De Quervain's Tenosynovitis
I have not had many experiences with De Quervain's Tenosynovitis, but I recently performed an evaluation on a woman with a classic case of the pathology. In this post, I perform a mini-review on the syndrome and give a reflection on own evaluation. Note: De Quervain's is a pathoanatomic diagnosis. My PT diagnosis was radiocarpal joint dysfunction with repetitive muscle overuse. Additionally, my patient was truly an -itis, her symptoms began days prior and she had repetitively began working despite having pain. Many patients may present with a longer duration of symptoms and would be classified as an -osis.
Tenosynovitis is an inflammation of the synovial sheath that surrounds a tendon. Swelling, decreased mobility, and pain often occur in the presence of tenosynovitis. The two tendon sheaths that become irritated are the Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB). [To recall these tendon, remember one is a longus and the other is a brevis. Then, think of the word apple (APL). If you can recall APL, remembering the second tendon is easy.] These two tendons are found in the first compartment of the wrist and together perform a movement called radial abduction. Typical patient presentation includes middle-aged women, pregnant, and overuse injuries. Impairments include pain over the first compartment of the wrist, decreased wrist and finger ROM and joint mobility, decreased grip strength, and difficulty grasping objects. Clinical diagnosis can be made by performing Finkelstein's test along with palpation of the involved tendons, A/PROM assessment, joint mobility assessment. The astute clinician should rule out 1st CMC osteoarthritis because the two pathologies will have a similar presentation.
My Eval and Treat
The treatment of De Quervain's Tenosynovitis should be based off the patient's individual irritability level and should address primary impairments. In my case example, the patient presented with high pain levels and decreased ROM noted in all planes with the greatest limitation moving into pronation. She had joint mobility restrictions at the 1st CMC joint as well as the radiocarpal joint. I ruled out 1st CMC OA because the patient did not meet the age criteria and palpation of the 1st CMC was unremarkable and joint mobility assessment did not reproduce her symptoms. For her treatment, I performed GI and II mobilizations at the radiocarpal joint for pain relief. Additionally, I prescribed gentle stretching of the APL and EPB in the pain free range as well as pronation AROM within the pain free. Finally, I gave the patient a wrist splint to avoid further over-use of the tendons while returning to work. Additionally, I gave advice on proper ergonomic set-up and workplace posture.
In reflection, I should have spent more time working proximal and central. I believe I did a nice job treating some primary impairments, but did I really address the cause of the problem? Probably not! Looking at the spine, shoulder girdle, and inquiring further about workplace set-up would have taken my eval to the next level. In my defense, the patient was a walk-in evaluation. I only had limited time and resources on the day of the evaluation. I will definitely investigate more proximal, central at the follow-up visit.
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11/7/2014 07:28:11 pm
Sounds like a textbook acute case. However, as a directional preference, I have found repeated wrist flexion plus a slight overpressure on the radial side into radial deviation works very well to reset the area for the proximal treatment. Let us know about her distal findings.
11/10/2014 07:42:59 pm
Dr. E! Thank you for the insights. I will check out repeated motions and directional preference next time I see her.
11/13/2014 09:53:04 am
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