the initial visit to correct the volar position of
the right capitate. To stabilize the capitate in a neutral position, a small, oval button was fashioned from
elastomere putty, and the patient was instructed to
place it between her elastic support and the capitate
on the volar surface of her wrist (Figure 2). This manipulation was used only during the initial intervention session, as the capitate appeared to remain in a
neutral position upon subsequent examinations.
Following the manipulation, MWM was performed.
All active motions of the wrist and thumb were lim-

ited by pain. To find the position that best allowed

for pain-free motion, the therapist had to experiment with and fine tune the direction and pressure
of the imposed carpal glide using feedback from the
patient. When the therapist manually glided the
proximal row of carpals into a position radial to the
previous resting position of the wrist, the patient was
immediately able to move into previously painful
ranges without discomfort. This position and the
now active pain-free thumb motion served as the
MWM technique for this patient and became the initial treatment intervention performed for each of
the remaining 11 physical therapy sessions.
Once the proper position, direction, and force of
the wrist mobilization were established, the patient
performed 3 sets of 10 repetitions of each of the
troublesome wrist and thumb motions: wrist flexion
and extension, wrist ulnar and radial deviation, CMC
radial abduction and adduction, and CMC palmar
abduction and adduction (Figure 3). To help address
the patients difficulties with weight bearing through
the wrist, the identical radial carpal glide was maintained as the patient performed progressive weight
bearing through the right upper extremity. With the
addition of the radial carpal glide, the patient was
able to bear weight without pain.
Although the patients passive range of motion
and accessory motion improved, end-range thumb
radial abduction was painful even with the maintained radial carpal glide. Through continued directional modification of the imposed glide, it was
found that a sustained ulnar glide of the trapezium
and trapezoid allowed pain-free CMC radial abduction. This technique was incorporated into the MWM
intervention program.
The patient presented at each session with some
amount of pain attributed to joint movement and
weight bearing (Table 2). At the onset of each session, she was asked to indicate her pain range in the
time since her last session and her current pain level
with movement attempts. MWM was the first intervention used, and the chosen techniques resulted in
immediate relief of the painful motion (0/10), as
verbally reported by the patient. This pain-relief phenomenon dictated the technique chosen.
The MWM intervention was supplemented by the
addition of an elastomere horseshoe added to the
elastic splint on the sixth visit. The purpose of the
elastomere horseshoe was to provide constant pressure toward radial deviation (Figure 2).
The MWM and elastomere inserts served as adjuncts to more conventional interventions for
tenosynovitis and joint limitations. Limitations in
joint accessory motions were addressed through joint
mobilization techniques as described by Edmond.6
These conventional mobilization techniques differ
from the MWM techniques in that they are completely passive, determined by examination of acces-

The finding of a volar position of the capitate is

curious. This finding could be interpreted several
ways, including malalignment of the carpal bones,
carpal instability of the capitate or the lunate
(intercalculated segmental instability), or merely an
anomaly in this particular patient. Although the significance of this finding is questionable, one hypothesis is that the initial trauma experienced by the patient resulted in a carpal instability or malalignment,
which in turn contributed to the tenosynovitis.
This patient with de Quervains tenosynovitis was
made unique by the complications of a carpal positional abnormality and restricted joint mobility
coupled with an unusual onset history (latent to the
initial trauma). The immediate diminution of pain
with altered wrist mechanics imposed by the therapist also made this case remarkable.
The conventional, conservative intervention for de
Quervains tenosynovitis commonly involves a
corticosteroid injection followed by immobilization
and splinting for 6 weeks. Though traditional antiinflammatory measures seemed appropriate as elements of the intervention plan for this patient,
splinting the already restricted area was unappealing
in light of her presenting functional limitations and
motion restrictions. Based on the positive results
found during the examination with a trial of MWM,
it was hypothesized that restoration of normal mobility and normal joint alignment would decrease the
strain on the involved tendons, thus augment resolution of the inflammation. The patient was amenable
to the intervention approach involving mobilization
because she did not want an injection. She also did
not want to be limited further with a splint.

TABLE 2. Overview of pain range, functional status, impairment status, and interventions.
Session

Daily Pain
Range

Functional Status

Impairment Status

Treatment Intervention

0/106/10

Difficulty
Brushing teeth
Fastening bra
Washing
Lifting
Gardening
Weight bearing
through the right wrist

Pain with all end-range thumb motions

Pain with wrist flexion, extension
Pain with forearm pronation,
supination
Tenderness over first dorsal tunnel
1-cm swelling at wrist
Pain with isometric resistive thumb
radial abduction
Positive Finklestein test
Decreased accessory motion in all
joints of wrist and first
carpometacarpal (CMC)
Volar subluxation of the capitate
Range-of-motion limitations for all
motions of the wrist and first CMC

Manipulation of the capitate

Mobilization With Movement (MWM)
Radial glide of the carpals combined
with active motion of the thumb and
progressive weight bearing through the
wrist
Conventional joint mobilization: carpals
and first CMC
Iontophoresis
Continuation of the elastic support that
the patient brought to the session
Elastomere volar capitate button added
to elastic support

0/104/10

Able to fasten bra

without difficulty

All impairments remain with the

exception of the capitate subluxation

MWM
Instruction in self-MWM as Home
Exercise Program (HEP)
Conventional joint mobilization: carpals
and first CMC
Instruction in concentric and eccentric
tendon-gliding exercises for the extensor
pollicis brevis (EPB) and abductor
pollicis longus (APL); HEP
Iontophoresis
Ice
Continuation of the elastic support

0/104/10

Able to brush teeth

Able to bear weight
Increased ease of
motion

All impairments remain but are

diminished

As on session 2

0/103/10

Able to lift

Pain with wrist flexion, extension

Pain with forearm pronation,
supination
Tenderness over first dorsal tunnel
Slight swelling at wrist
Positive Finklestein test (at end range
only)
Decreased accessory motion in all
joints of wrist and first CMC
Range-of-motion limitations for all
motions of the wrist and first CMC

As on session 2

0/102.5/10

Able to type 14 hours

without symptoms

As on session 4

As on session 2

0/102.5/10

Patient reports
increased fluidity of
movement

Occasional pain with wrist and thumb

motions
Tenderness over first dorsal tunnel
Slight swelling at wrist
Positive Finklestein test (at end range
only)
Decreased accessory motion in first
CMC
Range-of-motion limitation (30) into
CMC radial abduction

MWM
Instruction in self-MWM; HEP
Conventional joint mobilization to first
CMC
Instruction in concentric and eccentric
tendon-gliding exercises for the EPB and
APL; HEP
Iontophoresis
Elastomere horseshoe added to elastic
support

90

J Orthop Sports Phys Ther Volume 32 Number 3 March 2002

TABLE 2. Overview of pain range, functional status, impairment status, and interventions. (Continued)
Session

Daily Pain
Range

Functional Status

Impairment Status

Treatment Intervention

Not recorded

Occasional pain with wrist and thumb

motions
Tenderness over first dorsal tunnel
Slight swelling at wrist
Positive Finklestein test (at end range
only)
Decreased accessory motion in first
CMC
Range-of-motion limitation (30) into
CMC radial abduction
Weak APL (2/5)

As on session 6
Addition of instruction in active
assistive exercise for the APL; HEP

Not recorded

Occasional pain with wrist and thumb

motions
Slight swelling at wrist
Positive Finklestein test (at end range
only)
Decreased accessory motion in first
CMC
Range-of-motion limitation (15) into
CMC radial abduction
Weak APL (3/5)

As in session 7
MWM
Added ulnar glide of trapezium with
active radial abduction
Added instruction in rubber band and
manual resistance for APL exercise; HEP
Added instruction in transverse friction
massage

0/101.5/10

Occasional pain with wrist and thumb

motions
Slight swelling at wrist

MWM
Continuation of exercise program
Iontophoresis

10

0/101.5/10

Occasional pain with wrist and thumb

motions
Slight swelling at wrist
Weak APL (4/5)

11

0/101.5/10

Gardening without
pain

Occasional pain with wrist and thumb

motions
Slight increased girth at wrist

MWM
Continuation of exercise program
Iontophoresis

12

0/101/10

Infrequent episodes of
wrist pain

Slight increased girth at wrist

Review of HEP
Discharge

J Orthop Sports Phys Ther Volume 32 Number 3 March 2002

MWM
Continuation of exercise program
Iontophoresis
Trial of prefabricated thumb spica (2
weeks)

STUDY

FIGURE 2. Elastomere inserts.

CASE

FIGURE 3. Mobilization With MovementActive thumb motion

performed with superimposed radial glide of the proximal carpal
row.

91

sory motion, and intended to stretch tissues that may

be preventing normal arthrokinematics. The treatment program also included eccentric and concentric strengthening exercises, active range-of-motion
exercises, and tendon-gliding maneuvers.
Because the EPB inserts on the first phalanx of
the thumb and the APL inserts on the first
metacarpal, it was hypothesized that isolated movement of the first metacarpophalangeal joint would
promote gliding of the EPB on the APL. This was
done concentrically and eccentrically by blocking or
stabilizing the trapeziometacarpal joint and allowing
movement at the first metacarpophalangeal joint into
flexion and extension.
Transverse friction massage was implemented over
the first dorsal tunnel to break up adhesions and
promote healing.4 Anti-inflammatory physical agents
were used throughout most of the course of the patients intervention, including ice24 and
iontophoresis with Dexamethasone (40 mA.min).2,9
These physical agents were applied at the conclusion
of each intervention session.
The home exercise program (HEP) consisted of
active range-of-motion exercises within the pain-free
ranges of the wrist and thumb, strengthening exercises, tendon gliding, and self-administered friction
massage. The patient also performed self-MWM at
home. Specifically, the patient, while standing next
to a table and bearing weight through her wrist, provided her own forearm ulnar glide and relative
carpal radial glide. She then shifted her body weight
and her forearm over her stabilized hand, thereby
moving into pain-free wrist flexion and extension in
a weight-bearing position (Figure 4). The patient was
also instructed to move into pain-free active thumb
abduction while holding the carpals in a radially
glided position.
The patients progress plateaued around session
10. She continued to have minimal pain (01.5/10),
particularly with those activities that required gripping combined with supination. It was hypothesized
that a short period of immobilization in a splint
would eliminate the last painful limitations. The patient at this point had regained full motion of her
wrist and thumb; therefore, immobilization would
not worsen her previous complication of range limitations. The patient was given a prefabricated thumb
spica splint, which held her hand in the resting position. This did not prove to be of benefit and was discontinued.

FIGURE 4. Mobilization With MovementProgressive weight bearing performed with self-imposed relative radial glide of the proximal
carpal row.

The reduction in the patients reported pain level

was initially rapid. Using the pain scale value reported by the patient during the initial examination
(6/10) as a basis of comparison, the patient noted a
25% reduction in pain (4/10) after the initial inter-

vention, and a 50% reduction (3/10) following the

third intervention (Table 2). Upon completion of 12
intervention sessions, the patient reported infrequent
episodes of pain during the week. The range of this
pain was 01/10 on the verbal pain scale.
At the final intervention session, all impairments
resolved with the exception of a 0.5-cm increased
girth at the right wrist when compared to the left.
The patient had no signs of de Quervains
tenosynovitis. She displayed a negative Finklestein
test, painless resistive testing of the EPB and APL, no
tenderness over the first dorsal tunnel, and full painless range of motion of her wrist and thumb (Table
1). She regained full strength in her APL and no
longer had any positional malalignment of the
capitate. Unpredictable, infrequent wrist pain with
movement was the only remnant of the tenosynovitis.
This occurred during what the patient described as
scooping motions, such as grasping with supination,
but this pain was inconsistent. The patient was able
to perform all activities of grooming, transfers, gardening, and typing on a keyboard for prolonged periods of time at the conclusion of the 2-month physical therapy intervention period. She no longer had
any painful limitations of the functions of her daily
routine.
During follow-up at 4 months after the cessation of
therapy, the patient reported that she was still bothered by erratic wrist pain, at times reaching a 4/10
level. She was not able to identify a specific activity
that caused her discomfort. This pain was intermittent in nature and did not interfere with her function. At 1 year post-discharge, the patient, who had
continued in the same lifestyle and line of work, reported that she was experiencing no incidences of
wrist and thumb pain or limitations in function whatsoever.

92

J Orthop Sports Phys Ther Volume 32 Number 3 March 2002

RESULTS

DISCUSSION

A patient with de Quervains tenosynovitis complicated by wrist and first CMC stiffness and a carpal
positional abnormality was successfully treated
through the use of traditional physical therapy interventions, including physical agents, exercise, transverse friction massage, and standard joint mobilization, coupled with a more novel intervention, MWM
techniques. MWM proved to be an effective adjunct
to the treatment of a complicated de Quervains
tenosynovitis. During each treatment session, the use
of MWM as a physical therapy intervention provided
an immediate decrease in pain and an immediate
increase in motion for this patient with de
Quervains tenosynovitis. The prospect of positively
affecting tendon pathology in the wrist by imposing
subtle changes in joint alignment is engaging and
warrants further research.

ACKNOWLEDGEMENTS
The author would like to acknowledge and thank
Kim Campbell Smith for her talent and her drawings; Cheryl Riegger-Krugh, Carolyn Heriza, and
Arnold Levinson for their careful review of this
manuscript; and the late Jerry Krugh for his photography.

REFERENCES
1. Anderson M, Tichenor CJ. A patient with de Quervains
tenosynovitis: a case report using an Australian approach to manual therapy. Phys Ther. 1993;74:314
326.
2. Bertolucci LE. Introduction of anti-inflammatory drugs
by iontophoresis: double-blind study. J Orthop Sports
Phys Ther. 1982;4:103108.
3. Bunnell S. Surgery of the Hand. Philadelphia, PA: JB
Lippincott Company; 1970.
4. Chamberlain GJ. Cyriaxs friction massage: a review. J
Orthop Sports Phys Ther. 1982;4:1622.
5. Cyriax J. Illustrated Manual of Orthopaedic Medicine.
London: Butterworths; 1983.
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CONCLUSION

CASE

This patient presented with de Quervains

tenosynovitis, which was complicated by wrist stiffness, first CMC joint stiffness, and a carpal positional
abnormality. I hypothesized that the positional irregularity of the capitate found in the involved wrist
reflected a specific carpal sprain that occurred during the initial trauma to the hand. A subtle malalignment of the carpals could have resulted from this
sprain. Taking this hypothesis further, I suggest that
the resulting carpal malalignment, however slight,
might have negatively affected the line of pull or
function of the tendons crossing the joint, specifically the EPB and APL, causing irritation of this tendon complex over time. The fact that the symptoms
for de Quervains tenosynovitis did not appear until
3 weeks after the initial trauma also made this hypothesis plausible. MWM was one of several intervention methods employed in this case study to address
the problem of carpal malalignment and pain stemming from the first dorsal tunnel and tendon complex. Though the initial hypothesis and the following
line of thought are in no way substantiated in a case
study format, the case does provide impetus for research examining the correlation of capitate positional abnormalities and/or carpal instabilities with
de Quervains tenosynovitis.
Restoration of the patients previous functional
level cannot be attributed to the use of MWM alone,
as many physical therapy modalities were used. A
similar outcome could have resulted from the combined result of all the other interventions used with
this patient, some of which are of proven benefit.2,9,24 The case study format, however, does not
allow for delineation of confounding variables. The
immediate positive effects of MWM were convincing
to this therapist and support the use of MWM as an
effective addition to the standard treatment of de
Quervains tenosynovitis. During each intervention
session, MWM involving a sustained radial glide of
the proximal row of carpal bones resulted in increased range of pain-free thumb motion. This effect
was not time-dependent, as it occurred instantly
upon positioning of the wrist.
With this patient, alteration of joint position with
MWM resulted in an instantaneous decrease in the
symptoms of pain and limited motion that are associated with a tenosynovitis. The correlation between
joint function and alignment and musculotendinous
pathology is not a new concept for physical therapists. The stressful effects of excessive midfoot pronation on the muscles and tendons in the lower extremity are well known.15 Glenohumeral posterior
capsular tightness and/or anterior instability have
also been shown to be correlated with rotator cuff
pathology.22 Correction of abnormal foot or
glenohumeral alignment is used as a common inter-

vention for tendon-related disorders in those areas.

This case study presents the possibility that the same
phenomenon may also occur in the wrist. It is hypothesized that osseous positional faults can contribute to the symptoms of tendinitis and that MWM is
one intervention that can be used by the physical
therapist to aid in a successful patient outcome.
Therefore, one question raised from this case report
is: Can the MWM technique used in this case report
have altered the line of pull of the involved tendons
and/or reduced the stress on the tendons and the
fibro-osseous tunnel?

6. Edmond SL. Manipulation and Mobilization: Extremity

and Spinal Techniques. St Louis, MO: Mosby Yearbook,
Inc; 1993.
7. Finklestein H. Stenosing tendovaginitis at the radial
styloid process. J Bone Joint Surg.1930;12:509540.
8. Greene WB, Heckman JD, eds. The Clinical Measurement of Joint Motion. Rosemont, IL: American Academy
of Orthopaedic Surgeons; 1994.
9. Harris PR. Iontophoresis: clinical research in
musculoskeletal inflammatory conditions. J Orthop
Sports Phys Ther. 1982;4:109112.
10. Harvey FJ, Harvey PM, Horsley MW. De Quervains
disease: surgical or nonsurgical treatment. J Hand Surg
Am. 1990;15:8387.
11. Jensen MP, Karoly P, Braver S. The measurement of
clinical pain intensity: a comparison of six methods.
Pain. 1986;27:117126.
12. Kiefhaber TR, Stern PJ. Upper extremity tendinitis and
overuse syndromes in the athlete. Clin Sports Med.
1992;11:3947.
13. Kirkpatrick W, Lisser S. Soft tissue conditions: trigger
fingers and de Quervains disease. In: Hunter JM,
Mackin EJ, Callahan AD, eds. Rehabilitation of the
Hand: Surgery and Therapy. 4th ed. St Louis, MO:
Mosby Yearbook, Inc; 1995.
14. Lapidus P, Fenton R. Stenosing tenovaginitis at the wrist
and fingers: report of 423 cases in 269 patients. Arch
Surg. 1952;64:475487.
15. Messier SP, Pittala KA. Etiologic factors associated with
selected running injuries. Med Sci Sports Exerc.
1988;20:501505.
16. Muckart RD. Stenosing tendovaginitis of abductor pollicis longus and extensor pollicis brevis at the radial

17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

styloid (de Quervains disease). Clin Orthop.

1964;33:201208.
Mulligan B. Manual Therapy: NAGS, SNAGS,
MWMS, etc. Wellington, New Zealand: Plane View
Services; 1995.
Mulligan B. Mobilisations with movement (MWMs). J
Manual Manipulative Ther. 1993;1:154156.
Mulligan B. Mobilization with movement (MWM) for
the hip joint to restore internal rotation and flexion. J
Manual Manipulative Ther. 1996;4:3538.
Mulligan B. Spinal mobilisations with leg movement. J
Manual Manipulative Ther. 1995;3:2527.
Mulligan B. Spinal mobilizations with arm movement. J
Manual Manipulative Ther. 1994;2:7577.
Neer CS. Impingement lesions. Clin Orthop.
1983;173:7074.
Plancher KD, Perterson RK, Steinchen JB. Compressive
neuropathies and tendinopathies in the athletic elbow
and wrist. Clin Sports Med. 1996;15:331357.
Rivenburgh D. Physical modalities in the treatment
of tendon injuries. Clin Sports Med. 1992;11:
645659.
Sailer SM, Lewis SB. Rehabilitation and splinting of
common upper extremity injuries in athletes. Clin
Sports Med. 1995;14:411446.
Shea K, Shumsky I, Shea O. Shifting into wrist pain.
Phys Sportsmed. 1991;19: 5963.
Skirven T. Clinical examination of the wrist. J Hand
Ther. 1996;9:96107.
Vicenzino B, Wright A. Effects of a novel manipulative
physiotherapy technique on tennis elbow: A single case
study. J Manual Ther. 1995;1:3035.

Invited Commentary
This is the perfect case study! Perfect in that a
clinical treatment technique, which in this case
worked brilliantly, is documented. It also serves as a
perfect exemplar, in that potential pitfalls inherent
in case studies are evident: mechanistic insights into
treatments are lacking, and one can neither predictably identify who might benefit from the treatment
nor determine the validity of the treatment. Therefore, my commentary echoes the authors cautious
enthusiasm for the clinical technique Mobilization
With Movement (MWM). My comments will also try
to identify the pitfalls, amplify the caveats, and refine
the biomechanical rationale for MWM in an apparent case of de Quervains tenosynovitis.
In this case, the MWM technique, a radial glide of
the proximal row of carpals, provided immediate relief in this atypical patient with de Quervains
tenosynovitis. This is an amazing feat as the conservative management for de Quervains is anything but
predictably effective,4 and rarely is such pain relief
provided instantaneously. Ms. Backstrom should be
applauded for sharing how MWM can be incorpo-

rated into the management of musculoskeletal impairments.

It is apparentand I believe Ms. Backstrom and I
agree on thisthat the first dorsal compartment tendons, abductor pollicis longus (APL), and the extensor pollicis brevis (EPB) were irritated. We would
also agree that what makes this case of de Quervains
unusual is that the EPB and APL were irritated secondary to a carpal abnormality, and that MWM
eliminated the irritation. Where we might disagree,
however, is that I see this case as a wrist joint problem primarily and a thumb tendon problem secondarily. We also may differ on what the nature of this
carpal abnormality was, and how the radial glide of
the proximal carpal row (MWM technique) provided
relief. From my arm-chair therapist perspective, it
appears unlikely that any subtle capitate-specific
abnormality was the source of the irritation. Rather,
my suspicion is that a very specific carpal instability
(ie, a midcarpal instability) was present.
The MWM maneuver, as described, manually stabilizes the ulnar carpus (specifically, the triquetrum)
and tightens the radially based extrinsic ligaments

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STUDY

the capitate is likely insignificant. As well, the ability

to reliably identify this positional fault is unknown
and may in fact be very low. The author even states
that the positional faults . . .are not readily palpable
or visible on X-ray. . .5 This evaluative conundrum is
worsened by swelling about the wrist (which was
present) and the morphology of the third
carpometacarpal joint, because the size of the proximal metaphyseal flare of the metacarpal often makes
it difficult to identify the posture of the capitate. As
well, small carpal bosses are not uncommon in this
region.8
Ms. Backstrom does a fine job of clinically ruling
out first CMC arthrosis, cervical spine involvement,
and radial sensory neuritis, but a clinical screening
for classic carpal instabilities would likely have been
informative.7 In addition to the physical examination
mentioned above and standard radiographs, a carpal
instability series (plain films and cine-radiography),
which has the patient both axially load and move the
wrist while filming, is necessary.2,6,9
As is not uncommon after reading case studies, it
is still unclear as to with whom we should attempt
this MWM maneuver. Is this the silver bullet for de
Quervains? Absolutely not. Is the MWM radial
glide a simple maneuver to use for diagnostic and
therapeutic reasons in suspected midcarpal instability? Absolutely yes. In this case, it is apparent that
the MWM was effective in stabilizing the wrist, which
may have allowed pain-free thumb tendon excursion.
I do question, however, the biomechanical rationale
put forth by the author that the radial glide addressed the negatively affected line of pull or function of the tendons (APL and EPB). In fact, it
seems that a radial glide of the carpus would adversely create tension on the irritated APL and EPB,
hence, increase pain and impairment (which is another reason why this case appears to be primarily a
wrist instability problem, and secondarily a thumb
tendon problem). The probable midcarpal instability
may have been complicated further by a strain injury
to the extrinsic wrist ligaments coursing from the
radial styloid to the distal carpal row. In this scenario, a CIND-type instability, the radial glide would
have transiently tensioned, and therefore stabilized
the midcarpal joint. Therefore, a refined, alternative
hypothesis is that the MWM provided a stable and
pain-free midcarpal joint, resolved the joint dysfunction, and allowed the thumb and wrist to move painlessly.
The take-home message of this case is not that
MWM should be used for de Quervains
tensoynovitis, but rather that a thorough assessment
for a carpal instability is necessary when trauma to
the wrist is followed by joint and tendon pain and
impairment. As well, MWM appears to be a reasonable clinical technique for acute relief from pain and
impairment due to a carpal instability. Therefore, in

CASE

(eg, radioscaphocapitate ligament) as the proximal

row is moved radially. In patients with midcarpal instability, the classic maneuvers that relocate the
triquetrum on the appropriate helical-shaped hamate
facet, the source of midcarpal instability, are analogous to the MWM maneuver described in this case.
These carpal-relocating, ligamentous-tensioning maneuvers instantaneously eliminate the instabilityinduced global wrist pain associated with wrist movement, which in this case, is where the greatest
relative improvement in range of motion occurred.
These maneuvers include a radial glide of the proximal row and/or a dorsally directed boost to the
triquetrum onto the hamate.2,7,9 Therefore, I remain
skeptical that a positional fault of the capitate was
the primary source of the carpal instability. The
capitate is relatively fixed with its distal row partner,
the hamate, and it would take an extremely high
force application (not apparent in this case) to dislodge it and disrupt its ligamentous constraints.1
When the mechanism of injury, however, does not
produce a carpal dislocation, but rather, stabilizing
ligaments are sprained or torn, a carpal instability
is possible.
The author hypothesizes that the positional irregularity of the capitate found on the involved wrist
reflects a specific carpal sprain. However, to my
knowledge, no carpal instability pattern (besides a
frank volar dislocation) results in an isolated capitate
malalignment. To Ms. Backstroms credit, she acknowledges the possibility of an intercalated segment
instability, carpal instability dissociative (CID) of the
lunate, but no clinical or specialized imaging inquiry
was made. Again however, the case suggests a
midcarpal instability of the nondissociative (CIND)
type (because no instability pattern was noted on the
initial radiograph) may have been present. Coupled
with the positive response to the MWM, the patients
recalcitrant (even 4 months after injury), yet infrequent, wrist pain is a classic complaint of those with
a CIND wrist.2,3,9 It also suggests the presence of an
unresolved (yet minimally symptomatic) wrist instability, despite the noted resolution of the positional
malalignment of the capitate.
The likelihood that a tendon irritation was secondary to a midcarpal wrist instability is high. The fact
that the pain and impairment on the radial wrist was
treated successfully with a radial glide of the proximal row is not surprising. As well, the limited accessory wrist and thumb motion, due to a joint dysfunction, responded predictably well to a manual gliding
technique. The description of intermittent wrist
symptoms at the 4-month follow-up is consistent with
a CIND wrist. The capitate malalignment noted in
the evaluation, however, still remains problematic as
it is unclear how, or if, this was in any way causally
related to the symptoms. My intuition is that the
presence or absence of this subtle malalignment of

this case, the MWM may be more appropriately

termed SWM (Stabilization With Movement), as it
likely provided the stability necessary for normal
carpal joint and thumb tendon function.
Paul LaStayo, PhD, PT, CHT
Northern Arizona University
Flagstaff, AZ

REFERENCES
1. Berger RA. The anatomy of the ligaments of the wrist
and distal radioulnar joints. Clin Orthop. 2001:383:32
40.
2. Brown DE, Lichtman DM. Midcarpal instability. Hand
Clin. 1987;3:135140.

3. Cooney WP, Dobyns JH, Linscheid RL. Arthroscopy of

the wrist: anatomy and classification of carpal instability. Arthroscopy. 1990;6:133140.
4. Moore JS. De Quervains tenosynovitis. Stenosing
tenosynovitis of the first dorsal compartment. J Occup
Environ Med. 1997;39:9901002.
5. Mulligan B. Manual Therapy: NAGS, SNAGS,
MWMS etc. Wellington, New Zealand: Plane View
Services; 1995.
6. Recht MP, Burk DL Jr, Dalinka MK. Radiology of wrist
and hand injuries in athletes. Clin Sports Med.
1987;6:811828.
7. Skirvin T. Clinical examination of the wrist. J Hand
Ther. 1996;9:96107.
8. van der Aa JP, Noorda RJ, van Royen BJ. Symptomatic
carpal boss. Orthopedics. 1999;22:703704.
9. Wright TW, Dobyns JH. Carpal instability nondissociative. In: Cooney WP, Linscheid RL, Dobyns JH; eds. The
Wrist: Diagnosis and Operative Treatment. St. Louis,
MO: Mosby Year-Book; 1998:550.

Author Response
First, I need to thank my patient, who was enthusiastic and willing to try something new. Her wrist injury has challenged me and raised many questions
and ideas. Second, I need to thank Dr. Paul LaStayo
for bringing up additional concepts, questions, and
pathways of thought. I appreciate his expert and
thought-provoking commentary. My hope is that
through this response, I can clarify the points on
which we disagree, and further explain my own
thought processes.
While Dr. LaStayo and I have developed differing
rationales for what may be the causal factors for the
symptoms described in this case, and for the mechanism by which Mobilization with Movement (MWM)
provided relief, we actually agree that the
tenosynovitis is secondary to a wrist joint problem. I
believe that this point is one of the most intriguing
aspects of the case report. It encourages the clinician
executing an examination, and subsequent intervention, to move beyond the inflamed tendons alone to
the joints these tendons cross.
The finding of the capitate malalignment (reliable
or unreliable as it is) and its treatment through manipulation during the patients first visit did not hold
a tremendous amount of significance for my assessment of this patients condition at the time. It was
during the write-up of this manuscript that I began
to consider the possibility of a carpal instability.
Therefore, further diagnostics in terms of special
tests and radiographs were not done. I did not intend to imply that the capitate itself was the definitive source of instability, only that it might represent
an underlying instability, such as a Dorsal

Intercalculated Segmental Instability (DISI),3 where

the lunate assumes a dorsally directed position and
the capitate is relatively volar. I did not consider a
midcarpal instability nondissociative (CIND) type of
instability, as suggested by Dr. LaStayo, and I am
grateful for his thoughts and education regarding
this logical possibility. The concept of moving the
triquetrum into a stable position to facilitate normal,
pain-free motion is a very feasible explanation for
the success of the MWM technique in this patient. In
any case, I believe that de Quervains tenosynovitis as
a result of carpal instability may be a possibility and
warrants consideration during examination, preferably through specific examination techniques and
radiographs, as Dr. LaStayo suggested. The best answer to this question, of course, lies in a research
study that examines the correlation of wrist instability
with de Quervains tenosynovitis. Case studies merely
serve as a jumping-off point for continued research
with larger numbers of patients.
It appears that the mechanism by which the use of
MWM, along with other conventional interventions,
was successful in this case of de Quervains
tenosynovitis may be attributed to several, yet unproven, theories. Dr. LaStayos viable suggestion is
that the mechanism is one of stabilization of a
midcarpal laxity. Because of a CIND instability, the
hamate and triquetrum are not positioned correctly
and are therefore unable to move in a physiologically
normal manner. The result is pain and limited motion. This hypothesis of midcarpal instability is not in
conflict with the basic MWM premise that a malalignment exists (in this case, possibly due to an instabil-

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maneuver used in this case, radial glide, may have

served to correct this abnormal position and resultant increased angulation. In the context of a case
report, I can in no way state that this is unquestionably the mechanism by which MWM aided the patient described in this report, but I believe it is an
additional hypothesis that is worth investigating.
If not a silver bullet for de Quervains
tenosynovitis, MWM can certainly be considered a
pellet that may just hit the mark.
Karen Maloney Backstrom, PT, MS, OCS
University of Colorado Health Sciences Center
Denver, CO

REFERENCES
1. Edmond S. Manipulation and Mobilization: Extremity
and Spinal Techniques. St Louis, MO: Mosby; 1993.
2. Muckart RD. Stenosing tendovaginitis of the abductor
pollicis brevis at the radial styloid (de Quervains
disease). Clin Orthop. 1964;33:201208.
3. Watson KH, Black DM. Instabilities of the wrist. Hand
Clin. 1987;3:103111.

CASE

ity) that can be corrected through a gliding technique and superimposed pain-free movement.
The contribution of a corrected carpal position on
the tendons of the extensor pollicis brevis (EPB) and
abductor pollicis longus (APL) provides an area of
disagreement between Dr. LaStayo and me. Muckart2
has proposed that the etiology behind de Quervains
tenosynovitis involves the anatomy of the EPB and
APL tendons, which are angled acutely (105) at the
distal edge of the first dorsal tunnel. Muckart2 suggested that in response to the force of the angulated
tendons, the retinaculum thickens and inflammation
results. The larger the degree of angulation, the
worse the irritating effects on the retinaculum. This
angulation is greatest, thus most troublesome, when
the wrist is in a position of radial deviation.
Arthrokinematically, radial deviation of the wrist involves an ulnar glide of the carpals.1 My hypothesis is
that the imposition of a radial glide may be able to
counteract the forces of radial deviation (ulnar
glide) on the first dorsal tunnel and thereby lessen
this irritating angle. It is conceivable that injury to
the wrist may result in a relatively ulnar position of
the carpals, possibly due to instability, which in turn
would increase the tendon angulation. The MWM

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