As a board-certified orthopedic surgeon and hand surgeon, I frequently encounter patients struggling with radial-sided (thumb) wrist pain. A common culprit behind the pain is an ailment known as De Quervain’s tenosynovitis. This inflammatory condition can significantly impact hand grip and, as a result, many activities of daily living. Let’s delve into the causes, symptoms, and, most importantly, the treatment options available to get people experiencing De Quervain’s tenosynovitis back to pain-free living.
The Thumb’s Powerhouse: Understanding the Anatomy
Imagine the thumb as a master manipulator, essential for grasping, pinching, and wielding objects. At its base, two crucial tendons, the abductor pollicis longus and extensor pollicis brevis, reside in a narrow tunnel in your wrist called the first dorsal compartment. These tendons are enveloped by a sheath that acts like a lubricant, ensuring smooth gliding during thumb movements.
De Quervain’s Tenosynovitis: Inflammation Disrupts Harmony
De Quervain’s tenosynovitis disrupts this harmonious system. Inflammation within the sheath narrows the space in the tunnel, causing friction and pain whenever the tendons move. This can be likened to squeezing a thick rope through a narrow tube – it just doesn’t work smoothly.
What Triggers This Discomfort?
The exact cause of De Quervain’s tenosynovitis remains elusive, but several factors can play a role:
- Repetitive Thumb Actions: Activities that involve repetitive grasping, pinching, or twisting the wrist, like gardening, using specific tools, or playing racket sports, can overload the tendons, leading to inflammation.
- Hormonal Fluctuations: Pregnant and postpartum women are more susceptible due to hormonal changes that affect the tissues around the tendons. 
- Direct Injury: A fall or blow to the wrist can sometimes trigger this condition.
- Underlying Inflammatory Conditions: People with rheumatoid arthritis or other inflammatory disorders may be more prone.
The Telltale Signs: How to Recognize De Quervain’s Tenosynovitis
The most common symptoms are pain and tenderness at the radial side – the thumb side of your wrist. This pain often intensifies with gripping or pinching activities, like holding a grocery bag or turning a doorknob. Other signs to watch out for include:
- Swelling over the thumb side of the wrist
- Difficulty grasping or pinching objects secondary to pain
- A positive “Finkelstein Test,” which is performed by 1) placing the thumb fully flexed into the palm and 2) grasping the thumb with all remaining digits and then 3) ulnar deviating the wrist (flexing the wrist towards the direction of the pinky finger), essentially putting the inflamed tendons on stretch – this test is quite specific for patients with De Quervain’s.
Interestingly, De Quervain’s is predominantly a female condition mainly because it is observed among new moms. Theories have been raised identifying postpartum hormonal changes, nursing activities, baby lifting, and baby caring activities as potential causes. Frankly, given the high correlation between De Quervain’s patients and new motherhood, I believe each plays a role. I have seen this condition in new moms more than any other group. The other group is the post-breast cancer-treated patients who are on Aromatase Inhibitor (AI) therapy. This is the second largest group of patients we see, so if you add up new moms and breast cancer patients, you can see why it is a primarily female patient population disproportionately impacted by De Quervain’s.
Diagnosis: A Straightforward Approach
Diagnosing De Quervain’s tenosynovitis typically involves a physical examination. I’ll inquire about your symptoms and activities and perform tests to assess tenderness, swelling, and the range of motion in your wrist and thumb. An ultrasound scan might sometimes be used to visualize the inflamed tendons and confirm the diagnosis, but most often a good physical exam will make the diagnosis clear. The most common other condition which can be confused with De Quervain’s is osteoarthritis at the base of the thumb, which is extremely common, has some similar features but a careful exam and x-rays, if necessary, can distinguish the two from one another.
Taming the Inflammation: Treatment Options We Can Explore
Fortunately, De Quervain’s tenosynovitis often responds well to conservative measures:
- Rest: Avoiding activities that aggravate the pain is crucial for allowing the inflammation to subside. Immobilization with a splint or brace for a short period may be recommended.
- Ice Therapy: Applying ice packs for 15-20 minutes at a time, several times a day, can help reduce inflammation and pain.
- Anti-Inflammatory Medication: Over-the-counter oral medications like ibuprofen or naproxen can manage pain and inflammation. Similarly, topical medications like diclofenac can be used to reduce pain and inflammation as well. Since the tendons are just beneath the skin, this can be an effective method to treat the area without the possible side-effects of oral medications like reflux.
- Corticosteroid Injection: Injections of cortisone directly into the inflamed area can relieve pain. However, these are typically limited due to potential side effects with repeated use.
- Hand Therapy: Exercises to strengthen the muscles around the wrist and thumb and improve flexibility can aid recovery and prevent future problems. An additional treatment performed by hand therapists called iontophoresis or phonophoresis are highly effective ways to treat De Quervain’s as these are electrical and ultrasound-assisted methods of getting medications – typically dexamethasone (a corticosteroid) into the area of the first extensor compartment. This can be a remarkably effective method of getting corticosteroid medication into the area without the side effects which can be seen with injections.
Surgery: A Last Resort
If conservative measures fail to provide relief after a reasonable trial period, surgery might be considered. This outpatient procedure involves widening the first dorsal compartment to create more space for the tendons and alleviate pressure. This procedure takes less than 30 minutes to perform and has a short recovery period.
Preventing the Onset of Pain: Taking Control
While not always preventable, here are some strategies to reduce your risk:
- Maintain Proper Form: If you perform repetitive hand and wrist movements, ensure proper technique to avoid strain.
- Take Breaks: Don’t overdo it. Take frequent breaks during activities that involve repetitive thumb movements.
- Strengthen Your Forearms: Exercises that strengthen the muscles in your forearm can improve wrist stability and reduce stress on the tendons.
- Listen to Your Body: Pay attention to any pain or discomfort in your wrist. Stop the activity and consult a specialist if symptoms persist.
Sources:
https://orthoinfo.aaos.org/en/diseases–conditions/de-quervains-tendinosis/
https://my.clevelandclinic.org/health/diseases/10915-de-quervains-tendinosis
https://www.assh.org/handcare/condition/dequervains-tenosynovitis
https://www.ahta.com.au/de-quervains
