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

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Intervention in a Patient With Complicated

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De Quervain’s Tenosynovitis: A Case Report

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Karen Maloney Backstrom, PT, MS, OCS1
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Name _______________________________________________________________________________________________
Study Design:
Address Case study.
_____________________________________________________________________________________________ tunnel. A shallow groove in the
Objectives: To describe the use of conventional physical therapy interventions together with radius makes up the floor, and the
Mobilization
Address With Movement (MWM) techniques in the treatment of an individual with a
_____________________________________________________________________________________________ dorsal retinaculum of the wrist
complicated scenario of de Quervain’s tenosynovitis. forms the ceiling, of this unyield-
CityBackground: The patient was a 61-year-old woman who presented with
_______________________________State/Province signs and symptoms
__________________Zip/Postal Code _____________________
ing fibro-osseous tunnel.14 As the
consistent with de Quervain’s tenosynovitis of the right hand. Range limitations in all motions of
Phone _____________________________Fax____________________________Email tendons exit the first dorsal tun-
_____________________________
the right wrist and first carpometacarpal joint complicated her presentation.
Methods and Measures: Physical therapy included conventional intervention with superficial heat,
nel, they angulate acutely and
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ice, iontophoresis, and transverse friction massage directed to the first dorsal tunnel. Conventional
reach
No their insertions on the first
joint mobilization techniques addressed the motion limitations of the first carpometacarpal, metacarpal and proximal pha-
radiocarpal, and midcarpal joints. In addition, MWM techniques were utilized to promote lanx.3 The greater incidence of de
pain-free wrist and thumb mobility. The specific MWM techniques used with this patient involved Quervain’s tenosynovitis in women
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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

Check enclosedbones.(made payable to the JOSPT). that this angulation against the
Results: The described treatment regime, which involved conventional physical therapy retinacular roof of the dorsal tun-

Credit
interventions, along with
Card (circle MWM,MasterCard
one) aided in the complete
VISAresolution of this patient’s
American Expressimpairments nel is greater in females.3
and functional limitations. Muckart16 described the mecha-
Conclusion: The combination of conventional physical agents, exercise, and manual therapy, and
Card Number ___________________________________Expiration Date _________________________________________ nism by which this strong angula-
the less conventional MWM techniques, proved successful with this patient. MWM involving the
correction
tion results in a tearing stress to
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.
Because subtle changes in joint alignment may contribute to painful syndromes in the tendon stress is greatest when radial devia-
complexes that cross a malaligned joint, use of MWM as a treatment technique warrants tion of the wrist is combined with
To order
continued research. J Orthop Sports Phys Ther 2002;32:86–97. call, fax, email or mail to: a gripping motion of the thumb.16
Key Words: joint alignment, 1111 Norththerapy,
manual Fairfax Street, Suite 100, Alexandria, VA 22314-1436
tendinitis People who use their thumbs in
repetitive pinching, wringing, lift-
Phone 877-766-3450 • Fax 703-836-2210 • Email: subscriptions@jospt.org
ing, grasping, or extension activi-
ties of the wrist and hand are sus-
Thank you for subscribing! ceptible to inflammation and

D
e Quervain’s 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 bik- Surgical evidence implicates in-
ers.10,12,26 De Quervain’s tenosynovitis involves inflamma- flammation 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 Quervain’s
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, Mobilization With Movement
CO.
Send correspondence to Karen Maloney Backstrom, Physical Therapy Program, UCHSC, 4200 East Ninth (MWM) is an intervention tech-
Avenue Box C-244, Denver, CO 80262. E-mail: Karen.Backstrom@UCHSC.edu nique developed by Brian Mul-

86 Journal of Orthopaedic & Sports Physical Therapy


FIGURE 1. The region of the first dorsal tunnel.
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, congru-
ent position, but are subtly malaligned: ‘‘These
[faults] are not readily palpable or visible on
X-ray . . .’’17 The proposed mechanism for the effec-
tiveness of this intervention is the restoration of nor-
mal, pain-free, fluid movement through the correc-
tion of the joint malalignment. Mulligan17 suggests
that positional faults can occur in all extremity joints.
In comparison to other joint mobilization techniques
that cross the joint. MWM is used as part of a com-
plete 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 Quervain’s tenosynovitis. This case
report also serves as an initial step in a research pro-
cess 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 influ-
ence tendon disorders?
METHODS AND CASE DESCRIPTION
Interview Data
The patient was a 61-year-old epidemiologist re-
ferred to physical therapy with the diagnosis of de
Quervain’s tenosynovitis in the right wrist. She attrib-

CASE
used by physical therapists, MWM emphasizes the
uted her current symptoms of radial wrist pain and
restoration of normal joint alignment to allow for
stiffness to an injury that occurred 2 months prior to
normal arthrokinematics, rather than the stretching
the first physical therapy visit, when she jammed her
of tightened tissues to restore normal arthrokinemat-
hand against a table. The patient reported that the

STUDY
ics.
force went through the web space of her right, domi-
MWM techniques involve the sustained correction
nant hand and was followed by noticeable bruising
of subtle joint malalignment, which is accomplished
on the radial side of the wrist and hand. She did not
by passive mobilization. Active movement is then su-
seek medical intervention at the time. The symptoms
perimposed on the corrected joint position. The ac-
of pain with activities involving her thumb, stiffness,
tive movement chosen is one that previously pro-
and limited function, which caused her to seek physi-
duced pain, but when superimposed on a corrected
cal therapy, began 3 weeks after this reported injury.
joint position, occurs without pain.17–19
Radiographs taken 6 weeks following the initial in-
Determination of this technique’s effectiveness
jury ruled out scaphoid and other wrist fractures.
with a given patient requires some clinical trial and
She came to physical therapy 2 months after the in-
error. The decision to use a particular joint glide is
jury because pain was limiting her activities of daily
determined by the patient’s response. If the involved
living and she could no longer ignore the symptoms.
joint demonstrates an immediate increase in range of
She reported significant pain with grooming activities
motion, and there is no pain while the joint position
such as brushing her teeth, fastening her bra strap,
is maintained, this position is the one used for inter-
and washing. She also had difficulty lifting even
vention.17 Often, the selected joint position requires
small amounts of weight. Putting weight through the
small adjustments by the clinician to achieve pain-
right wrist during activities such as pushing up from
free movement, on which success of the technique
a chair was painful. She could no longer work in her
hinges.17–21,28
garden. Although she did not initially relate her pain
Once the most effective joint position is deter-
to the time she spent on the computer, she later
mined and secured, repetitive movement of the in-
noted increased pain after using the computer for 2
volved joint is used as intervention. Although the
to 3 hours. She described herself as a ‘‘binge’’ key-
specific technique used in this case study has not
board user, typing up to 14 hours on some days. The
been described in the literature, Mulligan,17 and
patient was using ibuprofen on a regular basis for
Vicenzino and Wright,28 have used similar tech-
pain relief related to this injury.
niques, and describe positive results for other
musculotendinous conditions, such as ‘‘tennis elbow’’
and rotator cuff tendinitis. Correcting minute joint
Physical Examination
malalignments through the use of MWM may posi- Pain Description The patient complained of stiff-
tively affect the function of a joint and the tissues ness and sharp pain along the radial side of her

J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002 87

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 involv-
ing 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 moder-
ately slumped sitting posture, which included a for-
ward head, rounded shoulders, and a slight increase
of high thoracic kyphosis. Swelling was evident in the
right wrist. Girth measurements revealed a 1-cm dif-
ference 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. Mea-
surements 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 acces-
sory 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
TABLE 1. Pre- and postintervention goniometric measurements.
Joint Motion
Wrist flexion
Wrist extension
Wrist ulnar deviation
Wrist radial deviation
1st carpometacarpal palmar abduction
1st carpometacarpal radial abduction
88
left. The therapist determined this by bilaterally pal-
pating 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 patient’s 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 adduc-
tion 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 overpres-
sure of the cervical spine. This assessment was used
to screen for referred pain from the C5–C6 nerve
roots. To rule out entrapment of the superficial ra-
dial 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 Quervain’s tenosynovitis. These
included pain, swelling and tenderness in the area of
the first dorsal tunnel, pain with isometric activation
of the EPL and APB (‘‘hitchhiker’s 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.
Range of Motion
Preintervention Left Preintervention Right Postintervention Right
94° 86° 108°
94° 52° 90°
46° 33° 48°
22° 20° 30°
60° 48° 58°
60° 58° 62°
J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002
 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 sig-
nificance of this finding is questionable, one hypoth-
esis is that the initial trauma experienced by the pa-
tient resulted in a carpal instability or malalignment,
which in turn contributed to the tenosynovitis.
This patient with de Quervain’s tenosynovitis was
made unique by the complications of a carpal posi-
tional 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 thera-
pist also made this case remarkable.
The conventional, conservative intervention for de
Quervain’s tenosynovitis commonly involves a
corticosteroid injection followed by immobilization
and splinting for 6 weeks. Though traditional anti-
inflammatory measures seemed appropriate as ele-
ments 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 mobil-
ity and normal joint alignment would decrease the
strain on the involved tendons, thus augment resolu-
tion 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.
Intervention
The patient received 12 intervention sessions over
the course of 2 months. A summary of the patient’s
reported pain level, functional status, impairment
status, and intervention is given in Table 2.
The patient came to the first session with an elas-
tic 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 through-
out 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 neu-
tral 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 ma-
nipulation was used only during the initial interven-
tion 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-
J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002
ited by pain. To find the position that best allowed
for pain-free motion, the therapist had to experi-
ment 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 ini-
tial 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 patient’s difficulties with weight bearing through
the wrist, the identical radial carpal glide was main-
tained as the patient performed progressive weight
bearing through the right upper extremity. With the
CASE
addition of the radial carpal glide, the patient was
able to bear weight without pain.
Although the patient’s passive range of motion
and accessory motion improved, end-range thumb
STUDY
radial abduction was painful even with the main-
tained radial carpal glide. Through continued direc-
tional modification of the imposed glide, it was
found that a sustained ulnar glide of the trapezium
and trapezoid allowed pain-free CMC radial abduc-
tion. 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 ses-
sion, 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 inter-
vention used, and the chosen techniques resulted in
immediate relief of the painful motion (0/10), as
verbally reported by the patient. This pain-relief phe-
nomenon 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 pres-
sure toward radial deviation (Figure 2).
The MWM and elastomere inserts served as ad-
juncts 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 com-
pletely passive, determined by examination of acces-
89
TABLE 2. Overview of pain range, functional status, impairment status, and interventions.
Daily Pain
Session Range Functional Status Impairment Status Treatment Intervention
1 0/10–6/10 Difficulty • Pain with all end-range thumb motions • Manipulation of the capitate
• Brushing teeth • Pain with wrist flexion, extension • Mobilization With Movement (MWM)
• Fastening bra • Pain with forearm pronation, • Radial glide of the carpals combined
• Washing supination with active motion of the thumb and
• Lifting • Tenderness over first dorsal tunnel progressive weight bearing through the
• Gardening • 1-cm swelling at wrist wrist
• Weight bearing • Pain with isometric resistive thumb • Conventional joint mobilization: carpals
through the right wrist radial abduction and first CMC
• Positive Finklestein test • Iontophoresis
• Decreased accessory motion in all • Continuation of the elastic support that
joints of wrist and first the patient brought to the session
carpometacarpal (CMC) • Elastomere volar capitate button added
• Volar subluxation of the capitate to elastic support
• Range-of-motion limitations for all
motions of the wrist and first CMC
2 0/10–4/10 • Able to fasten bra • All impairments remain with the • MWM
without difficulty exception of the capitate subluxation • 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
3 0/10–4/10 • Able to brush teeth • All impairments remain but are • As on session 2
• Able to bear weight diminished
• Increased ease of
motion
4 0/10–3/10 • Able to lift • Pain with wrist flexion, extension • As on session 2
• 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
5 0/10–2.5/10 • Able to type 14 hours • As on session 4 • As on session 2
without symptoms
6 0/10–2.5/10 • Patient reports • Occasional pain with wrist and thumb • MWM
increased fluidity of motions • Instruction in self-MWM; HEP
movement • Tenderness over first dorsal tunnel • Conventional joint mobilization to first
• Slight swelling at wrist CMC
• Positive Finklestein test (at end range • Instruction in concentric and eccentric
only) tendon-gliding exercises for the EPB and
• Decreased accessory motion in first APL; HEP
CMC • Iontophoresis
• Range-of-motion limitation (30°) into • Elastomere horseshoe added to elastic
CMC radial abduction 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)
Daily Pain
Session Range
7 Not recorded
8 Not recorded
9 0/10–1.5/10
Functional Status Impairment Status
• 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)
• 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)
• Occasional pain with wrist and thumb
motions
• Slight swelling at wrist
Treatment Intervention
• As on session 6
• Addition of instruction in active
assistive exercise for the APL; HEP
• 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
• MWM
• Continuation of exercise program
• Iontophoresis

CASE
10 0/10–1.5/10 • Occasional pain with wrist and thumb • MWM
motions • Continuation of exercise program
• Slight swelling at wrist • Iontophoresis
• Weak APL (4/5) • Trial of prefabricated thumb spica (2
weeks)

STUDY
11 0/10–1.5/10 • Gardening without • Occasional pain with wrist and thumb • MWM
pain motions • Continuation of exercise program
• Slight increased girth at wrist • Iontophoresis
12 0/10–1/10 • Infrequent episodes of • Slight increased girth at wrist • Review of HEP
wrist pain • Discharge

FIGURE 2. Elastomere inserts. FIGURE 3. Mobilization With Movement—Active thumb motion

performed with superimposed radial glide of the proximal carpal
row.

J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002 91

sory motion, and intended to stretch tissues that may
be preventing normal arthrokinematics. The treat-
ment program also included eccentric and concen-
tric 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 move-
ment 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 pa-
tient’s 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 exer-
cises, 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, pro-
vided 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 patient’s progress plateaued around session
10. She continued to have minimal pain (0–1.5/10),
particularly with those activities that required grip-
ping combined with supination. It was hypothesized
that a short period of immobilization in a splint
would eliminate the last painful limitations. The pa-
tient at this point had regained full motion of her
wrist and thumb; therefore, immobilization would
not worsen her previous complication of range limi-
tations. The patient was given a prefabricated thumb
spica splint, which held her hand in the resting posi-
tion. This did not prove to be of benefit and was dis-
continued.
RESULTS
The reduction in the patient’s reported pain level
was initially rapid. Using the pain scale value re-
ported 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-
92
FIGURE 4. Mobilization With Movement—Progressive weight bear-
ing performed with self-imposed relative radial glide of the proximal
carpal row.
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 0–1/10 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 Quervain’s
tenosynovitis. She displayed a negative Finklestein
test, painless resistive testing of the EPB and APL, no
tenderness over the first dorsal tunnel, and full pain-
less 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, gar-
dening, and typing on a keyboard for prolonged pe-
riods of time at the conclusion of the 2-month physi-
cal 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 both-
ered 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 intermit-
tent in nature and did not interfere with her func-
tion. At 1 year post-discharge, the patient, who had
continued in the same lifestyle and line of work, re-
ported that she was experiencing no incidences of
wrist and thumb pain or limitations in function what-
soever.
J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002
DISCUSSION
This patient presented with de Quervain’s
tenosynovitis, which was complicated by wrist stiff-
ness, first CMC joint stiffness, and a carpal positional
abnormality. I hypothesized that the positional ir-
regularity of the capitate found in the involved wrist
reflected a specific carpal sprain that occurred dur-
ing the initial trauma to the hand. A subtle malalign-
ment 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, specifi-
cally the EPB and APL, causing irritation of this ten-
don complex over time. The fact that the symptoms
for de Quervain’s tenosynovitis did not appear until
3 weeks after the initial trauma also made this hy-
pothesis plausible. MWM was one of several interven-
tion methods employed in this case study to address
the problem of carpal malalignment and pain stem-
ming from the first dorsal tunnel and tendon com-
plex. 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 re-
search examining the correlation of capitate posi-
tional abnormalities and/or carpal instabilities with
de Quervain’s tenosynovitis.
Restoration of the patient’s 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 com-
bined result of all the other interventions used with
this patient, some of which are of proven ben-
efit.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
Quervain’s tenosynovitis. During each intervention
session, MWM involving a sustained radial glide of
the proximal row of carpal bones resulted in in-
creased 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 associ-
ated with a tenosynovitis. The correlation between
joint function and alignment and musculotendinous
pathology is not a new concept for physical thera-
pists. The stressful effects of excessive midfoot prona-
tion on the muscles and tendons in the lower ex-
tremity 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-
J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002
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 hy-
pothesized that osseous positional faults can contrib-
ute 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?
CONCLUSION
A patient with de Quervain’s tenosynovitis compli-
cated by wrist and first CMC stiffness and a carpal
positional abnormality was successfully treated
through the use of traditional physical therapy inter-
ventions, including physical agents, exercise, trans-
verse friction massage, and standard joint mobiliza-
tion, coupled with a more novel intervention, MWM
techniques. MWM proved to be an effective adjunct
to the treatment of a complicated de Quervain’s
CASE
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
STUDY
Quervain’s 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 draw-
ings; Cheryl Riegger-Krugh, Carolyn Heriza, and
Arnold Levinson for their careful review of this
manuscript; and the late Jerry Krugh for his photog-
raphy.
REFERENCES
1. Anderson M, Tichenor CJ. A patient with de Quervain’s
tenosynovitis: a case report using an Australian ap-
proach 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;4:103–108.
3. Bunnell S. Surgery of the Hand. Philadelphia, PA: JB
Lippincott Company; 1970.
4. Chamberlain GJ. Cyriax’s friction massage: a review. J
Orthop Sports Phys Ther. 1982;4:16–22.
5. Cyriax J. Illustrated Manual of Orthopaedic Medicine.
London: Butterworths; 1983.
93
 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;12:509–540.
8. Greene WB, Heckman JD, eds. The Clinical Measure-
ment 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;4:109–112.
10. Harvey FJ, Harvey PM, Horsley MW. De Quervain’s
disease: surgical or nonsurgical treatment. J Hand Surg
Am. 1990;15:83–87.
11. Jensen MP, Karoly P, Braver S. The measurement of
clinical pain intensity: a comparison of six methods.
Pain. 1986;27:117–126.
12. Kiefhaber TR, Stern PJ. Upper extremity tendinitis and
overuse syndromes in the athlete. Clin Sports Med.
1992;11:39–47.
13. Kirkpatrick W, Lisser S. Soft tissue conditions: trigger
fingers and de Quervain’s 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;64:475–487.
15. Messier SP, Pittala KA. Etiologic factors associated with
selected running injuries. Med Sci Sports Exerc.
1988;20:501–505.
16. Muckart RD. Stenosing tendovaginitis of abductor pol-
licis longus and extensor pollicis brevis at the radial
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 predict-
ably identify who might benefit from the treatment
nor determine the validity of the treatment. There-
fore, my commentary echoes the author’s 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 appar-
ent case of de Quervain’s tenosynovitis.
In this case, the MWM technique, a radial glide of
the proximal row of carpals, provided immediate re-
lief in this atypical patient with de Quervain’s
tenosynovitis. This is an amazing feat as the conserva-
tive management for de Quervain’s 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-
94
styloid (de Quervain’s disease). Clin Orthop.
1964;33:201–208.
17. Mulligan B. Manual Therapy: ‘‘NAGS,’’ ‘‘SNAGS,’’
‘‘MWMS,’’ etc. Wellington, New Zealand: Plane View
Services; 1995.
18. Mulligan B. Mobilisations with movement (MWMs). J
Manual Manipulative Ther. 1993;1:154–156.
19. Mulligan B. Mobilization with movement (MWM) for
the hip joint to restore internal rotation and flexion. J
Manual Manipulative Ther. 1996;4:35–38.
20. Mulligan B. Spinal mobilisations with leg movement. J
Manual Manipulative Ther. 1995;3:25–27.
21. Mulligan B. Spinal mobilizations with arm movement. J
Manual Manipulative Ther. 1994;2:75–77.
22. Neer CS. Impingement lesions. Clin Orthop.
1983;173:70–74.
23. Plancher KD, Perterson RK, Steinchen JB. Compressive
neuropathies and tendinopathies in the athletic elbow
and wrist. Clin Sports Med. 1996;15:331–357.
24. Rivenburgh D. Physical modalities in the treatment
of tendon injuries. Clin Sports Med. 1992;11:
645–659.
25. Sailer SM, Lewis SB. Rehabilitation and splinting of
common upper extremity injuries in athletes. Clin
Sports Med. 1995;14:411–446.
26. Shea K, Shumsky I, Shea O. Shifting into wrist pain.
Phys Sportsmed. 1991;19: 59–63.
27. Skirven T. Clinical examination of the wrist. J Hand
Ther. 1996;9:96–107.
28. Vicenzino B, Wright A. Effects of a novel manipulative
physiotherapy technique on tennis elbow: A single case
study. J Manual Ther. 1995;1:30–35.
rated into the management of musculoskeletal im-
pairments.
It is apparent—and I believe Ms. Backstrom and I
agree on this—that the first dorsal compartment ten-
dons, abductor pollicis longus (APL), and the exten-
sor pollicis brevis (EPB) were irritated. We would
also agree that what makes this case of de Quervain’s
unusual is that the EPB and APL were irritated sec-
ondary 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 prob-
lem primarily and a thumb tendon problem second-
arily. 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 stabi-
lizes the ulnar carpus (specifically, the triquetrum)
and tightens the radially based extrinsic ligaments
J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002
(eg, radioscaphocapitate ligament) as the proximal
row is moved radially. In patients with midcarpal in-
stability, the classic maneuvers that ‘‘relocate’’ the
triquetrum on the appropriate helical-shaped hamate
facet, the source of midcarpal instability, are analo-
gous to the MWM maneuver described in this case.
These carpal-relocating, ligamentous-tensioning ma-
neuvers instantaneously eliminate the instability-
induced global wrist pain associated with wrist move-
ment, which in this case, is where the greatest
relative improvement in range of motion occurred.
These maneuvers include a radial glide of the proxi-
mal 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 dis-
lodge 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 ir-
regularity 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. Backstrom’s credit, she ac-
knowledges 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 patient’s
recalcitrant (even 4 months after injury), yet infre-
quent, 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 instabil-
ity, despite the noted resolution of the ‘‘positional
malalignment of the capitate.’’
The likelihood that a tendon irritation was second-
ary 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 proxi-
mal row is not surprising. As well, the limited acces-
sory wrist and thumb motion, due to a joint dysfunc-
tion, 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
J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002
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 proxi-
mal 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
CASE
Quervain’s? Absolutely not. Is the MWM radial
glide a simple maneuver to use for diagnostic and
therapeutic reasons in suspected midcarpal instabil-
ity? Absolutely yes. In this case, it is apparent that
STUDY
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 ad-
dressed the ‘‘negatively affected line of pull or func-
tion of the tendons (APL and EPB).’’ In fact, it
seems that a radial glide of the carpus would ad-
versely create tension on the irritated APL and EPB,
hence, increase pain and impairment (which is an-
other 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 sce-
nario, 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 dysfunc-
tion, and allowed the thumb and wrist to move pain-
lessly.
The take-home message of this case is not that
MWM should be used for de Quervain’s
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 reason-
able clinical technique for acute relief from pain and
impairment due to a carpal instability. Therefore, in
95
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;3:135–140.
Author Response
First, I need to thank my patient, who was enthusi-
astic and willing to try something new. Her wrist in-
jury 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 mecha-
nism 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 interven-
tion, 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 ma-
nipulation during the patient’s first visit did not hold
a tremendous amount of significance for my assess-
ment 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 in-
tend to imply that the capitate itself was the defini-
tive source of instability, only that it might represent
an underlying instability, such as a Dorsal
96
3. Cooney WP, Dobyns JH, Linscheid RL. Arthroscopy of
the wrist: anatomy and classification of carpal instabil-
ity. Arthroscopy. 1990;6:133–140.
4. Moore JS. De Quervain’s tenosynovitis. Stenosing
tenosynovitis of the first dorsal compartment. J Occup
Environ Med. 1997;39:990–1002.
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;6:811–828.
7. Skirvin T. Clinical examination of the wrist. J Hand
Ther. 1996;9:96–107.
8. van der Aa JP, Noorda RJ, van Royen BJ. Symptomatic
carpal boss. Orthopedics. 1999;22:703–704.
9. Wright TW, Dobyns JH. Carpal instability nondissocia-
tive. In: Cooney WP, Linscheid RL, Dobyns JH; eds. The
Wrist: Diagnosis and Operative Treatment. St. Louis,
MO: Mosby Year-Book; 1998:550.
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 Quervain’s tenosynovitis as
a result of carpal instability may be a possibility and
warrants consideration during examination, prefer-
ably through specific examination techniques and
radiographs, as Dr. LaStayo suggested. The best an-
swer to this question, of course, lies in a research
study that examines the correlation of wrist instability
with de Quervain’s 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 Quervain’s
tenosynovitis may be attributed to several, yet un-
proven, theories. Dr. LaStayo’s 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 mo-
tion. This hypothesis of midcarpal instability is not in
conflict with the basic MWM premise that a malalign-
ment exists (in this case, possibly due to an instabil-
J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002
ity) that can be corrected through a gliding tech-
nique 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 Quervain’s
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 sug-
gested 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 in-
volves 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
J Orthop Sports Phys Ther • Volume 32 • Number 3 • March 2002
maneuver used in this case, radial glide, may have
served to correct this abnormal position and result-
ant increased angulation. In the context of a case
report, I can in no way state that this is unquestion-
ably the mechanism by which MWM aided the pa-
tient described in this report, but I believe it is an
additional hypothesis that is worth investigating.
If not a silver bullet for de Quervain’s
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 Quervain’s
disease). Clin Orthop. 1964;33:201–208.
3. Watson KH, Black DM. Instabilities of the wrist. Hand
Clin. 1987;3:103–111.
CASE
STUDY
97