June 15, 2021 6 min read
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.
Stenosing tenosynovitis of the APL/EPB is also known as:
Answer: a) De Quervain’s disease
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.
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.
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 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.
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.
[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]
My professional favourite for De Quervains is: Pro Rheuma wrist thumb brace.
We have an excellent range of wrist and thumb supports that may be suitable for your clients.
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 firstname.lastname@example.org
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