De Quervain’s Tenosynovitis
De Quervain’s Tenosynovitis (Tendonitis) | Denver, Colorado
De Quervain’s tendonitis, oftentimes referred to as tenosynovitis, is a common condition I see in my hand surgery practice in the Denver metropolitan area.
De Quervain’s is a thumb-sided wrist tendinitis resulting from irritation and inflammation of several tendons that travel through an anatomic tunnel known as the first dorsal compartment (in depth anatomy here). Commonly known as 'texter’s thumb,' 'gamer’s wrist,' or 'mommy’s wrist,' it is exacerbated by activities involving ulnar wrist deviation and thumb extension.
Examples of this would include excessive texting, lifting a child out of a crib, or the position required to support a newborn's head during breastfeeding.
De Quervain’s Diagnosis & Treatment
Figure 1 - To diagnose De Quervain’s, place your thumb in palm, wrap your fingers around your thumb, and then tip your wrist toward the floor as shown. If this is exquisitely painful, you likely have this condition.
Diagnosing De Quervain’s is straightforward with the Eichoff or Finkelstein test, involving wrist ulnar deviation and thumb extension (see Figure 1, full explanation here). Additional imaging or testing is rarely needed beyond a physical examination and discussion with your doctor.
The crux of treatment can be employed at home and revolves around knowledge-based activity modification, avoiding exacerbating positions. If this fails to improve your symptoms, using a wrist brace that also includes the thumb is recommended. For detailed instructions on ideal brace wear, please reference my Bracing Framework.
Professional help would include steroid injections or surgery. Unfortunately, physical therapy rarely has a meaningful effect in reliably treating De Quervain's.
De Quervain’s Surgery
If the above treatments have failed to resolve your symptoms, some patients go on to benefit from De Quervain's release surgery.
Surgery for De Quervain’s involves a 2-3 cm incision on the thumb side of the wrist to allow me to access the first dorsal compartment. I then divide the roof of that compartment to release the pressure on the tendons. This also allows me to clean up any associated inflammation along the tendons to help with your pain.
Typical recovery from this surgery occurs over 4-6 weeks. I use absorbable sutures that do not need to be removed. Many patients benefit from a few weeks of intermittent splinting and some gentle exercises with therapy to regain wrist strength and mobility following surgery.
Additional Information
If you’d like more information on De Quervain’s tenosynovitis, please continue reading through the frequently asked questions below. You can also access my ‘deep dive’ section to the right of the FAQs where I have links to the longer-form articles I have written about various topics related to De Quervain’s and its treatment.
Rules of Thumb Newsletter
Dr. G's simple, actionable weekly guides to combat the injuries, aches, and pains of the hand and upper extremities.
The Basics
-
De Quervain's tenosynovitis is a tendinitis on the thumb side of the wrist. It results from irritation and inflammation of the tendons in the first dorsal compartment, a tight anatomic passageway that passes across the wrist to the base of the thumb.
-
De Quervain's is typically caused by repetitive overuse of the wrist, hand, or thumb, leading to irritation along the tendons in the first dorsal compartment.
Common activities associated with this condition include texting, gaming, repetitive use of scissors, lifting a child from a crib, or the wrist position required to support a newborn’s head during breastfeeding.
-
De Quervain’s can happen at any age. People who engage in activities that require repetitive ulnar deviation and thumb extension, such as texting, gaming, scissor use, lifting babies, and breastfeeding, are prone to developing De Quervain's.
I most commonly see it in active individuals in their 20s to 50s.
De Quervain’s Symptoms & Diagnosis
-
Typical symptoms include aching or sharp pain on the thumb side of the wrist. This pain is often made worse with specific movements, like ulnar deviation and thumb extension.
Many patients also notice associated swelling of the wrist and even up into the forearm.
In rare cases, numbness or tingling can occur over the back side of the thumb.
-
De Quervain’s is a ‘clinical diagnosis,’ which means no fancy tests, imaging, or labs are needed. An experienced doctor can determine the diagnosis following a careful discussion and examination.
De Quervain's can be diagnosed using the modified Eichoff or Finkelstein test. Different providers may call it by different names. This test involves turning the palm 90 degrees to the floor, bending the thumb into the palm, wrapping the fingers around the palm, and tilting the hand to the floor in ulnar deviation (full demonstration here.
Careful…if you try this test at home, and you have De Quervain’s…you might leap out of your seat in pain! This is a strong indicator of De Quervain's tenosynovitis.
-
Additional imaging is generally unnecessary for De Quervain’s. A discussion and examination with your doctor is typically sufficient.
De Quervain’s Treatment
-
Knowledge is everything with De Quervain’s. Once you understand the tendons that are affected and he positions that stress them, you can work to modify how you use your wrist on a daily basis.
One high-yield tip is to use your biceps to lift objects, not your wrist. We will often stress the relatively weak tendons involved in De Quervain’s with improper lifting form (think of the wrist position to lift a baby out of a crib from under its arms). Instead, if you turn your hands palm up and lift with your biceps, you will distribute the lifting loads more appropriately.
If activity modification isn’t sufficing, the next step up the treatment ladder is to use a brace. For this condition, the brace must encompass both the wrist and the thumb. This is known as a ‘thumb spica’ brace. For a full guide on the proper way to use a brace, please see my Bracing Framework.
-
While some patients do benefit from exercises known as tendon glides, the overall benefit of therapy in De Quervain’s is low. Because of this, therapy is not a routinely recognized method of treating this condition.
-
When activity modification and bracing strategies do not overcome your symptoms, you may wish to consider a steroid injection.
In this procedure, a small amount of steroid is placed into the first dorsal compartment. This will coat your tendon in anti-inflammatory steroid medicine. This will decrease the irritation and inflammation over 2-3 weeks after injection, easing the pain of De Quervain’s.
While these can offer tremendous relief, they must be approached with some caution. This particular injection can cause cosmetic side effects on occasion. This includes skin bleaching in some and fat atrophy in others. Fat atrophy refers to a process in which the normal fat under the skin shrinks, causing a divot-like appearance in the wrist. In some cases, these cosmetic changes can be permanent, so it is something to consider before receiving an injection for De Quervain’s.
De Quervain’s Release Surgery
-
The surgery for De Quervain’s is called a De Quervain’s release. In this procedure, a 2 to 3-cm incision is made on the thumb side of your wrist. Through this, I access and open the first dorsal compartment.
I will then examine your tendons and clean up any associated inflammation responsible for the pain. A single absorbable suture is placed to bring the compartment walls back together loosely (not tight like where you started!). This will prevent any rolling or snapping of the tendons out of the compartment after healing. I then close your skin with all absorbable sutures.
-
De Quervain’s release surgery is a day surgery typically performed in an outpatient surgery center. In most cases, anesthesia options are up to you.
Some patients elect to have numbing medicine injected into their wrist (like the dentist) and remain wide awake for the 20-minute procedure.
Most patients will choose a ‘twilight’ sedation (similar to a wisdom tooth extraction or colonoscopy procedure) during which they feel asleep but are breathing on their own without the need for a breathing tube.
-
Following De Quervain’s release surgery, you will be placed into a post-operative splint. All my patients have a visit with a Certified Hand Therapist within a week or so of surgery. At this visit, the splint is removed and some gentle exercises are begun.
I will then meet with you approximately 3 weeks after surgery to evaluate your healing process. The sutures I use are absorbable, so they will not need to be removed in the office.
The next stage of healing is variable. Some patients have resolved their inflammation and are ready to return to most activities at 3 weeks. Others take a little more time to heal, and we support them with continued therapy and intermittent bracing. The majority of patients feel 80-90% recovered by 6 weeks.
-
Restrictions are fairly simple after De Quervain’s release surgery. The surgical dressing and splint must stay on and dry until your post-op visit with our hand therapists. Finger movement and light to moderate use of the hand is allowed and encouraged, beginning the day of surgery.
The goal of your postoperative healing window is to get the tendons of the first dorsal compartment moving without pain. If you remember that ‘pain is your guide’ throughout your healing, you will be appropriately adhering to your restrictions. If it hurts, don’t do it! Some patients continue to use a splint intermittently through the recovery process to achieve this goal.
Most patients begin strengthening their pinch and grip around 3 weeks and the majority resume full activity by 6 weeks.
-
All surgeries have risks, many of which are generic to surgery itself. I go over these in detail with you before surgery as part of the informed consent process. Examples include bleeding, infection, damage to surrounding tendons/nerves/vessels, anesthesia risks, or failure of the procedure.
The most common risk of De Quervain’s release surgery is what we call a ‘neuropraxia.’ This is when a nerve ‘goes to sleep’ after surgery.
There are sensory nerve branches that cross directly over where I work to release the first dorsal compartment in your wrist. In surgery, we have to identify and carefully retract that nerve out of the way in order to complete the surgery. Sometimes, even just this light touch of retracting the nerve aside will cause the nerve to ‘panic’ and shut down for a period of time.
If this happens to you, you will notice an area of numbness or tingling over the back of your thumb or hand. This nerve is not involved in any of the movement, strength, or motor function of your thumb. The nerve will typically ‘wake up’ over a period of a few weeks to a few months after surgery.
