DeQuervain’s Tenosynovitis Treatment & Surgery

What is DeQuervain’s Tenosynovitis?

DeQuervain’s Tenosynovitis is a very common cause of pain in the thumb and wrist. This is also known as washer woman’s wrist. DeQuervain’s tenosynovitis is a painful condition affecting the tendons on the thumb side of your wrist. It hurts when you turn your wrist, grasp an object or when you try to pinch an object. It can also cause a clicking sensation when you move the thumb. Pinching, grasping and other movements of your thumb and wrist aggravate the pain.

The tendons that move the thumb away from the other fingers pass through a tunnel at the side of the wrist. This tunnel keeps the tendons close to the bone when the thumb moves. In DeQuervain’s, the tissue that forms the wall of the tunnel becomes thickened, narrowing the tunnel and restricting the tendon movement. The friction of the tendons rubbing against the narrowed tunnel each time it passes through makes them become more swollen and stiffer, making thumb and wrist movement painful.

How Do I Know I Have it?

In the early stages, you may just have some pain in the wrist near the base of the thumb off and on, especially with thumb movements or wrist movements. Most people will ignore this and carry on with their activities as normal.

As it gets worse, you will notice that the pain in the wrist is more frequent and affects simple activities like brushing your teeth, opening doors or bottles, and reaching behind the back. Typing or using the mouse may also be painful. You may notice some swelling at the side of the wrist below the thumb.

What Causes DeQuervain’s Tenosynovitis?

DeQuervain’s Tenosynovitis in most people is a repetitive strain injury. Most cases of DeQuervain’s result from chronic overuse of the wrist, especially in jobs that require repeated use of the hand and wrist. It is caused by frequent wringing actions and movements that load the wrist while it is held in slight flexion and tilted towards the body. The most common cause of this in the past was washing and wringing clothes, giving rise to it being called “washerwoman’s sprain”. These days, the most common cause is carrying a baby and pumping milk for breastfeeding, and it is now commonly known as “mummy thumb”.

Other causes are direct injury to the wrist resulting in scar tissue that restricts tendon movements, inflammatory arthritis, or poor hand posture when typing and using a mouse for long hours daily. Doing housework with a lot of wringing and scrubbing also can cause it. You may not associate it with these activities, because the thickening builds up slowly over time until it is bad enough to notice. Usually this takes years or decades, although occasionally it can happen soon after a twisting sprain to the wrist or after doing a lot of housework.

It is most common in first time mothers or grandmothers, and in people between 40-60 years of age. It may also appear in the late stage of pregnancy due to hormonal changes and water retention.

How is DeQuervain’s Tenosynovitis Treated?

Conservative Treatment

If it is mild or early (within a few weeks), DeQuervain’s can be treated by resting the wrist and thumb in a splint, anti-inflammatory medication and gentle exercises to free the tendons. Ultrasound or laser therapy by a certified hand occupational therapist can also help. You need to rest and avoid activities that cause the pain for at least 2-3 months.

Anti-Inflammatory Medication

Treatment involves resolving the swelling around the tendon sheaths in this condition. It is generally successful if treated early. This can involve anti-inflammatory medication and resting the wrist and thumb in a splint for 4 to 6 weeks in early cases.

Steroid Injections

If it has been present for more than a month, or you are experiencing a lot of pain even with simple wrist and thumb movements, then a steroid injection is recommended. A small amount of steroid is injected with a very fine needle into the tunnel containing the tendons. This reverses the changes in the tunnel and tendon, making them softer and looser. The wrist and thumb movements usually go back to normal within 1-2 weeks of the injection. If you do not want to wait 2-3 months for it to recover with rest and therapy, this is also a very good option for early DeQuervain’s.

Risks of steroid injection for DeQuervain’s are uncommon. These include infection, increased pain and swelling for a day or two after injection (steroid flare reaction) and thinning and lightening of the skin. This may cause the tendons and veins to appear more prominent. It may take 2 years for the skin colour and thickness to return to normal.

Surgery

Unfortunately, whether with rest and therapy or steroid injections, 30-50% of patients who recover from DeQuervain’s will experience it again within 3-6 months of recovery. This is because the changes in the tendon and tunnel may not have reversed completely and returning to the same activities will cause them to thicken and tighten again.

If it comes back, or if a steroid injection cannot cure it, then surgery is the best option. This is a minimally invasive, 30-minute procedure done under local anaesthesia either in the clinic or hospital as a day surgery. Through a tiny cut hidden in a line at the wrist, the thickened tunnel lining is cut open, freeing the tendons. The incision is then stitched up with one or two stitches that do not need to be removed. The wound heals in one week, and wrist and thumb movement return to normal over 4-6 weeks. There are usually minimally visible scars, and the condition never comes back again in the operated wrist.

While surgery is necessary for those who have failed rest and therapy or steroid injections, it is also an excellent and simple solution for those who want a fast and permanent solution instead of going through either prolonged therapy or an injection, only to risk it recurring after a few months.

Risks of surgery are uncommon when done by experts. These include infections (<0.001%), injury to the superficial radial nerve which may cause pain and numbness in the back of the hand (5%), and pain or stiffness requiring more than a month to go away (5%).

How Do I Prevent it?

The way to prevent DeQuervain’s is to avoid or minimise activities requiring frequent or strong wringing or repetitive side to side wrist movements.

This means avoiding wringing or squeezing actions such as squeezing clothes or towels dry and carrying a baby by hand. Hang your clothes or towels to dry without squeezing first, or if you must, use a gentle squeeze only. Using a baby carrier and breast-feeding pillow will help you carry the baby without straining the hand and wrist.

Pay strict attention to your hand posture when using the keyboard and mouse and take a break every 30-60 minutes to stretch the fingers, thumb and wrist.

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