De Quervain’s Tenosynovitis: A Patient’s Guide To Curing Wrist Pain
What is De Quervain’s Tenosynovitis?
Let’s do another intro article to get you up to speed on a common hand and wrist condition known as De Quervain’s tenosynovitis.
In its most basic form, this is a tendinitis of the thumb-side of your wrist.
If you take a quick moment to make a thumbs-up motion and look down at your wrist. Do you see the two tendons that stick out to form a ‘box’ on the thumb side of your wrist (see Figure 1)? The lower of those two tendons is an anatomic location known as the first dorsal compartment. Essentially, it’s a collection of tendons that run in a tight tunnel.
Fun fact: The ‘box’ you see on your wrist (see Figure 2) is known as the ‘anatomic snuffbox.’ No, seriously, that’s the ‘doctor’ name for it. You can also feel your pulse inside that box (isn’t anatomy cool?).
So. These tendons run in a very tight tunnel just above the anatomic snuffbox (see Figure 3). With repetitive overuse of your wrist, hand, or thumb, you can develop irritation along the tendons inside the tunnel.
Irritation leads to inflammation. Which leads to thick, fibrous scar tissue formation in the tunnel. Which leads to friction in a tight space. Which leads to pain!
Classically, the absolute worst position for this condition is a position of wrist ulnar deviation and thumb extension (see Figure 4 above). “Dr. G, enough of the technical jargon, I don’t even recognize that position, I rarely do that funky motion with my hands.”
Think again…
Recognize it now?
That’s right. This condition is commonly known as ‘texter’s thumb,’ ‘gamer’s wrist,’ or (cringe) ‘mommy’s wrist’ (see Figures above).
Ulnar deviation and thumb extension is the position we use to text, play video games, pick babies up out of a crib, and breastfeed.
And you know what the other big culprit is? Scissors!
So if you have a project that requires repetitive scissor use (elementary teachers beware), you’re going to want to modify your positioning, take breaks, and be on the lookout for early signs of irritation.
How Is De Quervain’s Diagnosed?
Continuing with the theme of diagnosing yourself (for carpal tunnel syndrome, see here), this is one of the easiest conditions in all orthopedics to diagnose. If you learn one thing, learn the modified Eichoff or Finkelstein test (there we go with the names again).
Here’s how to do it, with pictures and video to help. Warning, this can be painful if you have De Quervain’s tenosynovitis (hence, easy to diagnose):
Turn your palm ninety degrees to the floor.
Bend your thumb down into your palm.
Wrap your fingers around your palm.
And now tip your whole hand to the floor, into ulnar deviation.
Video 1 - The Finkelstein’s, or modified Eichoff maneuver
Did this send you through the roof with pain? I warned you!
If it did, then you can be 99% sure you have this condition. Other common symptoms include aching on the thumb side of your wrist, pain when you squeeze directly on the tunnel (see Figure 3 above), and in rare cases, a sense of numbness or tingling over the back side of your thumb.
Knowledge Is Power. And The Best Treatment.
You may have noticed there’s a similar structure to most things we treat in hand surgery. Treatment exists on a spectrum — from doing the least invasive thing possible…all the way to surgery on the other end.
And you know what’s really effective for treating De Quervain’s?
Knowledge.
What do I mean by that? Do you remember those photos I showed earlier of all the activities that involve ulnar wrist deviation and thumb extension? Texting, gaming, scissors, lifting a baby out of a crib, breastfeeding…
Well, now you know what things exacerbate this condition. Which means you now know that you shouldn’t do those activities!
Actually, more specifically, don’t do those activities in that position. This is where the treatment strategy ‘activity modification’ comes in. You’re not going to stop nursing your baby. But can you modify the way you hold her so as to avoid this position? Absolutely.
Change how you text. Change how you grip the scissors. Ask for help from a friend if you’re feeling sore.
The point is to let the inflammation calm down long enough to be able to extinguish it for good.
This is not a “No pain, no gain” scenario. Quite the opposite. Instead, here’s the simplest and best piece of advice I can possibly give you: if it hurts…don’t do it.
A Brace To Augment Recovery
Ok, so you’ve tried activity modification, but you still aren’t 100% better. Or you want to speed up your recovery. Here’s where we level up to bracing.
To treat De Quervain’s tenosynovitis, you need a brace that crosses the wrist AND includes at least half of your thumb. If you’re not immobilizing part of your thumb, you may as well not wear it. Meaning, a standard wrist brace won’t do the trick.
And yes. It is annoying to have your thumb in a brace. We use our thumbs all the time. But I hate to tell you…that’s sort of the point :).
In my mind, here’s the ideal bracing schedule. I also go into this in more depth in my Frameworks for Bracing article here.
Weeks 1-3: Wear the brace as close to 24/7 as you can. Pretend I put you in a cast. We are stopping that inflammation in its tracks so this doesn’t linger for months and months. Invest the time now.
Weeks 4-6: Wean yourself slowly out of the brace, with the goal of throwing that thing in a drawer by the end of week 6.
Week 4: Take your brace off for light things around the house (eg, brushing your teeth, making your coffee)
Week 5: Take your brace off for medium-level activities around the house (eg, don’t sleep in the brace, take the milk out of the fridge without the brace)
Week 6: Try a few cautious heavy or high-level things here and there. See how you feel. Progress slowly. If it hurts, don’t do it!
These are all treatments you can try over the counter, on your own. Let the above be your guide and you’ll be starting off right.
Therapy For De Quervain’s Has Only A Mild Effect
If this still doesn’t have the De Quervain’s under control, it’s time to consider professional help. There is debate as to the role of physical or occupational therapy in De Quervain’s. In speaking with our therapists, there is general consensus that some measure of tendon glide exercises and K-taping can definitely help with this condition. But this is not a condition that needs or benefits from strengthening. So while therapy is an option for some, it’s not the cure-all.
Injections Work - With A Downside
Yet another step up from therapy would be an injection. In this setting, I place a steroid injection (eg, cortisone) into the first dorsal compartment. If you’ll recall from above, this is the tight tunnel these tendons run within and is where all the inflammation gets trapped. And festers.
Steroid injections can be highly effective for De Quervain’s. But they do come with one real downside. Anywhere between 10 and 30% of patients can experience one of two cosmetic side effects. One is bleaching of the skin in the area of the injection. In some cases, this can be permanent. The other is fat atrophy, or a sort of ‘sinking in’ of the skin around the injection site. This can also be permanent. While not functionally detrimental in any way, many patients are not fond of these side effects. You should know all the facts before you proceed!
Surgery Is A Reliable Fix
And if you’ve tried all of the above, and even one or two steroid injections haven’t worked, you may want to consider surgery.
This is a fairly quick and simple procedure that is not unlike carpal tunnel release surgery. If you remember from our series on carpal tunnel (found here), surgery involves dividing the thick ligament that forms the roof of the carpal tunnel. De Quervain’s release surgery is very similar. After incising the skin and moving a small nerve branch out of the way that gives you sensation to the back of your thumb, I divide the roof of the first dorsal compartment. That releases your inflamed tendons from their site of compression and allows your body to resolve the inflammation through its natural mechanisms as you heal.
Wrapping It Up
Hopefully, you now have a better understanding of De Quervain’s tenosynovitis, as well as the treatment options available to you.
Even better, you can treat yourself for De Quervain’s by using the knowledge from the first half of this article. In addition to feeling better, this can save you time and hard-earned money by (potentially) staying out of a specialist’s office (like mine!).
