Steroid Injections vs. Surgery:
What Really Works for De Quervain’s Tenosynovitis?
De Quervain’s Tenosynovitis
De Quervain’s tenosynovitis (DQT) is an overuse-related condition affecting the synovial sheath of the first extensor compartment of the wrist, involving the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons. It is characterized by pain and tenderness near the radial styloid, particularly during wrist and thumb movements.
Although the exact cause of DQT remains unclear, it is believed to result from thickening of the tendon sheath and extensor retinaculum, along with degenerative changes in the affected tendons. This thickening may cause the tendons to become entrapped within the tight compartment during movement. While the role of inflammation is debated, repetitive strain and mechanical overload appear to be primary contributing factors.
The condition is often aggravated by repetitive ulnar deviation of the wrist combined with frequent thumb extension and abduction. Additionally, hormonal factors may play a role, which could explain the higher prevalence of DQT in women, particularly those between the ages of 30 and 50. Studies suggest that the condition is up to six times more common in women than in men, with a notable incidence among individuals of childbearing age.
The Role of Smartphone Usage in De Quervain’s Tenosynovitis
The potential link between smartphone uses and DQT has been explored in various studies, with activities such as texting, prolonged app usage, and mobile gaming being investigated as potential risk factors. However, many studies fail to consider key variables, including hand posture while using a smartphone, device size, and the impact of overall hand and wrist activity levels. Additionally, individual factors such as muscle strength, ergonomics, and physical fitness may influence the likelihood of developing DQT. More comprehensive research is needed to fully understand how smartphone habits contribute to the development or exacerbation of this condition.
Among college students, the prevalence of De Quervain’s tenosynovitis (DQT) has risen with the increasing use of smart devices such as smartphones, computers, and tablets, alongside various hand-intensive activities. Engaging in tasks that require repetitive hand movements—such as playing ping pong, musical instruments like the guitar, writing, painting, and conducting hands-on scientific research—appears to elevate the risk of developing DQT.
Activities primarily associated with leisure, including mobile gaming and social media use, have been linked to a higher incidence of DQT, likely due to the repetitive nature of hand movements involved. Additionally, prolonged engagement in these activities—exceeding six hours per day—has been identified as a significant risk factor.
With advancements in smartphone technology, screen sizes have progressively increased in recent years. However, studies examining the relationship between mobile gaming and DQT have not consistently identified screen size as a major contributing factor. Interestingly, individuals using devices with smaller screens (5.0–5.5 inches) or larger screens (6.0–6.5 inches) appear to have a higher risk of developing DQT. This trend may be influenced by differences in hand size between men and women, though further research is needed to confirm this hypothesis.
Diagnosis:
There is currently no universally accepted standard test for diagnosing De Quervain’s tenosynovitis (DQT). However, Finkelstein’s test is widely regarded as the most reliable clinical assessment tool.
The Radial Synergy Test assesses De Quervain’s Tenosynovitis (DQT) by evaluating pain in the first dorsal wrist compartment during resisted ulnar abduction of the small finger.
Procedure:
-
Forearm Pronated: The patient ulnarly abducts the small finger against resistance. Pain = Positive test.
-
Forearm Supinated: The maneuver is repeated. Pain = Positive test.
-
The test is positive if pain occurs in either position and negative only if both are pain-free.
Electromyography (EMG) Confirmation:
EMG of EPB and APL muscles confirmed synergistic activation during the test, supporting its diagnostic value.
MRI
Magnetic resonance imaging (MRI) plays a crucial role in confirming the diagnosis, assessing disease severity, and guiding treatment decisions. It provides detailed insights into the number of tendons slips, the presence of an intervening septum, and the extent of involvement of each tendon, which can help in prognosis and management planning.
Image A: Axial T2-weighted fat-suppressed (FS) MRI shows increased signal intensity surrounding the tendons of the first extensor compartment, indicating inflammation. Multiple tendon slips of the abductor pollicis longus (APL) are visible (thin arrows), while tenosynovitis also extends around the extensor pollicis brevis (EPB) tendon (thick arrow) at this level.
Ultrasound
Ultrasound imaging can reveal multiple tendons slips with variable insertions, which may contribute to increased friction and predispose the patient to tenosynovitis. This characteristic arrangement can produce a "lotus root" appearance, where the tendon slips appear as small, round hypoechoic areas resembling holes in a cross-section of a sliced lotus root.
Management of Symptoms in De Quervain’s Tenosynovitis:
Image B: Axial ultrasound imaging demonstrates multiple slips of the abductor pollicis longus (APL) tendon (thin arrows), creating the characteristic "lotus root" sign due to their distinct appearance. Surrounding synovial thickening is evident (arrowheads), while the extensor pollicis brevis (EPB) tendon appears as a separate structure (thick arrow).
Effective management of De Quervain’s tenosynovitis (DQT) requires patient education on activity modification, function, and pain management, combined with one or more interventions. Treatment selection depends on the severity, duration of symptoms, and prior treatments attempted.
Physiotherapy as a Key Treatment Approach
Physiotherapy plays a crucial role in managing DQT by reducing pain, improving function, and preventing recurrence. Evidence suggests that structured rehabilitation programs can be highly effective, particularly when combined with other conservative interventions. Physiotherapy interventions include:
-
Manual Therapy – Techniques such as soft tissue mobilization and joint mobilizations may help reduce pain and improve wrist and thumb mobility.
-
Therapeutic Exercises – Strengthening and stretching exercises for the wrist, thumb, and forearm muscles can enhance function and prevent recurrence.
-
Neuromuscular Re-education – Focusing on movement patterns to reduce excessive stress on the first extensor compartment.
-
Ultrasound Therapy – Used to promote tissue healing, though evidence regarding its effectiveness is still limited.
-
Extracorporeal Shockwave Therapy (ESWT) – A non-invasive technique that may reduce pain and improve function, though more research is needed.
-
Laser Therapy and Acupuncture – Alternative modalities with inconclusive evidence on their efficacy.
Comparison with Other Non-Surgical Treatments
Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections (CSI), and splinting are commonly used conservative treatments. Corticosteroid injections have been shown to provide significant pain relief, but recurrence rates can vary, especially with blind injections. Ultrasound-guided injections improve accuracy and outcomes by targeting sub-compartments more precisely.
The role of thumb spica immobilization remains debated. While some studies suggest short-term benefits when combined with CSI, others indicate that prolonged immobilization (3–4 weeks) does not provide significant added value. Patients often report frustration with restricted hand function during immobilization.
Surgery:
A transverse incision was made to decompress the first extensor compartment, ensuring complete release of any sub-compartment and assessing the excursion of EPB and APL tendons separately. Postoperatively, patients were immobilized in a thumb spica slab for 3 days, followed by a thumb spica splint for 3 weeks before resuming activities.
Follow-Up and Assessment
Patients were reviewed at 3 weeks, 6 weeks, and 6 months to assess functional outcomes, recurrence, and complications using:
-
DASH Score: Evaluates upper limb function on a 5-point Likert scale.
-
PRWE Score: Assesses wrist pain and disability (pain: 5 items, function: 10 items; scored 0-50 each).
-
VAS Scale: Measures pain intensity on a 0-10 cm visual scale (0 = no pain, 10 = worst pain).
-
Long-Term Outcomes
-
6 months was chosen as the key follow-up period, as recurrence beyond this time is rare.
-
Patients unresponsive to steroid injections or experiencing relapse were considered for surgery.
-
Surgical release remains the gold standard, with long-term studies showing excellent results and no recurrence.
References
-
Finkelstein, M. and Ibarra, M. (2023) 'Assessment and management of De Quervain's tenosynovitis', Journal of Clinical Orthopaedics and Trauma, 14(3), pp. 214-223. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10611995/ (Accessed: 31 March 2025).
-
Jung, J. Y. et al. (2019) 'Role of imaging in the diagnosis of de Quervain’s tenosynovitis: A review', Journal of Pain Research, 12, pp. 379-387. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC7076607/ (Accessed: 31 March 2025).
-
Medlicott, M. (2023) 'Management strategies for de Quervain's tenosynovitis in clinical practice', WMJ, 122(2), pp. 110-115. Available at: https://wmjonline.org/wp-content/uploads/2023/122/2/110.pdf (Accessed: 31 March 2025).
-
Taylor, H. D. et al. (2021) 'De Quervain’s tenosynovitis: Surgical management outcomes', Journal of Hand Surgery, 46(8), pp. 803-808. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10652590/ (Accessed: 31 March 2025).
-
Nassar, A. et al. (2017) 'MRI and sonographic features in the diagnosis of de Quervain's tenosynovitis', American Journal of Roentgenology, 209(6), pp. 1350-1357. Available at: https://www.ajronline.org/doi/10.2214/AJR.17.19078 (Accessed: 31 March 2025).
-
Lee, H. et al. (2020) 'Ultrasound findings in De Quervain’s tenosynovitis: A retrospective study', Journal of Ultrasound in Medicine, 39(2), pp. 145-150. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10020267/(Accessed: 31 March 2025).
-
Kim, S. H. et al. (2020) 'Efficacy of corticosteroid injection versus surgical release in the treatment of De Quervain's tenosynovitis', Journal of Hand Surgery, 45(10), pp. 893-898. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10052622/ (Accessed: 31 March 2025).