De Quervain's

tendinosis
Pathology
- Stenosing tenosynovitis of first dorsal
compartment of wrist

- due to inflammation, thickening,

stenosis of synovial sheath

- 2 tendons concerned: extensor pollicis

brevis and abductor pollicis longus
Causes
◦ tenosynovitis (inflammation of fibrous tendon sheath) over APL and EPB tendon

◦ prolonged repetitive and overuse of thumb

◦ thumb posture in sustained hyperabduction (common in filing clerk, golfers,

knitters)

◦ repeated forceful thumb pressing

◦ always involved in twisting objects, taking heavy objects

Risk factors
◦ Age: adults between 30 and 50 are most likely to get
◦ Gender: women are 8 to 10 times more likely to get
◦ Motherhood:
- pregnancy → hormone change: affect the laxity of the joint and ligament,
increase the risk of stretch injury
- Holding baby with excessive thumb abduction or out stretch wrist may
increase the risk of developing the disease
◦ Motions: overuse of thumb and wrist during household tasks such as washing
clothes & twisting towels or prolonged use of smartphone or tablet with repeated
forceful thumb pressing or gripping are also in high risk
Clinical presentation
◦ Pain at radial side of wrist, may radiate to thumb or forearm
- aggravated by repetitive lifting, gripping, or twisting motions of the hand
◦ Swelling in the anatomical snuff box
◦ Tenderness over radial styloid process
◦ Decreased CMC abduction ROM of the 1st digit
◦ Palpable thickening of the extensor sheaths of the 1st dorsal compartment
◦ Decrease in wrist strength, power, pinch grip
◦ Severe case: prominent radial styloid process, numbness of thumb and index fingers
◦ Gradual onset
Clinical assessment
Interview for history
● Overuse injury vs acute trauma
● Prior history of symptoms
● Repetitive movements of the upper extremity with work or activities of daily
living (ADL)
● Pain level: localized pain over the base of the thumb and dorsolateral aspect
of the wrist near the radial styloid process, resting pain, exertion pain
● Hand dominance
● Pregnant or currently in the post-partum stage

Physical examination:
● Finkelstein test
● Stress test
Provocative test
Finkelstein's test
- Examiner grasps the thumb and ulnar
deviates the hand sharply
- A positive test is indicated by sharp,
local pain over the radial aspect of the
wrist
Provocative test
Eichhoff's test
- the examiner grasp and ulnar
deviate the hand when the person
has their thumb held within their fist.
- positive result: sharp pain occurs
along the distal radius
- false positive results, while a
Finkelstein's test performed by a
skilled practitioner is unlikely to
produce a false positive.
Provocative test:
Wrist hyperflexion and abduction of the thumb (WHAT) test
- the wrist is hyperflexed and the thumb abducted in full MP and IP extension, resisted against the
therapist’s index finger (increasing abduction resistance to thumb)

- positive result: unable to maintain force against examiner

- high sensitivity (99%) and low specificity (24%)

- active testing by shearing the tendons of the first

extensor compartment against the palmar distal

edge of the pulley

Differential diagnosis
◦ Osteoarthritis of the first carpo-metacarpal
joint

- positive grind test: by axial loading, push

and rotate thumb metacarpal bone,
grinding may be felt within the joint,
production of pain and crepitus
Differential diagnosis
◦ Intersection syndrome:
- inflammation at the intersection of the
muscle bellies of the abductor pollicis longus
and extensor pollicis brevis cross over the
extensor carpi radialis longus and the
extensor carpi radialis brevis
- mechanism of injury: repetitive resisted
extension, as with rowing, weight lifting, or
pulling
- pain locate about 4 cm from wrist joint
Differential diagnosis
◦ Wartenberg’s Syndrome:
- compression of superficial branch of radial nerve (only sensory manifestations and no motor
deficits)
- pain is located 8 cm proximal to the radial styloid (Wartenberg's point between ECRL,
brachioradialis)
- symptoms: numbness, tingling, and paresthesia of the posterior aspect of the thumb
- may give positive Tinel’s sign
- Finkelstein’s test may also be misleadingly positive (thumb does not have to be flexed to elicit a
positive test)
- difference between de Quervain’s tenosynovitis: patients with SRN compression tend to have
symptoms at rest, independent of the position of the wrist and thumb
- SRN compression and de Quervain’s tenosynovitis may present simultaneously
 Treatment -- Medication
⇒ Corticosteroid injection into the sheath of the first dorsal compartment
◦ Reduces tendon thickening and inflammation
◦ A dose of 0.5 mL of 1% plain lidocaine and 0.5 mL of a long-acting corticosteroid
preparation can be injected either sequentially or simultaneously.
◦ Complications: postinjection flare, infection, atrophy of subcutaneous fat, local
depigmentation, and tendon rupture
- Atrophy → hollowing-out of the skin, loss of normal pigmentation
(atrophic changes generally resolve > 6 months, presence still disturbing)

⇒ Anti-inflammatory medication (NSAIDS)

◦ reduce pain and inflammation
◦ e.g: ibuprofen and naproxen

⇒ Prolotherapy under ultrasound guidance:

◦ regenerative injection therapy: introduces small volumes of an irritant into the insertion sites of
the damaged tendon, which promotes the growth of normal tissue.
◦ common side effects: self‐limited postinjection pain and mild bleeding
Treatment -- Non-operative treatment
⇒ Splinting:

◦ thumb spica splint (forearm is in the neutral position with the wrist extended to 25 degrees and the
thumb in functional position)

◦ avoid excessive stretch to tendon sheath during movement in order to prevent further irritation to the
tendon

⇒ therapuetic exercises: thumb adduction, radial, palmar abduction, extension

⇒ lifestyle changes: Avoiding repetitive or aggravating movements

Use of assistive devices, modifying workplace (e.g: use of mouse pad)
⇒ Icing
⇒ Acupuncture
⇒ Infrared light therapy
⇒ Cold laser treatments
- reduce inflammation and pain and promote healing
Treatment -- De Quervain release Surgery
- after failure of non-operative treatment to provide relief
- small incision is made → identify dorsal extensor retinaculum → perform the
release longitudinally along tendon (prevent potential subluxation of first
compartment of tendon) → identify APL and EPB tendon and release APL, EPB
tendon tendon from surrounding retinaculum and tendon sheath
- Complications: pain may occur after surgery due to neuroma, inadequate
decompression, instability, tendon scarring
Treatment -- De Quervain release Surgery
- Complications:
◦ Superficial radial nerve injury,
◦ Adhesions in the scar causing neuritis in this high-contact area, greatly limiting hand and
wrist function. (avoided through careful blunt dissection of the subcutaneous tissue and
gentle traction)
◦ Persistent entrapment symptoms: if the tendon slips of the abductor pollicis longus are
mistaken for the tendons of the abductor pollicis longus and the extensor pollicis brevis
→ extensor pollicis brevis tendon may remain entrapped within the septated first dorsal
compartment
→ surgical re-exploration may allow a previously overlooked tendon to be released
◦ Subluxation of released tendons: with wrist flexion and extension, the tendons of a widely
released first dorsal compartment snap over the radial styloid (avoided by carefully limiting
the release to the thickest middle 2 cm of the first dorsal compartment or by reconstructing a
loose roof to the released sheath. Reconstruction of the sheath with a slip of local tissue may
relieve symptoms.)
-
END
Radiological diagnosis: Plain radiographs are nondiagnostic of the condition but may show nonspecific
signs and can help exclude other causes of pain such as fracture, carpometacarpal arthritis, and
osteomyelitis. Signs include: Soft-tissue swelling over the radial styloid, Focal abnormalities of the radial
styloid
Ultrasound: very diagnostic. Findings include: Edematous tendon thickening of APL and EPB at the level
of the radial styloid (compare with the contralateral side), Increased fluid within the first extensor tendon
compartment tendon sheath, Thickening of overlying retinaculum and the synovial sheath

MRI is very sensitive and specific and useful for detecting mild disease where ultrasound may be
equivocal. The presence or absence of intertendinous septum can be assessed. Findings include:
Tenosynovitis,

● Tendinosis
○ Tendon enlargement maximal at radial styloid and often greater at the medial aspect of the
tendon
○ Slightly increased intratendinous T1 and T2 signal compared to other tendons
○ Striated appearance of tendons due to multiple enlarged slips
● Longitudinal tendon tear
○ Linear high T2 signal due to fluid within the split
○ More common in APL