Medial De Quervain’s

The purpose of this case study is to assist our graduates to fully reflect on a client that they have seen throughout the week. This will also form part of information that we can distribute to clients where they can read up on real life cases where we have been able to help clients and allow them to be pain free! Clients are refered to as Mr.X/Ms.X to keep their privacy.

TITLE OF BLOG: De Quervain’s

Section 1: About your client and how you diagnosed the condition (think about how they presented, what subjective and objective information did you gather to help you diagnose?)

Mr. X presented to us with radial sided pain on the right wrist. The pain was described as a “burning and pulling” sensation aggravated with any thumb movement which eases with rest. Mr. X is a professional piano player, performing at various concerts, festivals and gigs. He also explained that this pain was triggered during a performance where he felt a ‘pop or click’ and knew he had triggered something in his right wrist. Mr. X also explained he has previously had De Quervain’s on his left wrist where he received a cortisone injection and has had no symptoms since. Mr. X is currently awaiting ultrasound results on his right wrist where he plans to get another cortisone injection in his right wrist. Along with piano playing, Mr X. enjoys gaming such as twitch.

Upon examination, the Finklestein test was positive and reproduced all symptoms at the radial styloid described by Mr. X. Palpation through the base of thumb and first dorsal compartment extensor tendons on radial side of wrist, anatomical snuffbox, radial styloid process and up through the forearm also reproduced pain and felt tender. Pain was also elicited during radial and ulnar deviation.

Section 2: Your diagnosis and about the condition (what is your possible diagnosis?)

Possible diagnosis:

De Quervain’s

Pathophysiology background:

De Quervain’s is a chronic overuse injury where the tendons in the thumb become inflamed. This condition is commonly seen in activities such as golfing, fly fishing, piano and occupations including office workers, musicians, and carpenters. De Quervain’s affects the abductor pollicis longus and extensor pollicis brevis tendons located in the first dorsal compartment of the wrist. Synovial sheath line these tendons to separate it from the other five dorsal wrist compartments. These tendons run through a fibrous tunnel, approximately 2cm along the radial styloid and underneath extensor retinaculum transverse fibres. Here, during acute trauma or repetitive motion, these tendons are at risk of entrapment as the two tendons are continually gliding over each other through a small tunnel that causes irritation of the surrounding sheath of the tendons. Therefore, the tendons thicken and become swollen and consequently, movement becomes restricted and painful.

Section 3: Differential Diagnosis (what is another condition to consider and why?)

Osteoarthritis/osteoporosis of radial styloid, C6 cervical radiculopathy, scaphoid or radial styloid fracture, trigger thumb, intersection syndrome and carpal tunnel can all be differential diagnoses for De Quervains.

The most common/relevant differential diagnosis is carpal tunnel. Both conditions present very similar with swelling and pain in the wrist that increases with repetitive movement. However, while De Quervain’s refers to thickening of the tendon and tendon sheath, carpal tunnel refers to compression of the median nerve. Carpal tunnel is also associated with sensations of numbness and tingling in the hand and forearm. Given, Mr. X has previously experienced De Quervain’s on the left wrist, is familiar with the condition and is presenting the same, De Quervain’s is the most likely diagnosis.

Section 4: Treatment (what did you do and why?)

Manual therapy, therapeutic exercise, splinting, patient education, anti-inflammatory medication and corticosteroid injections are common treatments used for persistent symptoms of De Quervain’s (Satteson & Tannan, 2022). My first session with Mr. X involved some massage over the wrist and forearm as well as dry needling up the forearm as recommended by Goel & Abzug (2015) to relax tight musculature that may be associated with pain and enhance fluid drainage from muscle tissue. Goel & Abzug (2015) supports this technique in conjunction with therapeutic strengthening and active range of motion exercise to promote gliding and healing of tendons within first dorsal compartment. Hence, resisted thumb flexion and abduction isometric exercises were prescribed applying between 50-60% of resistance and holding for 30-40s. Repetitions between 8-12 should be performed as many times as possible throughout the day and before piano performances to warm up the muscles. Education was also provided on use of anti-inflammatories, heat cream and rest when symptoms begin to worsen or during flare-ups which is supported by Howell (2012). Activity modification was also discussed regarding gaming and piano practice time, neutral wrist positioning during repetitive typing actions and use of frequent rest breaks to limit prolonged periods of aggravated tendons (Goel & Abzug, 2015).

Section 5: Plan (where to go from here? How many sessions might they need? What’s the goal?)

Due to Mr. X having an important performance on Thursday, it was advised to ease off on the aggravating activities until then. I also advised use of anti-inflammatories and heat creams like ‘deep heat’ to help manage symptoms while awaiting ultrasound results. Mr. X reported ‘deep heat’ is often not hot enough and therefore ‘rapigel’ was recommended as this is a stronger heat cream that can hopefully improve the effect.

Given Mr. X has previously received cortisone injection on the left wrist with good effect and is already planning to get it in the right wrist, symptoms will most likely be alleviated for next session. Cortisone injections have some good evidence backing up its effect for De Quervain’s. Goel & Abzug (2015) found prolonged relief in 80% of patients. Additionally, Satteson & Tannan (2022) discovered symptomatic relief in 50% of patients with one injection and relief with a second injection in 40-45%. However, we understand cortisone injections may not have long term effects and therefore if symptoms fail to improve or is ongoing after two injections, operative treatment is recommended (Satteson & Tannan, 2022). 

In saying this, physiotherapy management is beneficial post-injection to focus on wrist and forearm strengthening (Goel & Abzug, 2015). Considering, Mr. X is a professional pianist, ongoing physiotherapy input providing dry needling and soft tissue massage through the wrist and forearm to help loosen surrounding muscles is beneficial. Ideally, I would like to Mr X. to come once-twice a month for  manual therapy but also continue strengthening exercises for the wrist, hand, and forearm. Progressing into more concentric-eccentric exercises such as light dumbbell wrist flexion and extensions have been proven to enhance strength and prevent De Quervain’s symptoms (Goel & Abzug 2015). 

References:

Goel, R., & Abzug, J. M. (2015). de Quervain’s tenosynovitis: a review of the rehabilitative options. Hand, 10(1), 1-5.

Howell, E. R. (2012). Conservative care of De Quervain’s tenosynovitis/tendinopathy in a warehouse worker and recreational cyclist: a case report. The Journal of the Canadian Chiropractic Association, 56(2), 121.

Satteson E, Tannan SC. De Quervain Tenosynovitis. [Updated 2022 Feb 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK442005/