de Quervain’s Tenosynovitis: A Clinical Review and Novel Approach to Treatment Using Trigenics®
By Dr. Jason D. Nyman, BSc (Hons Kin), DC
December 01, 2002
De Quervain’s tenosynovitis is a common, painful condition of the wrist. It was first described by Fritz de Quervain in 1895 as a stenosing tenosynovitis of the thumb abductors about the radiostyloid process.1 The prevalence of this condition, although not well documented, seems to be increasing with new occupational demands, such as prolonged work at computer workstations and piecework on assembly lines.2 It is a common by-product of occupational activities, which demand frequent thumb pinching and wrist movement.
There are numerous synonyms for this condition in the literature, including de Quervain’s disease, stenosing tenosynovitis, first dorsal compartment tenosynovitis, and Washer Woman’s Sprain.3 It may also be referred to in more general terms as a cumulative trauma disorder of the wrist.
De Quervain’s tenosynovitis is caused by a stenosing inflammation of the tendon sheath in the first dorsal compartment of the wrist.4 The first dorsal compartment at the wrist enshrouds the tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB).5 The tendons of these two involved muscles form the anterior boundary of the anatomical snuff box, which assists in the clinical identification of this condition.
The purpose of this paper is to review the clinical features of de Quervain’s Tenosynovitis, including its etiology, signs and symptoms, diagnostic characteristics and current management strategies. An overview of de Quervain’s tenosynovitis is also provided in terms of its management with a new, advanced soft tissue therapy known as Trigenics.
The specific etiology of de Quervain’s tenosynovitis is variable. It may be the result of a strain, an acute trauma, or an excessive, unaccustomed/new exercise. However, it is more commonly caused by the result of cumulative microtrauma.3,6 Age related loss of vascularity in tendons might also contribute to the development of this disorder.6 Thus, de Quervain’s disease is commonly seen in adults who use their hands and thumbs in a repetitive manner.
Cumulative trauma disorders (CTDs) arise from repetitive overuse where the resulting microtrauma exceeds the tissue’s ability to heal itself.2 CTDs are also known by the terms repetitive overuse disorders, repetitive strain disorders, repetitive motion disorders or occupational overuse injuries.2 They are a common cause of upper extremity occupational illness.
The tenosynovitis in de Quervain’s occurs in the first dorsal compartment of the wrist. The APL and EPB tendons pass through the first dorsal compartment, sharing a common tendon sheath.5 Friction between the tendons, the sheath, and the underlying osseous structures results in synovitis.1 The synovial-lined tendon sheath is the site of maximum inflammation. The enclosed tendons may also be involved in the inflammatory response.6
Pathologically there is increased vascularization in the outer sheath, with edema, that increases the thickness of the sheath thereby constricting the existing tendon.1 Micro-adhesions may form between the sheath and the tendon resulting in increased sheath thickness of two to four times its normal size.1
Increased resting muscle tone in the APL and EPB muscles secondary to myofascial adhesions and/or trigger points (myopoints) might also contribute to increased friction in the first dorsal column.
De Quervain’s tenosynovitis is relatively prevalent, especially among individuals who perform repetitive activities using their hands. Secretaries and assembly line workers represent typical patients.
Clinically, there appears to be as high as an 8:1 predilection of females to males.3 Many women also appear to suffer from de Quervain’s tenosynovitis during pregnancy or the postpartum period.7 There is no correlation that exists between the incidence of de Quervain tenosynovitis and any particular race.3 Some degree of morbidity may be associated with the disease, if the patient experiences progressive pain and associated limitation in activities requiring use of the involved hand. There is no mortality associated with the disease.3
Signs & Symptoms
The patient often complains of an aching type of discomfort over the radial styloid process, which radiates into the thumb and/or lateral forearm.3,4 This aching pain is aggravated by wrist and thumb movements, and by maintaining wrist postures for prolonged periods of time. Pinching and grasping strength may also be diminished.
The patient may experience associated dysesthesias, such as numbness, tingling, burning, and cramping.2 The distribution of these symptoms should be evaluated carefully, especially if there is any objective weakness or numbness.2
The history should include questions regarding the symptom onset, frequency, duration, location, referral patterns, previous investigation or therapy, and all aggravating or palliative factors. Details about the patient’s occupational demands including job duties performed, frequency, duration, environment and ergonomics should also be gathered.3
Occasionally, non-work related activities such as hobbies or sports might also contribute to the development of this condition. There may also be pre-existing medical or degenerative conditions. Therefore, the patient’s full past and current medical and social/recreational histories should be explored. Inquire about specific repetitive activities that may have contributed to onset of symptoms, such as computer use, materials handling, knitting, golf, or racket sports.
Examination should begin with careful inspection of the involved and uninvolved wrists. Localized swelling may be discernable in the posterior lateral wrist near the radial styloid process. Look for deformities, redness, skin changes, or raised contours of the wrist.
Palpate for tender, swollen, or inflamed tissue related specifically to the EPB and APL muscles and their tendons in the first dorsal compartment of the wrist. A ratchet-like crepitus may also be appreciated by lightly palpating the area while the patient actively extends and flexes the thumb and/or wrist.
Range of Motion
Active, passive (with overpressure) and resisted range of motion (ROM) should be performed on the wrist and thumb through all possible and full ROMs. Compare the involved and uninvolved wrists. A goniometer may be used to measure asymmetrical losses in ROM.
Ligamentous Stress Tests
Stress the ligaments at the wrist to check their integrity and pain status. Be cautious not to elicit a false positive by firmly grasping the inflamed synovium while stress testing the ligaments.
Muscle Action & Testing
Muscle testing is particularly important in isolating the involved muscles and staging their functional performance. The strength, power and endurance of each muscle should be assessed. The length and flexibility of the muscles around the joint should also be considered. Note any discrepancies from side to side.2
The EPB extends the proximal phalanx of the thumb at the carpometacarpal (CMC) joint.5 It also extends the metacarpophalangeal (MCP) joint of the thumb, abducts the CMC joint, and assists in abduction (radial deviation) of the wrist.8 To test the EPB, the examiner stabilizes the patient’s wrist and instructs the patient to resist pressure against the dorsal surface of the proximal phalanx, in the direction of flexion. Weakness is indicated by the decreased ability to extend the first MCP joint.8
The APL abducts the thumb and extends it at the CMC joint.5 It also abducts (radial deviation) and assists in flexing the wrist.8 With the wrist stabilized, the patient will resist the examiner’s pressure against the lateral surface of the distal end of the first metacarpal in the direction of adduction and flexion. Weakness is noted by the decreased ability to abduct the first metacarpal and abduct the wrist.8 Contracture of this muscle presents as an abducted and slightly extended position of the first metacarpal with slight radial deviation of the hand.8
Joint Play/Motion Palpation
Each of the individual joints about the involved and uninvolved wrists should be assessed for freedom of movement and tenderness. For the wrist, the movements are long axis distraction (LAD), anteroposterior (AP) glide, medial-lateral glide, side tilt, and rotation. At the intermetacarpal joints, AP glide should be assessed. Finally, LAD, AP glide, rotation and medial-lateral glide should performed on the thumb.9
Perhaps the most classic finding in de Quervain tenosynovitis is a positive Finkelstein test. The patient is instructed to make a fist with the thumb wrapped inside the fingers. The examiner then stabilizes the forearm and passively ulnar deviates the wrist. Pain at the radial wrist, over the APL and EPB tendons, indicates a positive test when it is significantly more tender than the uninvolved side.4,9
Other standard orthopedic tests or observations of the wrist, such as Phalen’s test and Tinel’s Sign, may be included selectively to help confirm the diagnosis and rule out other structures that may be involved conjointly or secondarily.
Functional everyday tasks or occupation/sport specific tasks can often provide insight in to more subtle lesions. They may also provide baseline data to gauge treatment response. Weight bearing through the wrist to assist in standing from a seated position and push-ups are examples of functional tests. Grasping a hammer or tennis racquet firmly, are additional tests.
Generally, radiographic examination is not required for diagnosis de Quervain’s tenosynovitis.3 Plain film radiographs may be helpful in assessing the CMC joint for degenerative changes and/or to rule out other osseous pathology, such as Kienboch’s disease or a fractured scaphoid. If indicated by the history or physical examination, radiographs may also be helpful in ruling out rheumatoid arthritis (RA) as it can be associated with de Quervain’s tenosynovitis.3
There are no lab studies that directly support the diagnosis of de Quervain’s tenosynovitis. Lab tests may be helpful in ruling out rheumatoid arthritis or other inflammatory disorders if the history and examination suggest this is a differential.3
The differential diagnosis of de Quervain’s Tenosynovitis should include:3,4
Dorsal ganglion at the wrist.
Osteoarthritis/DJD at first CMC joint.
Kienbock disease (ie, osteonecrosis of the lunate).
Degenerative arthritis at the radioscaphoid joint.
Cervical radiculopathy, particularly at C5 or C6 nerve root.
Carpal tunnel syndrome (ie, median nerve compression within the wrist).
Cheiralgia paresthetica or neuropathy of the radial sensory nerve (ie, superficial radial nerve) at the wrist (AKA Wartenberg’s Syndrome).
Scaphoid fracture characterized by tenderness at the floor of the anatomical snuffbox.
Intersection Syndrome – caused by irritation at the intersection of the APL, EPB and the ECRL/ECRB, about 4 cm proximal to the wrist joint.
Subluxation, joint dysfunction or irritation of the carpal bones including the scaphoid and the lunate bones.
A review of the literature reveals a wide spectrum of treatments used to manage this condition. Suggested treatments include, NSAIDs, immobilization with a thumb spica splint, provocative activity avoidance, cryotherapy, moist heat, corticosteroid injections, ultrasound phonophoresis of topical corticosteroids, and manual therapy.1,2,3,4,5,7 Surgical decompression of the first dorsal compartment may also be considered if symptoms are intractable or non-responsive to conservative management. Surgery and corticosteroid injections inherently present some degree of added risk.3
To treat de Quervain’s tenosynovitis effectively, the cause of the problem, the symptoms, and the related neuromuscular dysfunction must be addressed. Ergonomic and/or work modifications logically address the improper or overuse issues that contribute to the onset of the tenosynovitis. Cryotherapy and/or NSAIDS deal with the symptoms of inflammation. What is often missing in the proposed treatment is therapy directed at the related neuromuscular dysfunction.
The APL and EPB muscles are likely overworked, weakened and/or shortened as a result of the cumulative microtrauma. Tests performed in the examination will confirm the extent of dysfunction. Therapeutic stretches and exercises will help to correct this dysfunction over time. However, it would be helpful to rapidly restored the optimal neuromuscular function of these muscles through treatment. One such method is Trigenics.
Introduction and Rationale
Trigenics is a new paradigm in soft tissue assessment and therapeutics.10,11 It is primarily based on a neurological rather than strictly mechanical model of treatment.12 The desired outcome is to instantaneously relax, strengthen and/or lengthen muscles in order to improve function, thereby decreasing symptoms of inflammation and pain.12
There are three key components in Trigenics, neuromyogenics, acugenics and autogenics.13 Neuromyogenics refers to the use of resisted voluntary movement to elicit neuromuscular reflexes, such as reciprocal inhibition or the inverse myotatic reflex. Acugenics describes the therapist/patient interface through direct contact on the targeted muscle or tendon via a technique called proprioceptive dynamic acupressure (PDA). Thirdly, Autogenics incorporates respiratory and auto-suggestive techniques into the therapy. These three components interact synergistically to enhance the overall treatment response.13
Trigenics treatment primarily involves two core procedures, Trigenics Strengthening (TS) and Trigenics® Lengthening (TL). Assessment findings direct the Trigenist to procedure selection. A cumulative relaxation effect on the targeted muscle may be achieved with successive treatment applications.10
Anticipated benefits of Trigenics® treatments include the following:10,13
Restoration of optimal resting muscle tone or Gamma Bias.
Restoration of intra-articular mobility and joint biomechanics.
Restoration of unimpeded myofascial glide via neuromyol reduction.
Restoration of tissue flexibility and increased ROM.
Decreased spasm and pain.
Increased muscle strength and/or length.
TS Procedures – de Quervain’s Tenosynovitis
For the APL TS, the seated patient’s elbow is flexed to approximately 90o. The wrist is extended almost fully with adduction. The patient slowly flexes the wrist, with some ulnar deviation, while adducting the thumb during full exhalation. The trigenist lightly resists the patient’s movement at 10-20% effort, allowing near full ROM.
For the EPB TS, the procedure is similar. However, thumb flexion is preferred to adduction. PDA for APL TS and EPB TS is directed at myopoints in these same muscles and tendons, detected via interactive palpation between the examiner and the patient.
TL Procedures – de Quervain’s Tenosynovitis
The TL procedure for the APL and EPB may be performed nearly simultaneously. The seated patient’s wrist is fully flexed and partly ulnar deviated. The thumb is fully flexed and adducted at the CMC and MCP joints. The Trigenist strongly resists the patients near maximal thumb extension and thumb abduction, during wrist extension and slight radial deviation, by applying resistance to the 1st metacarpal. PDA is directed at the APL and EPB myopoints in the muscle(s) and or tendons.
Other Recommendations and Exercises
Trigenics may be used as a stand-alone intervention for de Quervain’s tenosynovitis, often with gratifying results. Complimentary therapies will also assist the patient in achieving a good outcome.
Aggressive cryotherapy is helpful to control the inflammation initially and then possibly later to minimize any associated rehabilitation trauma. Stretches for the APL and EPB should be prescribed at regular intervals to restore optimal muscle length and flexibility. Isometric and/or isotonic exercise will help to restore or enhance muscular endurance. Theraband or small hand weights are helpful. Review the exercises with the patient frequently to ensure proper technique.
De Quervain’s Tenosynovitis is a painful condition that commonly affects the wrist. Cumulative microtrauma from repetitive and/or forceful wrist movements is the most common cause. Clinical diagnosis is often straightforward and classically characterized by a positive Finkelstein Test. Numerous management strategies have been suggested to treat this condition. Trigenics® offers an effective conservative treatment intervention for this condition by addressing the strength/length relationship of the APL and EPB muscles from a neurophysiological and biomechanical approach.
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