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De Quervain's Tendinitis



 

De Quervain's (dih-kwer-VAINS ten-oh-sine-oh-VIE-tis) is a painful condition affecting the tendons on the thumb side of your wrist. If you have de Quervain's tenosynovitis, it will probably hurt every time you turn your wrist, grasp anything or make a fist.


Although the exact cause of de Quervain's tenosynovitis isn't known, any activity that relies on repetitive hand or wrist movement — such as working in the garden, playing golf or racket sports or lifting your baby — can make it worse.

De Quervain's tendinitis occurs when the tendons around the base of the thumb are irritated or constricted. The word "tendinitis" refers to a swelling of the tendons. Thickening of the tendons can cause pain and tenderness along the thumb side of the wrist. This is particularly noticeable when forming a fist, grasping or gripping things, or when turning the wrist.


A
natomy


Two of the main tendons to the thumb pass through a tunnel (or series of pulleys) located on the thumb side of the wrist. Tendons are rope-like structures that attach muscle to bone. Tendons are covered by a slippery thin soft-tissue layer, called synovium. This layer allows the tendons to slide easily through the tunnel. Any swelling of the tendons located near these nerves can put pressure on the nerves. This can cause wrist pain or numbness in the fingers.


C
auses


De Quervain's tendinitis is caused when tendons on the thumb side of the wrist are swollen or irritated. The irritation causes the lining (synovium) around the tendon to swell, which changes the shape of the compartment. This makes it difficult for the tendons to move as they should.


Tendinitis may be caused by overuse. It can be seen in association with pregnancy. It may be found in inflammatory arthritis, such as rheumatoid disease. De Quervain's tendinitis is usually most common in middle-aged women.


Chronic overuse of your wrist is commonly associated with de Quervain's tenosynovitis.


When you grip, grasp, clench, pinch or wring anything in your hand, you use two major tendons in your wrist and lower thumb. These tendons normally glide unhampered through the small tunnel that connects them to the base of the thumb. If you repeat a particular motion day after day, it may irritate the sheath around the two tendons, causing thickening that restricts the movement of the tendons.


Other causes of de Quervain's tenosynovitis include:


Direct injury to your wrist or tendon; scar tissue can restrict movement of the tendons


Inflammatory arthritis, such as rheumatoid arthritis


R
isk factors


People between the ages of 30 and 50 have a higher risk of developing de Quervain's tenosynovitis than do those in other age groups. The condition is more common in women than in men, and it may be associated with pregnancy. Baby care, which involves using your thumbs as leverage to lift your child hundreds of times a day, may also be associated with the condition.


Jobs or hobbies that involve repetitive hand and wrist motions may contribute to de Quervain's tenosynovitis as well.


-Excessive training or activity


-Muscle weakness


-Muscle tightness


-Joint stiffness


-Poor sporting technique or equipment


-Poor posture or ergonomic set-up


-Inadequate warm-up


-Injury to the neck, upper back or nerves


S
ymptoms


•Pain may be felt over the thumb side of the wrist. This is the main symptom. The pain may appear either gradually or suddenly. Pain is felt in the wrist and can travel up the forearm. The pain is usually worse when the hand and thumb are in use. This is especially true when forcefully grasping objects or twisting the wrist.


•Swelling may be seen over the thumb side of the wrist. This swelling may occur together with a fluid-filled cyst in this region.


•A "catching" or "snapping" sensation may be felt when moving the thumb.


•Pain and swelling may make it difficult to move the thumb and wrist.


•Numbness may be experienced on the back of the thumb and index finger. This is caused as the nerve lying on top of the tendon sheath is irritated.


C
omplications


If de Quervain's tenosynovitis is left untreated, it may be hard to use your hand and wrist properly. If the affected tendons are no longer able to slide within their tunnel, you may develop a limited range of motion.


D
iagnosis


The Finkelstein test is conducted by making a fist with the fingers closed over the thumb and the wrist is bent toward the little finger.


The Finkelstein test can be quite painful for the person with De Quervain's tendinitis.


Tenderness directly over the tendons on the thumb side of the wrist is a common finding with this test.


T
reatment


Treatment for de Quervain's tenosynovitis may include medications, physical or occupational therapy, or surgery. Treatment is generally successful if begun early on, though the pain may recur if you can't discontinue the repetitive motions that aggravate your condition. If you start treatment early on, your symptoms of de Quervain's tenosynovitis should generally improve within four to six weeks. When de Quervain's tenosynovitis starts during pregnancy, symptoms usually get better around the end of pregnancy or when breast-feeding stops.


Medications


To reduce pain and swelling, your doctor may recommend using NSAIDs.


Therapy


Initial treatment of de Quervain's tenosynovitis may include:


Immobilizing your thumb and wrist, keeping them straight with a splint or brace to help rest your tendons


Avoiding repetitive thumb movements whenever possible


Avoiding pinching with your thumb when moving your wrist from side to side


Applying ice to the affected area


You may also see a physical or occupational therapist. These therapists may review your habits and give suggestions on how to make necessary adjustments to relieve stress on your wrists. Your therapist can also teach you exercises focused on your wrist, hand and arm to strengthen your muscles, reduce pain, and limit the irritation of the tendons. The therapist may also make a splint to keep your wrist and thumb from moving if off-the-shelf versions don't fit you
well.


Manual "hands-on" therapy from the physiotherapist such as massage, trigger point releases, joint mobilisation to the wrist, thumb and hand, stretches and electrotherapy can also assist with hastening healing and improving flexibility and function in patients with De Quervains tendonitis.


Exercises for De Quervains tendonitis


The following exercises are commonly prescribed to patients with De Quervains tendonitis. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms during the exercises or after with rest.


EPL Stretch


Begin with your elbow straight and your fingers curled up around your thumb. Gently bend your wrist towards the little finger side until you feel a mild to moderate stretch pain free. Hold for 5 seconds and repeat 5-10 times provided there is no increase in symptoms.


Wrist stretch


Press the back of the hand on your injured side with your other hand to help bend your wrist. Hold for 15 to 30 seconds. Next, stretch the hand back by pressing the fingers in a backward direction. Hold for 15 to 30 seconds. Keep the arm on your injured side straight during this exercise. Do 3 sets.


Tennis Ball Squeeze


Begin this exercise holding a tennis ball. Squeeze the tennis ball as hard as possible and comfortable without pain. Hold for 5 seconds and repeat 5-10 times provided there is no increase in symptoms.


Wrist Range-of-Motion Exercises



Wrist rotations loosen the tendons and improve mobility and range of motion in the wrist. Hold your hand with your palm facing you and make a loose circle with your thumb and fingers. Rotate your hand to the left up to 10 times, then rotate to the right. Wave your fist, in a knocking motion, five times, then tilt your fist side to side.


Hand Shake


The hand shake loosens the tendons and muscles in your wrist, forearm and fingers. Hold both hands limp and shake your wrists back and forth and side to side so that your hands flop loosely. Shake for 30 seconds, relax and repeat two more times.


Wrist Flexes, Extensions and Rotations


These exercises are similar to the range-of-motion exercises, but the addition of weight strengthens the tendons and muscles rather than stretching them.
Sit with your forearms resting on your knees and your hands extending over the edges of your knees. Hold a 1- to 2-lb. weight in the affected hand, turn your palm up and curl your hand toward your forearm 10 times. Turn your palm toward the floor, then raise your knuckles to the ceiling 10 times. Rotate your arm in a circle left and right 10 times each.


Finger spring


Place a large rubber band around the outside of your thumb and fingers. Open your fingers to stretch the rubber band. Do 2 sets of 15.


Splints


Splints may be used to rest the thumb and wrist.


Surgery


If your case is more serious, your doctor may recommend outpatient surgery. Surgery involves a procedure in which your doctor inspects the sheath surrounding the involved tendon or tendons, and then opens the sheath to release the pressure and restore free tendon gliding.


Your doctor will talk to you about how to rest, strengthen and rehabilitate your body after surgery. A physical or occupational therapist may meet with you after surgery to teach you new strengthening exercises and help you adjust your daily routine to prevent future problems.


P
rognosis of De Quervains tendonitis


With appropriate management and physiotherapy, most minor cases of De Quervains tendonitis that have not been present for long can usually recover within a few weeks. In more severe and chronic cases, recovery can be a lengthy process and may take more than 6 months in those who have had their condition for a long period of time. Early physiotherapy intervention is therefore vital to hasten recovery. In rare cases that do not respond to conservative treatment, surgery or other interventions may be indicated.