The best hand therapy treatment for De Quervain's disease

Answer a fun quick question about tenosynovitis, learn more about what defines this condition and find some helpful tips on the best hand therapy treatment.

Answer this Quick Question

Stenosing tenosynovitis of the APL/EPB is also known as:

1. De Quervain’s disease
2. Keinbock’s disease
3. Preisser’s disease
4. O’Keefe’s disease

Answer: a) De Quervain’s disease

De Quervain’s disease defined

Definition: De Quervain’s disease is a condition characterised by inflammation of the APL and EPB tendons and / or their sheaths in the first dorsal compartment of the wrist. There is also some discussion in the literature as to whether it is just the tendons / sheaths or indeed the edge of the pulley itself (extensor retinaculum).

Anatomy:The extensor retinaculum sits across the dorsum of the wrist and divides the extensor tendons into different compartments. Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB) sit in the first dorsal wrist compartment, which is the most radial one. The extensor retinaculum acts as a pulley and stops the tendons from bowstringing, holding them close to the bone over the radial styloid. As their names suggest, the APL and EPB tendons abduct and extend the base of the thumb (the IPJ is extended by EPL).

Pathomechanics:  Usually, this condition arises when there is repeated stress to this area of the wrist, from repetitively performing an activity requiring thumb abduction / extension (often with wrist radial / ulnar deviation). Repetitive friction of the tendons under the pulley results in the pulley and or tendon/sheath becoming inflamed. The more inflamed these structures become, the more they swell, which in turn increases the friction / irritation, so it becomes a vicious cycle.

Clinical signs and symptoms:  Clients will usually present reporting pain at the radial side of his/her wrist / base of thumb. It is painful with movement of the thumb and / or wrist. The first dorsal wrist compartment is usually tender to palpate over or distal to the radial styloid.

Possible risk factors:  This condition is common in new mums, with 24/7 caring for baby, including nappy changes, feeding, settling, rocking, carrying, bathing, lifting in / out of car seat / capsule etc. It is not hormonally determined, as it also occurs in adoptive parents and other full time caregivers (e.g. dad / grandparents, if they are the primary caregiver). It is not only caregivers of babies / small children that develop this condition, however, as it is sometimes seen in those performing jobs / tasks requiring repetitive thumb use plus wrist RD/UD (e.g. marking tyres as a parking warden, meat packers, some machinery operators). In other cases sometimes the inflammation in the area may be as a result of a direct blow to the radial aspect of the wrist.

Clinical tests:

Finkelsteins test: The examiner grasps the client’s hand, places the thumb across the palm and sharply ulnar deviates the wrist. Always compare to the unaffected side. A positive test reproduces their sharp pain at the radial aspect of the wrist / base of thumb.

Hitchhikers test: The client lifts his/her thumb up as if hitchhiking, while the examiner resists the movement. A positive test reproduces their sharp pain at the radial aspect of the wrist / base of thumb. Again always compare to the unaffected side.

Observation and palpation: look for swelling / redness / heat (not always present) and palpate for tenderness over the affected tendons at the level of the radial styloid.

Hand Therapy for De Quervains Tenosynovitis

The goal of hand therapy for these clients is pain free return to full function. The focus of hand therapy is splinting, anti-inflammatory modalities, education and activity modification, followed by strengthening once acute symptoms have settled.

Splinting

Splinting needs to include the thumb AND the wrist, as the APL and EPB tendons cross both these joints. Your splint selection should be based on severity, exacerbating activities, lifestyle, timeframes, etc.

Education

Clients who understand the anatomy and biomechanics associated with their condition are more likely to understand how certain activities and / or positions /movements can exacerbate their symptoms. This makes it easier to understand how to modify activities, to prevent ongoing exacerbation of symptoms.

Here are my top 3 hand therapy techniques for De Quervains tenosynovitis:

1. Splinting.As mentioned above, your splint should always include wrist PLUS thumb. You may start with something like a semi-flexible cast (softcast / benecast) which you could make removable, or make over a water resistant lining. Most clients find this very comfortable and get immediate relief from pain. However, this won’t suit everyone’s lifestyle – mum’s with babies possibly would prefer something washable (e.g. if it gets dirty during a nappy change!), thus they may prefer a custom-made thermoplastic wrist/thumb spica. If that is too hard, or they find it comfortable to feed / nurse / settle baby in, they may prefer an off-the-shelf option, which are more padded and softer (see below). If your client needs something quite heavy duty, the Jura Black wrist and thumb brace is a great option.  
   
   
   
   
   
   
   
   For something supportive but lighter and lower profile, I love the Pro-Rheuma wrist thumb brace.
   
   
   
   
   
   
   
   
   Once symptoms are settling well and only a light support is required, an excellent choice is the Jura Polloform spica which comes in a variety of lengths to assist the weaning process.
   
   

2. Education / activity modification. Clients need to understand the anatomy and bio/pathomechanics of this condition, so that they can easily learn to modify activities so prevent symptom exacerbation. They should avoid or modify activities demanding wrist and thumb working together in painful positions – for example try different ways to lift baby, fit the car seat, clip the buckle, feed/settle/comfort/rock baby, etc. Similarly for those experiencing this condition from work related tasks, combined wrist plus thumb movements should be avoided. This is easiest to achieve through splinting.

3. Anti-inflammatory modalities. I like to use acupuncture for its anti-inflammatory effects. If this is part of your hand therapy toolkit (and your client is willing!), by all means try it! You may like to use ice and gentle STM with a topical anti-inflammatory cream. In the subacute and later stages, many clients find heat more soothing. I also advise the client to discuss with their doctor or pharmacist regarding anti-inflammatory medication, as these together with splinting provides the best outcome.
    

You could also try:

1. Gentle stretching of the wrist and thumb, starting in the pain free range can really help. When the wrist and thumb are splinted 24/7 for 6 weeks, the structures can become very tight, so to prevent this your client should remove their splint and gently stretch several times per day (but again, stressing the PAIN FREE RANGE). It is often easier to achieve a comfortable stretch after heat and massage.

2. Isometric loading. Soft tissues do not like to be immobilised for long periods. Having the wrist and thumb splinted 24/7 may result in weakening and poor organisation of the collagen fibres and increased cross linking between fibres. Isometric loading can very effectively prevent or reverse these effects, and because the loading is isometric it does not cause further friction / irritation of the inflamed soft tissues. I get clients to resist thumb MCPJ extension and then abduction, loading only to a point of about 2/10 discomfort, then holding that position for up to 20 seconds or until the discomfort dissipates. (This is based on Mulligan Pain Relief Phenomenon exercises)  

3. Corticosteroid injection.In 75% of cases, these clients settle with full time splinting and NSAIDs. If this is unsuccessful after ~6/52, CSI could be considered as about 98% settle with corticosteroid injection into the first dorsal wrist compartment. I usually refer clients on to a specialist to have this administered with or without ultrasound guidance. I advise the client to go back into their splint for 7-10 days post-CSI and then get them back to Hand Therapy, to commence the isometric loading program, to ensure benefits are long lasting.

[It is worth noting that about 2% are unsuccessful with these modalities (sometimes they have several slips of tendon, not just the 2 main ones) and need to proceed to surgical release / decompression. Post-operatively I would undertake wound cares, scar management, early pain free AROM and isometric loading. They may or may not continue with intermittent splint use, depending on surgeon’s protocols / preference]

Suitable supports

My professional favourite for De Quervains is: Pro Rheuma wrist thumb brace.

View our full range of wrist and thumb supports

We have an excellent range of wrist and thumb supports that may be suitable for your clients.
 

What are your tips for treating De Quervain’s tenosynovitis?

This blog is a discussion format. We have listed our views above but would love to know what you think, what your comments are or how you best treat De Quervain's disease in your practice. Feel free to email us at info@therapyproductsaustralia.com