Robert J. Snyder, MD
Recently, I saw a middle-aged female in my practice who complained of pain in her wrist radiating to her thumb. She said that the pain just started one day and that she had been treating it at home for about 2 weeks with Aleve and ice. She was concerned as she reported that she would soon be going on vacation and did not want to be in pain. She reported no accident or trauma, but said she had been doing yoga regularly. She exhibited no sign of swelling or bruising. She felt it strange that she could weight-bear comfortably on the wrist for long periods of time while she did yoga, but that insignificant grasping or twisting movements would cause her sharp pain.
After hearing her describe her symptoms, I had her perform a simple test, where she made a fist, closing her fingers over her thumb. I then had her bend her wrist toward the floor, in the direction of her pinky finger. This action elicited a yelp and wince from the patient and I knew we had our diagnosis-De Quervain’s Tendinitis.
Named for the Swiss surgeon who identified this disorder in 1895, De Quervain’s Tendinitis occurs when the tendons that stretch across the base of the thumb become inflamed or constricted, usually due to overuse. While pregnancy can be another cause for this condition, it is most often seen in middle-aged women. It can also be seen in people who have inflammatory diseases, such as rheumatoid arthritis.
Now for an anatomy lesson…When the tendon, on the thumb side of the wrist, becomes irritated, it causes the synovium (a thin, slippery coating around the tendons, which helps them glide smoothly) to swell. The tendons move through a sheath in the wrist and this swelling makes it difficult for the tendons to move through the sheath smoothly. They can even snap or pop, as they move through the restricted sheath space, due to the swelling. This swelling will also impinge on the nerves in the thumb and index fingers, causing numbness and pain.
Symptoms of De Quervain’s are:
- Pain at the base of the thumb at the wrist
- Swelling at the base of the thumb at the wrist
- Pain when grasping, twisting or closing the hand
- Pain can appear suddenly or over time
- Can be accompanied by the presence of a fluid-filled cyst
- Numbness in the thumb
- Referred pain into the forearm
- Snapping or catching of the tendon
I make my diagnosis by listening to the patient symptoms and by performing that simple test, called the Finkelstein test, where the patient closes their fingers over their thumb and bends the wrist toward the little finger. If a person has De Quervain’s, they usually will find this test to be quite uncomfortable. I do not have to take an X-ray or an MRI to diagnose De Quervain’s tendinitis.
Thankfully for the patient, treatment of De Quervain’s is most often done conservatively. If there is an activity that the patient has been doing that we can identify as a possible cause of the problem, we may want to avoid that activity, curtail or modify it so as not to cause further irritation to the tendon. If the patient has done nothing to treat the condition, I may just send them home with directions to take Aleve or Ibuprofen, rest and ice the area for a week and see if it improves. If the patient tries this at home and sees no improvement, I may perform a corticosteroid injection to help reduce the inflammation and pain. Usually, these treatments will alleviate the problem after a few months.
For more recalcitrant cases, I may prescribe Physical Therapy to help strengthen other muscles around the inflamed tendon and to help the patient relearn how to perform the activities aggravating the tendon. The Physical Therapist also can perform other modalities to reduce inflammation, such as laser therapy, application of heat, use of a TENS unit, treatment with cold packs and other therapies. I can also recommend that the patient wear a brace that will allow their thumb and wrist to rest and heal.
Rarely, the patient will not improve and their symptoms will only worsen. In that case, I would recommend surgery to open the sheath through which the inflamed tendons must travel. By doing so, you give the tendons more room to move, which reduces the irritation generated by their constant friction against the sheath. Surgery for De Quervain’s is performed as outpatient surgery and is a quick and simple procedure. There are always risks to surgery, including infection or damage to the radial sensory nerve. It is important to discuss these risks with your Orthopaedic specialist before having surgery.
For some individuals, symptom resolution may take up to a year and many patients become impatient and opt for surgery, when they would have eventually improved with time. Again, it is important to discuss any questions you have with your Orthopaedic specialist about recovery time and what is to be expected. Together, you can find the course of treatment that will work the best for you, your lifestyle and your work.