Houston Methodist. Leading Medicine

Hand FAQ

Question:

I went to see a physician's assistant for wrist and thumb pain that turned out to be de Quervain's. She gave me a splint to wear and recommended over-the-counter antiinflammatories. It didn't work. My pain just got worse and worse. I ended up getting a cortisone shot that seemed to do the trick. Should I have just gone to a specialist in the first place?

Answer:

Not necessarily. The standard of practice for de Quervain's is currently a trial of splinting, rest, and antiinflammatories. This is not based on hard core research data as this type of research on the treatment of de Quervain's doesn't exist. But it's clear that this treatment is palliative (makes patients feel better/gives pain relief). The net result might be to improve function and quality of life. It is not curative in the sense that it does not change the underlying disease process. de Quervain's tenosynovitis affects two thumb tendons. These tendons are called the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). On their way to the thumb, the APL and EPB tendons travel side by side along the inside edge of the wrist. They pass through a tunnel near the end of the radius bone of the forearm. The tunnel helps hold the tendons in place, like the guide on a fishing pole. This tunnel is lined with tenosynovium. The tenosynovium is a slippery covering that allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon is called tenosynovitis. In de Quervain's tenosynovitis, the inflammation constricts the movement of the tendons within the tunnel. But more recent data shows that in some cases, there isn't any active inflammation. This is considered a tendinosis, not a tendinitis. With tendinosis, instead of finding cells that show an inflammatory process, the collagen fibers making up the tendons and tenosynovium are laid down in a haphazard fashion (every which way). Changes in the mucous cause these normally slippery structures to dry out. The tendons can no longer slide and glide smoothly. The dryness causes a painful catching of the tendon over the bone. The natural history of this condition (what happens over time) is that it eventually goes away on its own. They say it is self-limiting. That's why conservative (nonoperative) care (and the least invasive choice possible) is selected. If, after a reasonable trial, the symptoms are no better (or even worse), then a steroid injection may be helpful. Accuracy in the placement of the needle to administer the steroid is extremely important. The surgeon must advance the needle administering the drug through the soft tissues inside the tendon sheath. The steroid drug must reach inside the sheath of both the abductor pollicis longus and the extensor pollicis brevis tendons to be effective. As we said, most people with de Quervain's just get better on their own over time. Surgery may be recommended if symptoms remain extremely painful even after six months of conservative care. Asif M. Ilyas, MD. Nonsurgical Treatment for de Quervain's Tenosynovitis. In The Journal of Hand Surgery. May/June 2009. Vol. 34A. No. 5. Pp. 928-929.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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