Finkelstein’s Test: A

Biomechanical Analysis
Keiji Kutsumi, MD, PhD, Peter C. Amadio, MD, Chunfeng Zhao, MD,
Mark E. Zobitz, MS, Tatsuro Tanaka, MD,
Kai-Nan An, PhD, Rochester, MN

Purpose: Finkelstein’s test is the classic diagnostic test for de Quervain’s disease. Finkelstein hypoth-
esized that the entry of the muscle bellies of the extensor pollicis brevis (EPB) and abductor pollicis
longus (APL) tendons into the first extensor compartment was responsible for the findings observed in
his now eponymous test. We agree with Finkelstein’s hypothesis and further hypothesize that this
position would induce measurable bulk (muscle mass within the retinaculum) and tethering (stretching
of synovial tissue) effects within the compartment. To test this latter hypothesis we measured the
excursion and gliding resistance of the EPB and APL tendons within the first compartment.
Methods: Fifteen fresh-frozen cadavers were used. Gliding resistance and excursion were mea-
sured in 4 different wrist positions, including the wrist position of Finkelstein’s test (30° ulnar
deviation). The bulk and tethering effect was calculated based on the mean gliding resistance over
the tendon proximal/distal excursion cycle and the gliding resistance at the terminal distal
excursion.
Results: The EPB tendon excursion was significantly more distal in 30° ulnar deviation than in 60°
extension. Additionally the bulk and tethering resistance was significantly greater in 30° ulnar
deviation compared with 60° extension. For the APL tendon there was no significant difference in
either the tendon excursion or the bulk and tethering resistance between 30° ulnar deviation and
60° extension.
Conclusions: We showed that in the position of Finkelstein’s test the EPB tendon is significantly
more distal and has significantly greater bulk and tethering effect compared with the other EPB
positions. This is not the case for the APL tendon in the position of Finkelstein’s test. These results
suggest that an abnormal Finkelstein’s test reflects differences of the EPB more than it does the APL.
(J Hand Surg 2005;30A:130 –135. Copyright © 2005 by the American Society for Surgery of the
Hand.)
Key words: Bulk, de Quervain’s disease, Finkelstein’s test, gliding resistance, tethering.

de Quervain’s disease, stenosing tenosynovitis of the

From the Biomechanics Laboratory, Division of Orthopedic Research,
Mayo Clinic Rochester Rochester, MN.
Received for publication November 18, 2003; accepted in revised form
June 3, 2004.
Supported by the National Institute of Arthritis and Muscular and Skin
Diseases, National Institutes of Health grant AR44391.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this article.
Reprint requests: Peter C. Amadio, MD, Biomechanics Laboratory,
Mayo Clinic, 200 First St SW, Rochester, MN 55905.
Copyright © 2005 by the American Society for Surgery of the Hand
0363-5023/05/30A01-0020$30.00/0
doi:10.1016/j.jhsa.2004.07.001
first dorsal compartment of the wrist, is one of the
most common causes of wrist pain.1 Finkelstein2 has
described a clinical test, which he called a “patho-
gnomonic objective sign,” in which the examiner
grasps a patient’s thumb and quickly deviates the
hand and wrist ulnarly. This test reproduces the pa-
tient’s pain in its characteristic location over the first
compartment of the extensor retinaculum. Finkel-
stein2 also presented what he called “a useful exper-
iment,” first described by Eichhoff,3 in which one
clenches one’s thumb in a fist and then ulnarly de-

130 The Journal of Hand Surgery


Figure 1. System for measuring gliding resistance.
viates the wrist. This maneuver also produces symp-
toms, to some extent even in unaffected individuals,
and was cited by Finkelstein2 to suggest that repeated
overstretching of the tendon sheath in this position
could result in an injury to the gliding mechanism.
Many clinicians now erroneously refer to this clenched
fist maneuver as Finkelstein’s test.1,4 Finkelstein2
stated that the extensor pollicis brevis (EPB) and
abductor pollicis longus (APL) tendons and the ten-
don sheath were stretched in this position.
If Finkelstein’s hypothesis is true, high gliding
resistance should be generated in the position in
which Finkelstein’s test is performed, as well as in
his experimental position, which is essentially the
same but produced actively rather than passively. We
hypothesized further that the bulk effect, which is
produced by muscles passing under the retinaculum,
and tethering effect, which is caused by stretching of
the synovial tissue around the EPB and APL tendons,
would be increased in the position of Finkelstein’s
test. To study this hypothesis we measured the ex-
cursion and gliding resistance within the extensor
retinaculum of the EPB and APL tendons in selected
wrist positions, focusing on terminal positions, in-
cluding the one described by Finkelstein.2
Materials and Methods
We used a device to measure tendon gliding resistance
that previously has been described and validated.5,6 The
measurement system consisted of one mechanical
actuator with a linear potentiometer, 2 tensile load
transducers, and a movable mechanical pulley to
satisfy the need for 3-dimensional wrist motion. The
mechanical actuator was a small linear slide, driven
by a precision-geared direct current motor. By regu-
Kutsumi et al / Finkelstein’s Test 131
lating the voltage the speed of movement could be
adjusted. The load transducers were custom-made
strain-gauge transducers (range, 0 –10 N; sensitivity
⬍ 0.01 N). The specimen was mounted on the testing
device by clamping the proximal end of the radius
and ulna. The wrist position was maintained by using
a custom-built external fixator that allowed the wrist
to be set at any selected angle of flexion, extension,
radial deviation, or ulnar deviation (Fig. 1).
Fifteen fresh-frozen human cadaveric upper ex-
tremities (mean age, 76; range, 56 –97y), amputated
15-cm proximal to the wrist joint, were used for this
study. Intact specimens, including the forearm, wrist,
and hand, were stored in a freezer at ⫺20°C and
thawed at room temperature immediately before test-
ing. All specimens were x-rayed to exclude gross
pathologic evidence of injuries or major degenerative
changes around the wrist and inspected to rule out
tenosynovitis or thickening of the extensor retinacu-
lum. Fascia distal and proximal to the extensor reti-
naculum was removed, including the fascia overlying
the EPB and APL tendons and muscles. The origins
of the APL and EPB were detached from the fore-
arm. The EPB and APL muscles and tendons prox-
imal to the retinaculum were separated carefully.
The excursions of the EPB and APL tendons in
each wrist position were measured separately by
moving passively from a position of full thumb in-
terpahalangeal (IP), metacarpophalangeal (MCP), and
trapeziometacarpal (TM) joint flexion to full exten-
sion at these joints. A 4.9-N weight was applied to
the proximal muscle to maintain tension on the ten-
don. These excursions then were used as the tendon
gliding distance during subsequent testing.
132 The Journal of Hand Surgery / Vol. 30A No. 1 January 2005
After measurement of tendon excursion the EPB
tendon was cut at the level of the MCP joint. The
distal tendon end and proximal muscle were con-
nected to the distal (F1) and proximal (F2) load
transducers, respectively. The distal transducer (F1)
was connected to a 4.9-N weight through a mechan-
ical pulley. The position of the pulley was changed
according to the wrist angle to represent the physio-
logic line of action for the tendon. The proximal
transducer (F2) was connected to the mechanical
actuator, which was placed to simulate the physio-
logic muscle angle (Fig. 1).
The tendon starting position was set at its most
distal excursion point. The tendon then was pulled
proximally by the actuator against the gliding resis-
tance and the 4.9-N weight at a rate of 2.0 mm/s. This
motion of the tendon toward the actuator simulated
excursion during thumb extension. The force of fric-
tion was in a direction opposite to the direction of
movement so that as the tendon moved away from
the weight the force of friction was added to the
4.9-N load, while in the other direction it was sub-
tracted. In contrast the bulk force only works to resist
distal motion of the muscles into the sheath, so it is
present only at the extreme of motion, and always
directed proximally. Thus because of the gliding
resistance between the tendon and retinaculum, for
this direction of motion F2 would be greater than
4.9 N. If a bulk and tethering effect is present in the
initial distal position, however, F2 initially may be
less than 4.9 N. At the end of the proximal movement
the actuator was stopped and reversed to move the
tendon distally at a rate of 2 mm/sec (ie, the weight
provided the driving force), simulating tendon excur-
sion during thumb flexion. For tendon motion in this
direction friction between the tendon and retinacu-
lum would cause the force of F2 to be less than
4.9 N. A bulk and tethering effect would reduce
further F2 at the terminal point of distal motion. F1,
F2, and the corresponding excursion were recorded
at a sampling rate of 10 Hz. After measuring the
gliding resistance of the EPB tendon the APL tendon
was tested in the same manner. The specimens were
kept moist throughout the testing procedure with
saline.
Four different wrist positions were tested: 60°
extension with neutral deviation (60E), 60° flexion
with neutral deviation (60F), 30° ulnar deviation with
neutral extension/flexion (30U), and 15° radial devi-
ation with neutral extension/flexion (15R). Thirty
degrees ulnar deviation in neutral extension/flexion
(30U) is the anatomic wrist position simulating the
Finkelstein’s test.
Relative Position of the EPB and APL
Tendons
At each wrist position the relative position of the
EPB and APL tendons at terminal thumb flexion (ie,
full flexion of IP, MCP, and TM joints) was ana-
lyzed. The results for various wrist positions were
reported as the change in excursion of EPB and APL
tendons as compared with neutral wrist orientation.
A positive value indicated distal excursion of the
tendon and a negative value indicated proximal mo-
tion.
Resistance
We hypothesized that the tendons would be subjected to
surface friction between the tendon and retinaculum
and resistance caused by increased bulk within the
retinaculum and tethering of the tendon to adjacent
structures such as the synovial sheath at terminal distal
tendon excursion. To differentiate the contributions of
each, 3 different data analyses were performed.
Mean gliding resistance. Gliding resistance was
calculated as the difference between the proximal
and distal force transducers. The mean gliding resis-
tance over a simulated thumb extension/flexion cycle
was calculated as the composite of the flexion and
extension gliding resistance over the whole excur-
sion: ([F2 extension ⫺ F1 extension] ⫹ [F1 flexion -
F2 flexion])/2. Because F1 extension should be the
same as F1 flexion during the testing (4.9-N weight),
the mean gliding resistance can be calculated as
(F2 extension - F2 flexion)/2. This method compensates
for effects such as those caused by variations in
shape and stiffness of the tendon along its length or
soft-tissue deformation, which may cause the F2
tracings in extension and flexion to deviate somewhat
from a purely parallel and symmetric relationship to
the 4.9-N load.
Terminal resistance. The gliding resistance at
the terminal point of flexion represents the force on
the tendon during thumb IP, MCP, and TM joint
flexion (thumb position during Finklestein’s test and
his experimental position). The terminal resistance,
F1 terminal flexion (4.9-N weight) ⫺ F2 terminal flexion
includes surface friction as well as any tethering
effect or bulk effect (Fig. 2).
Bulk and tethering resistance. The difference
between the mean gliding resistance and the terminal
 Kutsumi et al / Finkelstein’s Test 133

Figure 2. A single testing graph of an EPB tendon in 30° ulnar

Figure 3. Relative position of EPB and APL tendons in each
deviation. The solid line is F2extension and the gray line is
wrist position compared with neutral wrist orientation at
F2flexion. F1extension and F1flexion are 4.9 N (dotted line).
terminal thumb flexion (mean ⫾ SD). Results are shown as
Terminal resistance is noted by the value of F2flexion ⫺
the difference in terminal position of the EPB and APL ten-
F1flexion at the location of full flexion (black arrow).
dons compared with the neutral wrist orientation, with a
positive value indicating a more distal position. The terminal
resistance was a relative measure of the bulk and position of the EPB tendon was significantly more distal in
30U than in 60E. □, EPB tendon; , APL tendon.
tethering resistance. A positive value (ie, terminal
resistance greater than the mean resistance) would
indicate that these effects are present.
The gliding resistances for the APL tendon are
One-factor repeated-measures analysis of variance
shown in Figure 5. The mean gliding resistance of
models were run for each measure in each tendon.
the APL tendon showed a significant effect owing to
When the wrist angle was found to be a significant
factor a further analysis was performed using the wrist position (p ⬍ .05). The mean gliding resistance
Student-Newman-Keuls procedure. P values less was significantly greater in 60F compared with the
than .05 were considered significant. other wrist positions (p ⬍ .05). The terminal resis-
tance was significantly higher in 60E, however, com-
Results pared with the other wrist positions (p ⬍ .05). The
Excursion bulk and tethering resistance in 30U and 60E showed
The results are shown in Figure 3. There was a
significant effect owing to wrist position (p ⬍ .05)
for both tendons. The EPB tendon excursion was
significantly more distal (ie, bringing the muscle
bellies further under the extensor retinaculum) in
30U than in 60E. For the APL tendon there was no
significant difference in the position of the tendon
excursion between these 2 positions.

Resistance
The gliding resistances for the EPB tendon are shown
in Figure 4. The mean gliding resistance of the EPB
tendon showed a significant effect owing to wrist
position (p ⬍ .05). The mean gliding resistance of the
EPB tendon was significantly lower in 30U com- Figure 4. Resistance values for EPB tendon (mean ⫾ SD).
pared with the other wrist positions, except for 15R Gliding resistance was significantly lower in 30U compared
(p ⬍ .05). The terminal resistance, however, was with the other wrist positions, except for 15R. Terminal re-
sistance was significantly higher in 30U compared with the
significantly higher in 30U compared with the other
other wrist positions, except for 60E. Bulk and tethering
wrist positions except for 60E (p ⬍ .05). The bulk resistance in 30U and 60E were positive and 30U was sig-
and tethering resistance in 30U and 60E were posi- nificantly greater than 60E. □, Mean gliding resistance; ,
tive, and 30U was significantly greater than 60E. terminal resistance; , bulk and tethering resistance.
134 The Journal of Hand Surgery / Vol. 30A No. 1 January 2005
Figure 5. Resistances for APL tendon (mean ⫾ SD). Gliding
resistance was significantly greater in 60F compared with the
other wrist positions. Terminal resistance was significantly
higher in 60E compared with the other wrist positions. Bulk
and tethering resistance in 30U and 60E showed positive
values, but there was no significant difference between the 2
positions. □, Mean gliding resistance; , terminal resistance;
, bulk and tethering resistance.
positive values, but the difference between these 2
positions was not significant.
Discussion
Anatomically the musculotendinous junction of the
EPB is close to the first compartment. In Finkel-
stein’s test, when the thumb is in full flexion and the
wrist is in ulnar deviation, the EPB muscle belly is
pulled into the first compartment (Fig. 6), resulting
in a bulk effect. The synovial tissue around the EPB
and APL tendons also might be stretched in the
Finkelstein testing position, causing a tethering ef-
fect. Both bulk and tethering effects may induce pain
by directly stretching synovial tissue, especially
when the synovial tissue is inflamed or fibrotic, as
Figure 6. (A) Wrist neutral, thumb full flexion position. A line is drawn on the EPB muscle. (B) Wrist ulnar deviation, thumb full
flexion position (Finkelstein’s test position).
may be the case in de Quervain’s disease. Finkel-
stein’s original description of his maneuver is as
follows, “On grasping the patient’s thumb and
quickly abducting the hand ulnarward, the pain over
the styloid tip is excruciating. This is probably the
most pathognomonic objective sign.”2 Elliott7 has
noted that current descriptions of Finkelstein’s test1,4
include not only Finkelstein’s passive “pathognomonic
objective sign,” but also the active maneuver that
Finkelstein suggested as an experiment clinicians
could perform on themselves to explain how a first
compartment synovitis might occur. Because both
tests end with the hand in roughly the same position
it is likely that similar clinical findings result, regard-
less of which test is used. The EPB and APL tendons
should move distally not only in ulnar deviation but
also in extension of the wrist because the tendons run
volarly to the extension/flexion axis of the wrist. Our
results show that the main difference between the
Finkelstein test position and other extreme wrist po-
sitions is that the position of the Finkelstein’s test
places the EPB tendon in its most distal excursion.
This suggests to us that Finkestein’s test is primarily
a test of the EPB. This speculation is consistent with
a clinical observation that we have noticed, namely
that the provoked pain decreases when the thumb IP
and MCP joint are extended during Finkestein’s test.
Because the insertion of the APL tendon is proximal
to the MCP joint a change in the angle of the IP and
MCP joints would not affect the APL.
We believe that de Quervain’s disease is primarily
a pathology of the EPB, and specifically the EPB
subsheath, a position that has been considered by
others in the past based on the reoperation for failures
of de Quervain’s release surgery. In such cases the
EPB subsheath was found almost invariably to be

intact. Releasing the EPB subsheath resulted in com-
plete relief of symptoms.8
Septation in the first compartment is known to be
a common variation. In this study 8 septation and 7
nonseptation specimens were included. All of the
septations were partial and located at the distal part
of the first compartment. We did not find any differ-
ence in gliding resistance between these 2 groups.
We speculate that this may be because the location of
the septation was so distal that the muscle of the EPB
did not reach the region of septation during testing.
In this study the mean gliding resistance in the
30U position was relatively small. This was expected
because the EPB and APL tendons run straight in that
position, with little dorsally directed pressure on the
extensor retinaculum. It is reasonable to consider that
the mean gliding resistance would not be related
directly to the findings in Finkelstein’s test because
the test induces pain only at the maximum position of
IP, MCP, and TM joint flexion, combined with ulnar
deviation of the wrist. The terminal resistance in this
position is a combination of the surface friction and
resistance owing to bulk and tethering. By subtract-
ing the surface friction the bulk and tethering resis-
tance can be calculated and can be shown to be quite
substantial, especially for the EPB.
There are several limitations to this study. As a
cadaver study we cannot directly compare the results
with in vivo testing. Neither can we make any as-
Kutsumi et al / Finkelstein’s Test 135
sumption about the presence or absence of de Quer-
vain’s disease in the cadaver donors antemortem.
The strength of this study is that we directly mea-
sured the gliding resistance of the EPB and APL
tendons and investigated the bulk and tethering ef-
fects. Our results, although speculative, do propose a
plausible explanation for the positive Finkelstein’s
test, support Finkelstein’s original hypothesis, and
further suggest that de Quervain’s disease may be
primarily a problem of the EPB rather than of the
APL, or of the EPB and APL equally.
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