De Quervain’s Tenosynovitis Tendon Sheath Inflammation
De Quervain’s tenosynovitis causes pain around the base of the thumb. A pain often experienced when using or moving their thumb into a hitch-hiking posture and performing actions with the wrist and thumb angled as such that they are pointing down towards the floor. And functionally triggered with gripping, twisting, pinching and wringing actions. When triggered the pain can extend from the wrist down towards the base of the thumb and likewise extending up away from the wrist spreading into the lower forearm.
In the acute phase around the onset of symptoms the pain associated with De Quervain’s tenosynovitis is typically related to inflammation involving the synovium. The synovium is the inner lining of the sheath that surrounds many tendons as they travel across the moving parts of the body. This sheath has a number of roles from protecting and lubricating the tendon as well as and providing nutrition to the tendon it encases. With De Quervian’s inflammation of the synovium is generally in reaction to overuse of the tendons that help move your thumb. The trigger of which can come about in several ways.Causes Of De Quervain’s Tenosynovitis
The chronic overuse of the thumb and wrist is the most common cause and when gripping, clenching, grasping, pinching and wringing actions are repeatedly performed these actions may in-turn overload the tendon and tendon sheath ultimately causing thickening & swelling of the tendon-sheath complex. With many new mothers the constant lifting, carrying, patting… that comes with the role of being a new parent can cause sudden overload to these tissues with little time for adaption. De Quervain’s Tenosynovitis however is not exclusively a new mum issue. Similar to many other tendon complaints as a condition it is more prevalent in the 30-50 years old age bracket, an age where as a rule tendons are less tolerant of changes in load and are more reactive. Some of the other causes of De Quervain’s tenosynovitis include:- Inflammatory arthritis, such as rheumatoid arthritis.
- Injury/impact to the wrist or direct to the tendon. Although an uncommon cause a direct trauma may create a local damage and inflammation within the tendon-tendon sheath. As well as this local trauma may cause post traumatic scar tissue which then restricts freedom of movement of the tendons- tendon sheath which can create a vulnerability to developing irritation when overusing the thumb later on down the track.
Signs And Symptoms Associated With Thumb Tenosynovitis
Discomfort grasping objects, making a fist and/or performing pinching movements are ultimately the most common symptoms associated with this condition. People with thumb tenosynovitis may also notice or complain of experiencing the following:- Palpable creaking at, and above the wrist associated with the movement of the tendons
- Swelling visible near the base of the thumb at times the swelling can spread upwards towards the elbow (however usually no further than around 10-15cm up the arm). At times this swelling can be quite substantial and very noticable.
- “Catching” or “sticking” sensation when moving the thumb
- Reduced grip strength and/or pinch strength testing, this weakness is commonly associated with pain performing the tests and with similar lifting/gripping actions. Pain with movement of the thumb, specifically with actions where the thumb is moved downward into an ulna deviation direction (being the movement of the wrist downwards towards the little finger side of the hand). Movement in this direction is the foundation of the Finklestein’s Test. This test is what is referred to in physiotherapy as a “special test” and helps in assisting in the diagnosis of thumb tenosynovitis. A test whereby the arm is positioned into the hitch-hiking posture with the thumb tucked into the palm and a fist is formed by wrapping the fingers around the thumb and subsequently the wrist is bent downwards towards the floor. A positive Finklestein’s Test reproduces pain in the tendon area at the base of the thumb with this test and sometimes associated with limited downwards movement of the wrist performing this action when comparing to the opposite side.
Diagnosis Of Tendon Related Thumb Pain
Making a diagnosis of De Quervain’s tenosynovitis is typically a clinical one, meaning it is a diagnosis landed on from the location of the pain, associated history, combined with objective testing of the area often including the above discussed Finklestein’s test. Generally there is no need for imaging or any other investigations to make a diagnosis of gamers thumb unless looking to rule out other potential conditions capable of causing similar symptoms or should pain persist despite appropriate treatment. If situation arises an X-ray can assess any osteoarthritic changes at the joints and the use of an ultrasound scan or MRI can further examine any soft tissue changes potentially adding more useful info to the diagnostic picture.Treatment Of Gamers Thumb
Physiotherapy treatment for tendon related thumb pain is usually successful. Once the stress and overloading to the tendon complex is under control pain and functional limitations tend to resolve. It is in my experience that it is best to address the issue prior to it becoming chronic. The longer this sort of thumb pain is present the harder it is to resolve. A few of the physio approaches used in the management of tendon related thumb pain include:- Unloading (more commonly referred to as rest). As with many overload complaints relative rest plays a substantial roll in the rehabilitation process. Keeping pinching movements and gripping actions to a minimum in the early stages will often help the pain settle quicker in those first few days. Beyond this your physio can help by reviewing how you use your wrist and thumb and offer suggestions on how best to adjust daily activities in an attempt to reduce loading stress.
- The use of wrist braces, splinting and/or taping can assist in unloading the tendon complex, stabilizing the thumb enhancing the rest period whilst retaining some function. Braces can be a very effective short-term tool in the management of tendon related thumb pain.
- A physio is skilled in prescribing active management approaches offering in-clinic or at home exercises to restore mobility, strengthen muscles, reduce pain as well as limit tendon irritation.
- It the sub acute and chronic phases of the condition our Randwick physio team have found the use of shockwave therapy to be a very effect management tool in helping restore movement and manage pain. When used in isolation or when accompanied with other more classical physio manual therapy approaches.
- In the acute and sub-acute phases the application of ice can be an effective pain management tool
- Topical anti-inflammatory medication such as voltaren Emulgel can be used to good effect.
- In more stubborn situations cortisone injections can be use should physiotherapy treatment fail to yield satisfactory results.
- Should thumb pain persists despite appropriate more conservative treatment approaches then occasionally surgery is considered in an attempt to release “pressure” on the tendons and assist the tissues in gliding freely without pain. Professionally I have found that appropriate physio combining some combination of the above mentioned approaches is typically enough to settle even the most stubborn of De Quervain’s tenosynovitis complaints.
