de Quervain’s tenosynovitis
de Quervain’s tenosynovitis (also known as 1st compartment entrapment or tenosynovitis)
de Quervain’s tenosynovitis is an inflammation of the synovium or the inner lining of the tendon sheath of the abductor po1licis longus (APL) and extensor pollicis brevis (EPB) tendons at the level of the radial styloid in the 1st dorsal wrist compartment.
This is the most common radial-sided tendinopathy in sportspeople and a common cause of wrist pain in non-sportsperson adults. It occurs particularly with racquet sports, ten-pin bowlers, rowers, and canoeists. The left thumb of a right-handed golfer is particularly at risk because of the hyperabduction required during a golf swing.
The prevalence of de Quervain’s Tenosynovitis is 0.5% in men and 1.3% in women among the general population. It is most common among women between the ages of 30 and 50 years of age, including a small subset of women in the postpartum period. These women tend to develop symptoms about four to six weeks after delivery. Risk factors include the overuse of the hands, and repetitive hand activities that depend on wrist and thumb movements. Those who are employed in occupations that require repetitive and forceful hand movements, such as musicians and machinists, face an increased risk.
Figure 1. Relevant Anatomy: 1) Extensor retinaculum (fibrous sheath of the first extensor compartment). 2) APL and EPB muscle bodies. 3) Synovial sheath around APL and EPB, site of de Quervain’s tenosynovitis. 4) 1st CMC joint.
Figure 2. Forearm anatomy.
Tenosynovitis (formerly stenosing tenovaginitis), or thickening of the fibrous sheath of the first extensor compartment, is true de Quervain’s disease as described by de Quervain and Finkelstein in 1912 and 1930 respectively.
However, the tendon sheath can be likened to a tunnel with two trains passing through representing the APL and EBP tendons. Inflammation of the fibrous sheath (tenovaginitis), the tendons (tendonitis), inflammation of the synovium (synovitis), or external compression from the extensor retinaculum can all cause impaired gliding of the tendons through the tendon sheath and subsequent friction and pain.
A number of studies have shown that anatomical variations in the FDC, such as the presence of septum and multiple slips of the tendon are associated with de Quervain’s.
Patients will typically present tenderness at the first dorsal compartment over the radial styloid that can refer to the thumb or the lateral forearm along the length of the tendons.
Pain worsens with activities that involve repetitive movements of the wrist or hand, particularly involving the thumb.
Patients often report difficulties with activities that involve grasping, twisting and lifting as well as texting and playing video games.
Pain subsides with rest from such activities.
The dominant hand is no more likely to be involved than the non-dominant hand, and the disease can be bilateral.
Pain may be associated with localized swelling or crepitus in severe cases.
Pain at the radial styloid with active or passive stretch the thumb tendons over the radial styloid in thumb flexion (the Finkelstein maneuver or test)
1st CMC (carpometacarpal) joint OA
STT (scaphoid-trapezoid-trapezium) joint OA
Wrist joint OA
Superficial radial nerve neuritis (Wartenberg’s syndrome)
Fractures of the scaphoid or radial styloid
Diagnosis of de Quervain’s Disease is based on clinical findings.
Physical examination may reveal tenderness on palpation over the first dorsal compartment. If swelling is present, it is usually 1–2 cm proximal to the radial styloid following the course of the EPB and APL tendons.
The Finklestein test describes pain at the radial styloid with active or passive stretch to the thumb tendons over the radial styloid in thumb flexion.
Figure 3. Finklestein’s Test.
Imaging is often not required for diagnosis; however, imaging may help to confirm the diagnosis and/or to rule out other conditions
X-ray of the wrist and forearm: non-specific, to rule out other abnormalities, particularly osteoarthritis.
Ultrasound of the forearm, esp. area of tenderness: may reveal tenosynovitis of the tendon sheaths of the APL and EPB tendons in the area of tenderness.
MRI is indicated if there is persistent pain despite treatment or if the diagnosis is unclear after X-rays and ultrasound.
Initial treatment (Conservative Management):
Rest from aggravating activities, including any repetitive forceful wrist motions
Ice as needed
A short course of anti-inflammatory medication, e.g. naproxen 500mg PO bid x2wks
A short period of immobilization, for example, a thumb spica splint in 20 degrees of wrist extension may be used. The splint must immobilize the wrist and thumb, excluding the thumb interphalangeal joint, in order to offload the APL and EPB tendons.
Referral to physiotherapy to work on stretching, ROM exercises, and strengthening. Graded pain-free active exercises promote gliding of the tendons.
Corticosteroid injection is often advocated for as a first line treatment for de Quervain’s tenosynovitis.
The injection consists of 1ml of corticosteroid with 0.5 to 1ml of a local aesthetic. Success has been reported with a variety of corticosteroids (e.g. Bemethasone, triamcinolone, dexamethasone, methylprednisonlone). A small 27 or 25 gauge needle (1″ or 1.5″) is used for injection. The needle is placed in close proximity to the tendon or into the sheath but not into the tendon substance. In general one or two corticosteroid injection may be offered to patients. These can be given several weeks to months apart.
Surgery should be considered in resistant cases that have failed 3-6 months of non-surgical management.
All require decompression of the first dorsal compartment +/-
Reconstruction of the compartment to prevent subluxation
Author Dr. Alexander Popa MD PGY2 (PR ND, AF)
Reviewed by Dr. Alessandro Francella MD, CCFP, Dip sports med
Allbrook, V. (2019). ‘the side of my wrist hurts’: De Quervain’s tenosynovitis. Australian Journal of General Practice, 48(11), 753–756. https://doi.org/10.31128/ajgp-07-19-5018
Brukner, P., Khan, K., Clarsen, B., Cook, J., Cools, A., Crossley, K., Hutchinson, M. R., McCrory, P., & Bahr, R. (2018). Brukner & Khan’s clinical sports medicine. McGraw-Hill Education (India) Private Ltd.
KAY, N. R. (2000). De Quervain’s disease. Journal of Hand Surgery, 25(1), 65–69. https://doi.org/10.1054/jhsb.1999.0277
Nainwal (MPT), D., & Arunmozhi, R. (2020). A literature review on DE-QUERVAINS tenosynovitis. International Journal of Advanced Research, 8(7), 824–835. https://doi.org/10.21474/ijar01/11345 Some figures from: https://www.physio-pedia.com/De_Quervain%27s_Tenosynovitis