Summary of Condition 1,2,3
De Quervain’s disease/tenosynovitis is most commonly known as an inflammation of the extensor pollicis brevis and abductor pollicis longus tendons. However, newer research suggests that it is a degeneration of the two tendons making the conditions a tendinosis. Despite the pathology, thumb overuse and repetitive radial deviation causes the two tendons o continuously rub on the radial styloid, causing friction forces that lead to inflammation.
Primary impairments:
- Pain
- Edema due to inflammation
Other impairments can include:
- Decreased thumb extension and radial deviation strength, secondary to pain and edema
- Decreased range of motion, secondary to pain, edema, and possible weakness
Guide to Physical Therapy Practice
Guide to Physical Therapy Practice - Practice Pattern 4E - Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation
Suggested Management
Recovery Time
The Guide suggests that 80% of the patient population presenting with de Quervain's disease will achieve their anticipated goals within 2 to 4 months (6-24 visits).
Possible Interventions/Modalities
- Education and training regarding enhancement of performance, risk factors, etc.
- Therapeutic exercise
- Flexibility exercises
- muscle lengthening, range of motion exercises, stretching
- Relaxation
- movement strategies, relaxation
- Strength, power, endurance training
- active assistive, active, and resistive exercises
- task-specific performance training
- Functional training
- task adaptation
- ADL training
- home maintenance, household chores
- Manual therapy
- massage (connective tissue and therapeutic) and mobilization (soft tissue and peripheral joints)
- Electrotherapeutic modalities
- Iontophoresis
- Electrical stimulation
- Electrical muscle stimulation (EMS)
- Functional electrical stimulation (FES)
- Neuromuscular electrical stimulation (NMES)
- Transcutaneous electrical nerve stimulation (TENS)
- Physical agents
- Athermal agents
- Cryotherapy
- Hydrotherapy
- Light agents (infrared, laser)
- Sound agents (phophoresis, ultrasound)
- Thermotherapy
- Mechanical modalities
- Compression (taping)
- Flexibility exercises
Modality Treatment for Impairments 4,5,6
Relieving Pain
Thumb splinting
The patient will usually be prescribed a splint for thumb immobilization for up to 6 weeks. It was found to have a 19% success rate when compared with corticosteroid injections and NSAID use, but success increased to 88% for splinting and NSAIDs together.
Corticosteroid Injection
Corticosteroid and/or anesthetic injection into the extensor tendon sheath of the first dorsal compartment was found to have varying success ranging from 62% to 93%.
NSAIDs (Nonsteroidal anti-inflammatory drugs)
Usually combined with other treatment interventions. It was found to relieve inflammation of the extensor pollicis brevis and abductor pollicis longus tendons
Ice/heat packs
Usually combined with other treatment interventions. Heat can help relax and loosen tight musculature, and ice can be used to help relieve inflammation of the extensor sheath.
McKenzie wrist management
The patient is instructed to perform ulnar deviation and thumb metaphalangeal flexion with distraction at home 10-20 times at leasy every 3 hours. The patient is also instructed to avoid radially deviating their wrist. It was found that continuous ulnar deviation with radiocarpal distraction help patients with de Quervain’s disease recover quickly and successfully. There is little to no research supporting the success and efficacy of this intervention.
Massage
Deep tissue massage at the thenar eminence can help relax tight musculature that causes pain. (See video)
Stretching
Stretching the thenar eminence muscles into thumb extension and abduction can relax and lengthen this tight musculature that causes pain. (See video below)
Increasing Strength (See video below for each exercise)
Resisted finger and thumb extension
- Palm up position - for thumb extension and abduction strength
- Thumb up position - for thumb extension and abduction strength
Resisted radial deviation
In thumb up position
Resisted supination
In thumb up position
Resisted thumb opposition
In thumb up position
Improving Range of Motion
Ice/heat packs
See description above. Ice/heat packs can also relax tight musculature so that more range of motion can be attained.
McKenzie wrist management
See description above.
Stretching
See description above.
Decreasing swelling
Thumb splinting
See description above
Corticosteroid injections
See description above
NSAIDs
See description above
Ice/heat packs
See description above
McKenzie wrist management
See description above
Massage
See description and video above
Stretching
See description and video above
Home exercise/modality use
Any of above stretching and strengthening exercises can be done as a home exercise program (HEP). Patients can also use ice and heat packs at home. After education, patients can perform self massage techniques at home, and if chosen as the preferred intervention, McKenzie wrist management is meant to be done by the patient at home.
Potential Protocol 1
There isn't any evidence indicating a gold standard protocol for the treatment of de Quervain's disease, but there are suggestions on which interventions to use in acute and chronic stages.
Acute Stage Interventions:
- Risk factor/Aggravating activity education
- Activity modification education
- Thumb splint
- Massage
- Ice packs
Chronic Stage Interventions:
- Heat packs
- Massage
- Therapeutic exercise (including HEP)
- Stretching
- Strengthening
- Activity modification education (continued)
- Corticosteroid injections (if the acute stage interventions do not work)
References
1. De Quervain's Physio Pedia Website. Available at: http://www.physio-pedia.com/index.php5?title=De_Quervains. Accessed November 20, 2011
2. Kutsumi K, et al. Finkelstein's test: A biomechanical analysis. The Journal of Hand Surgery. 2005;30(1):130-135.
3. Andreu J-L, et al. Hand pain other than carpal tunnel (CTS): The role of occupational factors. Best Practice & Research Clinical Rheumatology. 2011;25:31-42.
4. Gonzalez-Iglesias J, Huijbregts P, Gernandez de las Penas C, and Cleland JA. Differential diagnosis and physical therapy management of a patient with radial wrist pain of 6 months' duration: A Case Report. J Ortho and Sports Phys Ther. 2010;40(6):361-368.
5. Ilyas AM. Nonsurgical treatment for de Quervain's tenosynovitis. J Hand Surg. 2009;34(5):928-929.
6. Kaneko S, Takasaki H, and May S. Application of mechanical diagnosis and therapy to a patient diagnosed with de Quervain's disease: A Case Study. J Hand Surg. 2009;22:278-284.