De Quervain's tenosynovitis is a painful inflammation of the tendons at the base of the thumb. This process involves the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. These muscles are located on the dorsal surface of the forearm and pass to the lateral side of the thumb through the fibro-osseous tunnel formed by the styloid process of the radius and the extensor retinaculum. Pain, which is the main complaint in this disease, occurs with abduction of the thumb, grasping movements and ulnar deviation of the hand. Swelling and hardening of the tissue may also be present.
Clinically Relevant Anatomy
Clinically Relevant Anatomy
Extensor pollicis brevis
- Beginning: ½ of the posterior surface of the body of the radius, interosseous septum of the forearm.
- Attachment: base of the proximal phalanx of the thumb.
- Functions: wrist joint: radial abduction;
- thumb: extension.
Abductor pollicis longus muscle
- Beginning: posterior surface of the radius and ulna, interosseous septum of the forearm.
- Attachment: base of the first metacarpal bone.
- Functions: wrist joint: radial abduction;
- thumb: abduction.
Etiology
- Currently, the cause of the disease is associated with myxoid degeneration (a process in which connective tissue is replaced by a gelatinous substance) rather than with acute inflammation of the synovium. In myxoid degeneration, there is excessive deposition of fibrous tissue and increased vascularization, which causes a thickening of the tendon sheath. This causes the extensor pollicis brevis and abductor pollicis longus muscles to become pinched.
- The main cause of the disease is repetitive movements in the wrist joint, especially those in which radial abduction of the thumb occurs with simultaneous extension and radial deviation of the wrist.
- The classic contingent of patients are mothers of newborns who constantly lift babies with a radially abducted thumb and wrist, moving from ulnar to radial deviation.
- The most common cause is chronic cumulative trauma.
- Cumulative injuries can occur from golfing, playing the piano, fly fishing, carpentry, or carrying a child for long periods of time. Also at risk are office workers and musicians.
- Repeated squeezing, grasping, clenching, squeezing or squeezing (when washing, for example) movements can cause inflammation of the tendons or their sheaths. This may lead to narrowing of the first dorsal compartment, resulting in a limitation in range of motion. If left untreated, inflammation and progressive narrowing (stenosis) can lead to scarring and subsequent restriction of movement of the thumb.
- In women, this disease occurs approximately 10 times more often than in men. Most often it occurs after the birth of a child and mainly occurs in women 30-50 years old. With the advent of new technologies and the proliferation of gadgets, it became known as “Blackberry Thumb Syndrome.”
Diet
Diet for thyroid disease
- Efficacy: therapeutic effect after a month
- Timing: constantly
- Cost of food: 1600-1700 rubles per week
A healthy diet and active lifestyle reduce the risk of viral infections and subacute thyroiditis. Patients' diets should include foods rich in omega-3 acids . These are flaxseed oil, arugula, green beans, seafood, fish, flax and chia seeds, dill, parsley, cilantro, beans, avocado. When choosing vegetable oils, it is better to choose olive, sesame, flaxseed, and walnut. Fish and seafood grown in natural conditions contain more omega-3 acids . For meat, it is better to prefer beef and veal, vegetables and fruits - any in season.
For any disease of the gland, vitamins and microelements are necessary:
- Selenium is contained in bran, whole grains, lentils, chickpeas, and beans.
- Zinc is found in seafood, pumpkin seeds, peas, beans, sesame seeds, peanuts, lentils, peanut butter, cabbage, spinach, zucchini, watercress.
- We get magnesium by eating wheat bran, nuts (cashews, almonds), soy, cocoa, buckwheat and oatmeal, brown rice, spinach.
- Sources of vitamin D are cottage cheese, fermented milk products, cheese, fish oil, vegetable oils, fish liver, and fish.
- Vitamin B 12 contains liver, fish, seafood, cheese, feta cheese, kefir, sour cream, green onions, lettuce, spinach.
- Sources of vitamin B9 are peanuts, broccoli, green onions, legumes, spinach, hazelnuts, salads, and wild garlic.
Clinical picture
Clinical picture of de Quervain's tenosynovitis
The main complaint of patients is pain in the wrist on the side of the radius, which radiates to the forearm when trying to grab something with the thumb or straighten it. The pain is described as “constantly aching, burning, twitching.” Often the pain is aggravated when performing grasping, squeezing or twisting movements. Examination may reveal swelling in the area of the anatomical snuffbox, tenderness in the area of the styloid process of the radius, decreased range of motion in the first metacarpal joint, palpable thickening of the first dorsal compartment, and tendon crepitus. Other symptoms include weakness and paresthesia of the hand. These symptoms appear with a positive Finkelstein diagnostic test.
Healing process after surgery
Pain after surgery is usually minimal and most patients do not require painkillers.
Typical pain symptoms disappear after surgery, and the radiating pain goes away after a few days. In rare cases, friction is felt in the tendons, which completely disappears after a few weeks. Negative sensations in the postoperative scar largely disappear after the first 6-8 weeks; after 3-6 months, patients no longer complain of pain in the scar. However, only after 12 months can we say that the scar has completely healed. © Dr. Klaus Lovka
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Survey
Inspection
Evaluation of a patient with signs and symptoms of de Quervain's tenosynovitis should begin with a thorough history followed by a physical examination.
History taking
- Overuse injury or acute injury.
- Have symptoms appeared before?
- Repetitive hand movements during work or daily activities.
- The pain is localized above the base of the thumb and in the dorsolateral region of the wrist near the styloid process of the radius.
- One hand dominance.
- Pregnancy or postpartum period.
Physical examination
Vital Signs
- Height.
- Weight.
- HELL.
- Pulse.
- NPV.
- Temperature (if required).
In a sitting position
- Resting hand/thumb position.
- Inflammation around the base of the finger on the dorsal side and/or near the styloid process of the radius.
Neurological examination
If you have symptoms such as numbness and tingling, as well as pain, it is necessary to conduct a neurological examination and check whether the symptoms are associated with pathology in the cervical spine. It is important to determine whether the central nervous system is involved in the process, whether the sensitivity of the skin at the base of the thumb and index finger is reduced (this area is innervated by the superficial branches of the radial nerve). Pay attention to a symptom such as hand weakness and determine whether it is due to pain or a neurological problem.
Dermatomes (C4-T1)
- Myotomes (C4-T1).
- Reflexes (C5, C6, C7).
- Pathological Hoffman reflex.
Palpation
During palpation, the most significant will be the detection of such a deviation as painful sensitivity over the base of the thumb and/or the 1st compartment of the wrist extensors above the styloid process of the radius. It is also possible to palpate the thickening of the synovial vagina. It is very important to rule out arthritis or a fracture of the scaphoid by palpating the first carpometacarpal joint to determine whether there is tenderness or deformity there.
- Dorsoradial region.
- Styloid process of the radius.
- “Anatomical snuffbox” - scaphoid, trapezius, extensor digitorum longus, extensor pollicis brevis, abductor pollicis longus and first carpometacarpal joint.
- Soft tissue surrounding the affected area.
Range of motion
Range of motion can also be used as a screening tool to rule out involvement of the cervical spine, proximal joints, and anatomical structures. Note any deviations in range of motion and be aware that when testing the thumb, there may be a clicking sound and a feeling of “sticking” in the thumb. All this is associated with reduced tendon mobility.
- Range of motion in the cervical spine.
- Flexion, extension, adduction and abduction of the shoulder (right and left).
- Flexion and extension in the elbow joint (right and left).
- Pronation and supination of the forearm (right and left).
- Wrist: Flexion, extension, ulnar and radial deviation.
- Fingers two to five:
- Abduction and adduction in the metacarpophalangeal joints.
- Flexion and extension (in the metacarpal, metacarpophalangeal and interphalangeal joints).
- Abduction and adduction (in the metacarpal-carpal, metacarpophalangeal joints).
- Opposition.
Muscle tests with resistance
In the presence of pain, strength naturally decreases. Note the maximum force possible in the absence of pain. This data will be useful in tracking the patient's progress during treatment.
- Grip strength.
- Pinch strength (finger squeezing force).
Muscle length
Watch for signs of hyper/hypomobility. Treatment will be prescribed based on dysfunction. Keep in mind that areas of hypomobility are often areas of referred pain.
- Congenital flexibility (clawed hand symptom).
- Extensors and flexors of the wrist.
Joint mobility
- Distal radioulnar joint.
- Wrist joint.
- Midcarpal joint.
- Thumb.
- Metacarpal, metacarpophalangeal and interphalangeal joints.
- Brush.
- Intercarpal joints.
Specific tests
Finkelstein test
- To confirm - Finkelstein test.
- To exclude: test for osteoarthritis of the first metacarpal joint (Grind Test);
- palpation to identify a scaphoid fracture;
- Upper Limb Tension Test, or ULTT B - to determine neuritis of the superficial sensory branch of the radial nerve;
- assessing the clinical likelihood of cervical radiculopathy;
- intercarpal instability.
Neurological tests
- Upper Limb Tension Test, or ULTT B.
- Test to detect damage to the radial nerve.
- Test to detect damage to the superficial sensory branch of the radial nerve.
- Tinel's sign.
Be careful with the position of your thumb while performing tests.
Circulation
- Pallor/Capillary refill.
- It is important to use the capsule-ligamentous apparatus in the acute phase of traumatic injury.
- Stress test of the collateral ligaments of the fingers (varus/valgus).
List of sources
- Thyroid diseases. Ed. L.I. Braverman. Moscow. Medicine, 2000, pp. 173-193.
- Petunina N.A., Trukhina L.V. Thyroid diseases. M.: GEOTARMEDIA, 2011. – P. 74-106.
- Dedov I.I., Melnichenko G.A., Andreeva V.N. Rational pharmacotherapy of diseases of the endocrine system and metabolic disorders. Guide for practicing doctors, M., 2006.
- Filatova S.V. Treatment of thyroid diseases using traditional and non-traditional methods. Ripol classic, Moscow. — 2010.— 256 p.
Differential diagnosis
- Intercarpal instability. The wrist is a complex anatomical area consisting of a large number of small bones and ligaments. Degenerative processes or direct trauma can lead to instability between the articulating bones, which in turn leads to pathological changes in the biomechanics of the hand and the appearance of pain. Scapholunate dissociation, scaphotrapeziotrapezial joint degeneration, and lunate-triquetral dissociation can all be associated with radial wrist pain.
- Fracture of the scaphoid bone.
- Most often, a scaphoid fracture occurs as a result of a fall on an outstretched arm with an extended wrist. In this case, pain occurs on the side of the radius, there is also swelling in the area of the anatomical snuffbox, limited range of motion, pain when performing a movement, especially at the end of the amplitude. If the patient has been injured and subsequently experiences pain in the wrist from the side of the radius, then it is first necessary to exclude a fracture of the scaphoid bone.
- Damage to the superficial branches of the radial nerve (Wartenberg syndrome). The superficial branches of the radial nerve innervate the dorsal surface of the first and second fingers and the first interdigital space. Nerve fibers can become compressed between the extensor carpi radialis brevis and brachioradialis tendons due to scar tissue formation after injury or from wearing tight jewelry. As a result of compression, ischemia develops and, as a result, numbness and tingling in the area of innervation.
- Radiculopathy of the cervical spine at the C6 level. Compression of the spinal nerve roots can cause sensory disturbances, muscle weakness, and weakened reflexes. The key dermatomes of the C6 segment are the radius of the second metacarpal and the index finger, which is approximately the same area where pain occurs in de Quervain's syndrome. It is precisely because of the similarity of symptoms that it is important to exclude cervical radiculopathy and carefully check the C6 segment.
- Osteoarthritis of the first metacarpal joint. Osteoarthritis of the first metacarpal joint usually occurs in people over 50 years of age and usually manifests itself as stiffness of the joint in the morning, decreased range of motion, and tenderness in the area. With this disease, the squeeze test will be positive.
- Crossover syndrome. With this syndrome, pain will occur closer to the back of the forearm, mainly in the middle and about 5 cm below the wrist.
Pathogenesis
Granulomatous infiltration of giant cells develops in the gland tissue in response to the introduction of the virus. The formation of giant cells is characteristic of autoimmune processes, and in some patients, autoantibodies to the thyroid gland appear in the blood. This fact indicates the presence of secondary autoimmune mechanisms in this disease. The introduction of the virus into a thyroid cell is accompanied by its destruction, while the contents of the follicle enter the blood and, against the background of destruction, thyrotoxicosis . Subsequently, the function of the gland is restored and temporary thyrotoxicosis is replaced by hypothyroidism and normalization of function (euthyroid state).
Treatment
The goal of treatment for de Quervain's tendonitis is to reduce pain caused by irritation and swelling.
Conservative treatment
The goal of nonsurgical treatment is to reduce pain and swelling. At the initial stage the following can be used:
- Immobilize the thumb or wrist joint with a splint or splint to rest the tendons. So far, clinicians have not reached a consensus on the duration of wearing orthoses: a number of experts recommend wearing them for 4-6 weeks, others recommend wearing them only during periods of pain.
- Avoiding repetitive movements and movements that aggravate the condition.
- Applying ice.
- Taking NSAIDs.
- Injections of corticosteroids into the synovial membranes.
- Physical therapy.
Patients may also be required to be immobilized for up to 6 weeks. To do this, use a bandage on the thumb. It was found that when wearing an orthosis, improvements occurred in 19% of cases. However, with simultaneous use of NSAIDs, this figure was even higher and amounted to 57%.
Ultrasound examination, according to some estimates, can have a positive effect on treatment results. In addition, it can act as a diagnostic tool. Injections administered under ultrasound guidance were more effective. In addition, there were no side effects. Ultrasound-guided injections performed into the extensor pollicis brevis area with septation are more effective than manual injection.
Another effective conservative treatment option is steroid injection, but more research is needed to establish its full benefits.
Direct injection of a small dose of cortisone into both tendons has worked well. For primary disease, the effectiveness of this measure is about 60-70%.
Recovery prognosis
As a rule, with timely and competent treatment, specialists guarantee positive dynamics. If conservative procedures are implemented, it is possible to count on a favorable prognosis in 50% of situations. After surgery, it is possible to achieve the maximum positive effect. However, if after surgical manipulation the patient continues to overload the hand, a relapse of the disease may occur. This indicates the need to change the nature of the patient’s work activity after completion of treatment.
Physical therapy
Friends, on July 17 in Moscow, as part of the #RehabTeam project, Anna Ovsyannikova’s seminar “Rehabilitation of the hand after a fracture of the distal radius (fracture of the “radius in a typical place”)” will take place.” Find out more... In addition, on July 18, she will conduct a seminar “Rehabilitation of the hand after fractures of the metacarpal bones (Boxer fracture).” Find out more...
Applying Ice/Heat
Heat can help relax tight muscles, and ice can help reduce inflammation of the extensor sheath.
Massage
Deep tissue massage in the area of the big toe can also help relax tight muscles, leading to less pain.
Stretching
You can also relax the tight muscles of the thumb eminence by stretching. This is facilitated by extension and abduction of the thumb.
Increased strength
- Finger extension with resistance.
- The position of the palm up is extension and abduction of the thumb.
- Thumb up - extension and abduction of the thumb.
- Radial deviation with resistance.
- Thumb up – supination with resistance.
- Thumb up – Opposing the thumb with resistance.
Increased range of motion
As mentioned above, stretching can help increase your range of motion. Applying ice/heat helps relax tight muscles, which also leads to increased range of motion.
Reduced swelling
The following measures may help reduce swelling:
- Thumb splinting.
- Corticosteroid injections.
- NSAIDs.
- Cold/warm.
- Massage.
- Stretching.
Preparation for surgery:
- Bleeding: The operation is performed on a hand that has been bled dry to ensure optimal visibility conditions and limit the risk of damage to important structures (nerves, blood vessels, tendons). The operated arm is wrapped in a rubber bandage and the shoulder is pressed with a pressure cuff during the operation.
- Disinfection of the skin and covering with a sterile cloth: To avoid infection, the skin is disinfected and the surgical site is covered with a sterile cloth.
- Magnifying glasses: The operation is performed using magnifying glasses, which help to clearly distinguish and thereby protect the important functional structures of the hand.
Exercises at home
Any of the stretching or strength-building exercises listed above can be incorporated into a home recovery program. At home, patients can also use ice packs or apply heat. After completing the training, patients can also perform self-massage at home.
To date, there have been no high-quality studies examining the effects of conservative treatment as a stand-alone intervention. The literature primarily describes the effects of corticosteroids and other injections compared with placebo. Studies that showed injections were better than splinting did not examine long-term results.
A Cochrane review states that there is “silver-level” evidence that corticosteroid injections are superior to splinting for pain relief. The authors, however, acknowledge that "the evidence is based on a short-term, very small, controlled clinical trial of low methodological quality that included only pregnant and breastfeeding women."
Walker presented a case study that examined the use of manual techniques in a patient with radial wrist pain. Although de Quervain's disease was immediately ruled out, the report advocated an approach using manual techniques. Particularly for the relief of pain and dysfunction in radial, radiocarpal, intercarpal and first metacarpal joint pain.
Ashurst described a case in which a patient diagnosed with de Quervain's disease was prescribed oral anti-inflammatory drugs, a brace, and relative rest. The patient wore the orthosis at night and was instructed to text as little as possible (a series of messages always preceded the onset of pain). This case supports the prescription of relative rest, in which the patient avoids aggravating movements but remains active.
Viikari-Juntura presented a literature review and found that wearing an orthosis is an essential component of the treatment of tenosynovitis. It was found that the use of an orthosis that allowed some movement was preferable to complete immobilization of the thumb. Rest from work, according to the survey, is neither necessary nor desirable. It was also found that heat, massage, and electrotherapy were not effective in improving the patient's physical capabilities.
Tests and diagnostics
Laboratory diagnostics include:
- General blood analysis. Changes are detected: the erythrocyte sedimentation rate increases (30-70 mm/h), normal or slightly increased number of leukocytes.
- Blood chemistry. Increased C-reactive protein, sialic acids, α2-globulin, fibrinogen.
- In the thyrotoxic stage, the levels of T3 and T4 increase with a simultaneous decrease in thyroid-stimulating hormone. Subsequently, the levels of T3 and T4 decrease, and an increase in TSH is noted. After 2-3 weeks from the onset of the disease, the titer of antibodies to thyroglobulin and thyroid peroxidase . After several months, the antibodies disappear.
Ultrasound of the thyroid gland. Subacute thyroiditis is characterized by: enlargement of the thyroid gland, blurred contours, decreased echogenicity in the affected area. Sometimes migration of zones of reduced echogenicity is observed if dynamic ultrasound is performed. In this case, normal echogenicity of the unaffected lobe is noted.
Normalization of the echostructure of the gland occurs with a delay when compared with clinical and laboratory parameters.
Scintigraphy of the gland. It is not considered a mandatory method and is used only in complex diagnostic cases. Scintigraphy shows a decrease in the uptake of the radioactive drug or no uptake. The inflammation zone is “cold”.
Fine needle aspiration biopsy of the gland and examination of the material. It is also a rare procedure in research. It is carried out when the diagnosis is uncertain. Histological examination reveals a picture of granulomatous inflammation with the presence of giant cells.
Gland bopsy
The diagnosis is confirmed by the Kreill test: it is considered positive if there is a good response to prednisolone . Within 1-2 days, patients experience a decrease in the size of the gland and pain.