What is it?
It is a painful condition that involves irritation of the two tendons that run through a tunnel on the thumb side of the wrist.
The tendons running from the forearm into the hand all have to cross the wrist joint, which is very mobile. Tendons run in tunnels or compartments, whose function is to fix the position of the tendon on the bone and prevent the tendons displacing. As they run through their compartment, tendons are surrounded by a thin covering of tissue which lubricates the tendon allowing tendons to run smoothly. In de Quervain’s syndrome the compartment becomes thickened, narrowing the size of the tunnel and obstructing the smooth movement of the tendon. This in turn can cause the lubricating layer to become inflamed.
What is the cause?
In many cases, there is no obvious cause. Many people attribute the symptoms to their job, but there is little evidence that work activities cause the condition, and it does not seem to be more common in any particular occupation. However, in jobs that require repetitive movements of the wrist and thumb, people may struggle to do their job normally because of pain.
De Quervain’s syndrome is more commonly seen in new mothers with small babies (possibly due to hormonal changes) and in those patients who suffer from diabetes, thyroid disease or rheumatoid arthritis.
What are the symptoms?
The main symptoms are pain and tenderness at the side thumb side of the wrist, and this can be aggravated by lifting the thumb or side to side movement of the wrist. There may also be swelling at the site of tenderness, and some patients develop quite a firm lump over the bony part of the wrist because of the thickening of the compartment. Occasionally, patients experience clicking or snapping of tendon.
How is the diagnosis made?
The diagnosis is made by clinical examination. The presence of tenderness over the compartment and pain on movement of the tendons within the compartment usually make the diagnosis clear. Doctors use a test called ‘Finkelstein’s manoeuvre’ to help make the diagnosis. This test involves putting a stretch on the thumb tendons to produce pain or discomfort over the compartment.
What is the natural history?
De Quervain’s syndrome is not harmful, and in most cases is self-limiting, meaning that it will resolve on its own without treatment, usually over the course of around 1 year. People with this condition often have two worries:
– If my wrist is painful and sore now, what will it be like in a year’s time? The answer is that it is highly likely to have resolved by then.
– If I use my hand and it is painful, am I doing it harm? No. The pain from de Quervain’s syndrome is a very ‘safe’ pain – it does not represent damage or harm to the local tissues, and even with the pain, it remains safe to use the hand fairly normally and as tolerated.
What is the treatment?
Most patients modify the way they use their hand and wrist to avoid pain for the duration of the condition, and there is no real requirement to ‘treat’ the condition. There are many options available to try and relieve pain, but not all work in 100% of cases, and some have risks associated with them that should be considered before any decision is made.
Activity modification: Adapting the way you perform certain activities or avoid any precipitating cause may help with symptoms.
Splints: Some people find a splint helps relieve the pain from de Quervain’s syndrome, but others find that they cause tenderness over the tendon compartment.
Painkillers: Painkillers are generally ineffective in treating de Quervain’s syndrome, and are therefore not recommended.
Physiotherapy: Physiotherapists often advocate tendon stretching exercises in order to help the tendons glide more smoothly in their compartment.
Steroid injections: Steroid is a powerful anti-inflammatory, and promotes the breakdown of fat and connective tissue. It produces local changes within tendon which weaken the tendon. Despite these potential issues, most patients report significant pain relief from a steroid injection. This pain relief tends to be short term, and there is no strong evidence that having a steroid injection shortens the duration of the condition overall. Steroid injections carry a risk which should be carefully weighed up against the benefit before going down this route. Having a steroid injection
Surgery: Surgery can be useful where the compartment thickening is preventing the tendons from moving, or where the pain from de Quervain’s syndrome is taking more time than usual to improve. At surgery, the compartment is ‘released’ – this simply means that the roof of the tunnel is cut to allow the tendons to run smoothly. Again, the risks of surgery need to be considered before this decision is made. One of the nerves supplying the back of the hand runs very close to the compartment, and is at risk of being damaged at the time of surgery or being tethered by the scar tissue that forms after the surgery. If this happens, it can leave patients worse off rather than better. Obviously, the decision to operate is a shared one between the patient and surgeon, and most operations go very smoothly without complication.
© Fife Hand Service 2020