What Causes De Quervain’s Tenosynovitis?
July 2, 2021
What Causes De Quervain’s Tenosynovitis?
July 2, 2021
You may have clients who experience pain because they have jobs that require repetitive tasks. Or, perhaps you’ve noticed discomfort in your hands but are reluctant to take time away from your practice. A common tenosynovitis complaint in the thumb is de Quervain’s tenosynovitis.
Understanding the Issue: A Brief Overview of De Quervain’s Tenosynovitis
Tenosynovitis is similar to tendinitis/tendinosis, but there are some critical distinctions. Tenosynovitis only occurs with tendons that are surrounded by a synovial sheath. Most of the sheathed tendons are near joints of the distal extremities, like the foot, ankle, wrist, and hand. The sheath reduces friction between the tendons and the binding retinacula that hold the tendons close to the joints.
Tenosynovitis involves an inflammatory reaction between the tendon and the surrounding synovial sheath, and there may also be some degree of fibrosis, thickening, or adhesion. In tendinitis/tendinosis, the primary pathology appears to involve tendon fiber degeneration. In tenosynovitis, the problem seems to be less about tendon degeneration and more about irritation between the tendon and its sheath. Tenosynovitis pain can result from inflammation, chemical irritation of nociceptors in the tendon or sheath, fibrous adhesions pulling on tissue, or several other factors.
De Quervain’s tenosynovitis involves two tendons on the radial side of the wrist in a region referred to as the anatomical snuffbox. The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons are affected in this condition. They share a common synovial sheath as they cross the wrist. Repetitive motion causes repeated friction between the tendons and their sheaths, leading to tenosynovitis.
Common Symptoms of De Quervain’s Tenosynovitis
A client with de Quervain’s tenosynovitis usually presents with a history of repetitive motion activities or repeated loading on the thumb or wrist. Occupations that require repetitive motion of the wrist and hand can lead to someone getting this condition, and massage therapists are particularly vulnerable because the two muscles involved act on the thumb.
Pain is usually felt over the radial side of the wrist during certain thumb motions. Additionally, there may be a weakness in grip strength because of reflex muscular inhibition, which occurs when sudden pain in the affected thumb causes the brain to shut off contractions in the activated muscles. Pain is most common when there is a load on the thumb with particular wrist positions, and may also radiate into the forearm.
The condition’s onset is usually gradual, although a specific activity often acts as the primary irritant. Tenosynovitis usually results from repetitive loads and rarely results from sudden trauma such as a direct blow to the area. Identifying these key facets of onset is important in the client’s history.
Swelling may be visible, though infrequent. The area is usually tender to palpation directly over the affected tendons. If the condition has been present for some time, there may be crepitus (grinding or grating sensations) during thumb movements. Crepitus is most common during thumb motions that also include ulnar deviation of the wrist.Both active and passive movements into the end range of wrist ulnar deviation are likely to cause pain when the thumb is flexed and held across the palm. At the end of ulnar deviation, the affected tendons are stretched, and pain results with either active or passive motions. Active abduction of the thumb against resistance is also likely to cause pain because the affected muscles will be engaged in a contraction that pulls on the tendon tissue.
Conditions Similar to De Quervain’s Tenosynovitis
Other conditions may have similar symptoms to de Quervain’s tenosynovitis. Synovial ganglions can cause pain in a similar location, for example. A synovial ganglion is an inflammation of synovial tissue near or around a joint that fills with a gel-like fluid. They tend to occur more commonly around the wrist. However, they usually show an enlarged swollen nodule and will generally not cause pain with resisted movement unless they are compressed at the same time.
Degenerative arthritis in wrist joints may also cause pain in a similar location, though again the pain is not likely to be felt with resistive movements. Pain also does not usually occur with direct pressure on the affected tendons. A scaphoid fracture may cause pain in the same area and is a common injury from falling on the hands. However, the scaphoid fracture is an acute injury as opposed to de Quervain’s tenosynovitis, which is a chronic condition. If there is acute trauma, a scaphoid fracture is more likely than tenosynovitis. If the condition involves repetitive overuse, tenosynovitis is a more likely cause.
How Massage May Help De Quervain’s Tenosynovitis
De Quervain’s tenosynovitis is usually treated with conservative measures first, including non-steroidal anti-inflammatory drugs (NSAIDs) to address inflammation. In some cases, a wrist or thumb splint is used to decrease movement. However, prolonged splinting can lead to further fibrosis and additional adhesions in the area, so it is not always a preferred strategy. Resting from the offending activity is essential.
Stretching is valuable to help reduce excess tightness in the muscles pulling on the involved tendons. Massage treatment seems to be helpful for this condition as well, so massage therapists should consider deep transverse friction performed directly on the APL and EPB tendons. Friction techniques may help reduce some degree of fibrous adhesion between the tendon and surrounding synovial sheath. It’s true that there is some debate around whether adhesions can be broken up with massage therapy, though other beneficial effects make friction techniques worthwhile.
Some research indicates that massage helps increase fibroblast activity in the affected tendons, contributing to reduced pain and improved function. Directly treating the tendons involved may also trigger high-level neurological responses that decrease pain. Specific applications, such as deep stripping techniques and stripping techniques with active engagement applied to the forearm muscles, appear very helpful. The affected thumb tendons of the APL and EPB extend into the forearm, so a detailed and thorough treatment of the entire length of these tendons is beneficial.
For any soft-tissue treatment to be successful, the individual needs to modify their activity so the body has a chance to heal. If the activity continues, the condition will likely recur or continue to get worse. Because occupational overuse causes so many of these conditions, some clients will find it challenging to find a way to reduce the offending activity. If conservative treatments are not effective, surgery may be the next option.
Massage Therapists Are at Risk, Too
This work-related injury is one of the most common for massage therapists, and often starts as minor discomfort at the end of the day. Left untreated, however, de Quervain’s tenosynovitis can become excruciating and end your career. Luckily for us, it is relatively easy to self-treat this area. Working in this area frequently and modifying your treatments will help significantly.
Treatment adaptations might include offering less deep tissue massage or learning to use a tool and active engagement techniques for deeper work. Offering more myofascial type treatments that require broader strokes and less specific thumb work will help, too.
Assessing for De Quervain’s Tenosynovitis
The Finklestein test is a special regional orthopedic test that stretches the APL and EPB muscles, and is performed actively or passively. To conduct this test, fold the thumb in flexion across the palm and flex the fingers fully to cover the thumb. While holding the thumb in this position, move the wrist into ulnar deviation. If this position is painful and reproduces the primary complaint, that is a good indicator that tenosynovitis might be involved.