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de Quervain tendinopathy

de Quervain tendinopathy
Literature review current through: Jan 2024.
This topic last updated: Nov 02, 2022.

INTRODUCTION — de Quervain tendinopathy affects the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons in the first extensor compartment at the styloid process of the radius (figure 1). It is characterized by pain and tenderness at the radial side of the wrist. Although de Quervain tendinopathy is often attributed to overuse or repetitive movements of the wrist or thumb, the cause is generally unknown.

The pathogenesis, clinical manifestations, diagnosis, and treatment of de Quervain tendinopathy are discussed here. An overview of the anatomy and basic biomechanics of the wrist is presented elsewhere. (See "Anatomy and basic biomechanics of the wrist".)

EPIDEMIOLOGY — de Quervain tendinopathy is a common cause of wrist pain in adults. It is most commonly diagnosed among women between the ages of 30 and 50 years of age, including a small subset of women in the postpartum period [1-3]. These women tend to develop symptoms about four to six weeks after delivery.

ETIOPATHOGENESIS — The etiology of de Quervain tendinopathy is not well-understood. In the past, it was frequently attributed to occupational or repetitive activities involving postures that maintain the thumb in extension and abduction. As an example, it has been thought that new mothers are at risk postpartum due to repetitive motion of hands required to lift and hold newborns. Hormonal causes and fluid retention are another plausible explanation. The evidence to support etiologic hypotheses is limited and is largely based on observational data. The histopathology does not demonstrate inflammation but rather myxoid degeneration (disorganized collagen and increased cellular matrix) in patients referred for surgery [4].

de Quervain tendinopathy affects both the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) at the point where they pass through a fibro-osseous tunnel (the first dorsal compartment) from the forearm into the hand [5-7]. These tendons are responsible for bringing the thumb away from the hand as it lies flat in the plane of the palm (ie, radial abduction). Similar to trigger finger (or stenosing flexor tenosynovitis), this disease involves a noninflammatory thickening of both the tendons and the tunnel (or sheath) through which they pass.

PRESENTATION — Patients with de Quervain tendinopathy describe pain at the radial side of the wrist that is more notable with thumb and wrist movement. Some patients may also notice some enlargement and tenderness on the radial side of the wrist. Pain when holding or gripping objects on the affected side is also common. The dominant hand is no more likely to be involved than the nondominant hand [8], and the disease can be bilateral. The pain may radiate to the thumb or forearm. Radiographs are normal in patients with this disorder.

DIAGNOSIS — The diagnosis of de Quervain tendinopathy is based upon the characteristic history of atraumatic radial wrist pain and the following physical examination findings:

Tenderness and enlargement at the first dorsal compartment over the radial styloid (picture 1)

Pain at the radial styloid with active or passive stretch of the thumb tendons over the radial styloid in thumb flexion (the Finkelstein maneuver or test)

de Quervain tendinopathy is diagnosed based on symptoms and examination and is not improved by imaging. Radiographs are expected to be normal, and ultrasonographic findings include a thickened extensor retinaculum, hypervascularity on Doppler ultrasonography, thickening of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) tendons, and partial thinning of the EPB tendon from stenosis by the thickened extensor retinaculum [9].

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of de Quervain tendinopathy includes:

Osteoarthritis of the trapeziometacarpal (TMC) joint

Intersection syndrome

Ganglia

Radial sensory nerve entrapment in the forearm

Calcific arthritis or tenosynovitis

Osteoarthritis of the trapeziometacarpal joint — Osteoarthritis of the TMC joint (the first carpometacarpal [CMC] joint) due to the normal human aging process is eventually observed in everyone. The pain and tenderness of TMC arthritis occurs at the base of the thumb, distal to the radial styloid. The grind test of the thumb, which is performed by axial compression and circumduction of the TMC joint, may elicit crepitation and pain. The Finkelstein test is sometimes, but not always, painful in both TMC arthrosis and de Quervain tendinopathy. When in doubt, selective local anesthetic injection can be used to differentiate the disorders. (See "Anatomy and basic biomechanics of the wrist", section on 'Metacarpals and carpometacarpal joints'.)

Intersection syndrome — Intersection syndrome is an acute tendinopathy that occurs more dorsal and proximal to the first dorsal compartment than with de Quervain tendinopathy (picture 2). This syndrome is associated with the area where the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) cross over the extensor carpi radialis longus and brevis in the distal forearm. In addition to swelling and tenderness in this area, there is often crepitation with wrist motion. A more detailed discussion of intersection syndrome is presented separately. (See "Evaluation of the adult with subacute or chronic wrist pain", section on 'Intersection syndrome'.)

Ganglia — The central and dorsal part of the wrist is a common site for ganglia, which are cystic swellings arising from a joint capsule or tendon sheath (picture 3). Ganglia can be associated with wrist pain during weightbearing in extension, but are often painless. A more detailed discussion of ganglia is presented elsewhere. (See "Ganglion cysts of the wrist and hand", section on 'Definition'.)

Radial sensory nerve entrapment — Although uncommon, the superficial radial nerve in the forearm may be entrapped between the tendons of the brachioradialis and the extensor radialis or at the wrist, where the most frequent offending agent is handcuffs [10]. Unlike de Quervain tendinopathy, superficial radial sensory nerve entrapment causes burning pain and paresthesias over the dorsum of the hand, wrist, thumb, index, and middle fingers [11].

Crystal-induced arthritis — Calcium hydroxyapatite and other crystal-induced arthropathies such as gout and pseudogout can cause acute wrist pain and swelling, including the radial side of the wrist. Significant tenderness, erythema, and swelling are more commonly observed with crystal-induced arthropathies than with de Quervain tendinopathy. (See "Clinical manifestations and diagnosis of calcium pyrophosphate crystal deposition (CPPD) disease" and "Clinical manifestations and diagnosis of gout".)

TREATMENT — de Quervain tendinopathy is a nonprogressive, albeit painful condition that is typically self-limited [12]. There are limited data on the natural history of de Quervain tendinopathy, but it seems generally to resolve in approximately one year and recurrence is unusual [8,12]. Most treatment options alleviate symptoms.

Overall approach — Treatment options for de Quervain tendinopathy include nonoperative measures, glucocorticoid injection, or surgery. Our approach to therapy is usually to start with nonoperative measures, which include a forearm-based thumb spica splint with the interphalangeal joint free, nonsteroidal antiinflammatory drugs (NSAIDs), and application of ice to the affected area. A local glucocorticoid injection can be tried in those whose symptoms have not improved with splinting and NSAIDs. Some patients who present with severe symptoms may benefit from a glucocorticoid injection at the initial presentation.

Most de Quervain tendinopathy resolves without surgery, but some people may opt for surgery in an effort to hasten the recovery.

Nonoperative management — We suggest a forearm-based thumb spica splint with the interphalangeal joint free. The splint may be worn according to patient preferences. Full-time wear of the splint is not necessary since there is evidence that immobilization does not alter the disease course [8]. We also suggest NSAIDs for pain relief, unless contraindicated by gastrointestinal, renal, or heart disease. (See "Initial treatment of rheumatoid arthritis in adults", section on 'NSAIDs'.)

The evidence to support the efficacy of splinting in altering the natural history of de Quervain tendinopathy is limited to observational studies [13-15]. As an example, a retrospective study comparing the use of splinting and NSAIDs, splinting plus glucocorticoid injection, or glucocorticoid injection alone in patients with de Quervain tendinopathy found that 88 percent of patients with minimal symptoms improved with splinting alone [13]. However, satisfaction with splinting and NSAIDs dropped to 32 percent among patients with moderate to severe symptoms.

Occupational therapists can assist with splints and recommendations regarding activity modification for symptom reduction [16,17], but referrals are limited for this condition.

Glucocorticoid injection — For patients with persistent pain and swelling despite splinting and NSAIDs, we suggest a local glucocorticoid injection (picture 4). However, for patients with severe symptoms, a glucocorticoid injection may be appropriate at the initial presentation. We use a glucocorticoid such as methylprednisolone or triamcinolone mixed with a local anesthetic such as lidocaine.

Limited data from observational studies and small randomized trials suggested that most patients experience pain relief after a single glucocorticoid injection [13,18-21]. One small randomized trial found that glucocorticoid injections resulted in better symptom improvement compared with placebo injection one week after injection [19]. Among those who responded to glucocorticoid injections, the beneficial effects were maintained during the 12-month follow-up period. Another randomized trial found that splinting plus glucocorticoid injection was better than splinting alone [21]. The data regarding the benefits of ultrasound guidance for injections are mixed, with some studies suggesting more favorable outcomes with such guidance [22,23] and others finding no added benefit [24].

The risks of glucocorticoid injections include fat atrophy (thinning of the skin) and hypopigmentation (a light patch of skin at the injection site), which are uncommon. Hypopigmentation tends to improve over extended periods of time. It is unclear, based on the limited data, whether there is an increased risk of skin issues with repeat injection.

Surgery — Surgery is generally reserved for patients with persistent symptoms despite nonoperative therapy and glucocorticoid injection. Most patients who understand that de Quervain tendinopathy is benign and self-limiting are unlikely to choose surgery. However, some patients may opt for surgery for faster relief of symptoms. Surgery seems to modify the disease course, but it has not been evaluated in randomized controlled trials of simulated surgery. Surgery involves opening (cutting, releasing) of the first extensor (dorsal) compartment and can be done as a simple office procedure using local or regional anesthesia [25,26].

Symptoms from de Quervain tendinopathy generally improve after surgery [27]. There is also tenderness and thickening of the scar that improves over the year after the procedure. Potential complications of surgery include injury of the superficial radial sensory nerve, continued symptoms from an incomplete release, infection, and an unsightly scar.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues in muscle and tendon injury diagnosis and management" and "Society guideline links: Muscle and tendon injuries of the upper extremity (excluding shoulder)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: de Quervain tendinopathy (The Basics)" and "Patient education: Tenosynovitis (The Basics)")

SUMMARY AND RECOMMENDATIONS

Etiopathogenesis – de Quervain tendinopathy affects the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons at the point where they pass through a fibro-osseous tunnel (the first dorsal compartment) at the styloid process of the radius (figure 1). This disease involves an idiopathic, noninflammatory thickening of both the tendons and the tunnel (or sheath) through which they pass. (See 'Introduction' above and 'Epidemiology' above and 'Etiopathogenesis' above.)

Clinical presentation – Patients with de Quervain tendinopathy describe pain at the radial side of the wrist worse with thumb and wrist movement. There is usually some enlargement and tenderness on the radial side of the wrist. (See 'Presentation' above.)

Diagnosis – The diagnosis of de Quervain tendinopathy is based upon the characteristic history of atraumatic radial wrist pain and the following physical examination findings (see 'Diagnosis' above):

Tenderness and enlargement at the radial styloid at the first dorsal compartment (picture 1)

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)

Differential diagnosis – The differential diagnosis of de Quervain tendinopathy includes osteoarthritis of the trapeziometacarpal (TMC) joint, intersection syndrome, ganglia, radial sensory nerve entrapment in the forearm, and calcific arthritis or tenosynovitis. (See 'Differential diagnosis' above.)

Approach to treatment – de Quervain tendinopathy is typically self-limited. Most treatments alleviate symptoms. The choice of therapy largely depends upon the individual patient's values and preferences. Treatment options include a forearm-based thumb spica splint with the interphalangeal joint free, nonsteroidal antiinflammatory drugs (NSAIDs) for pain relief, glucocorticoid injection, and surgery. (See 'Treatment' above.)

Nonoperative management – For patients with de Quervain tendinopathy, we suggest a forearm-based thumb spica splint with the interphalangeal joint free as well as a concurrent trial of NSAIDs for pain relief (Grade 2C). (See 'Nonoperative management' above.)

Glucocorticoid injection – For patients with de Quervain tendinopathy and persistent pain and swelling despite nonoperative management with splinting and NSAIDs, we suggest a local glucocorticoid injection (Grade 2C). Patients who present with severe symptoms may benefit from a glucocorticoid injection at the initial presentation. We use an intermediate-acting glucocorticoid for injection such as methylprednisolone or triamcinolone mixed with a local anesthetic such as lidocaine(See 'Glucocorticoid injection' above.)

Surgery – Surgery is generally reserved for patients with persistent symptoms despite nonoperative therapy and glucocorticoid injection. However, most patients who understand that de Quervain tendinopathy is benign and self-limiting are unlikely to choose surgery. (See 'Surgery' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Bruce Anderson, MD, who contributed to an earlier version of this topic review.

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