The Hand and Wrist in Sport

de Quervain's Tenosynovitis

Surface anatomy and skin incision

Photo courtesy of Interactive Hand 2000
© 2000 Primal Pictures Ltd.

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text describing this anatomy of this region and supporting images, and
a description of Finkelstein's test for this injury.

Mechanism of Injury	The most common form of tenosynovitis reported, this injury is most commonly seen in racket sports. The mechanism of injury is usually associated with repetitive ulnar deviation, which leads to inflammation of the abductor pollicis longus tendon (APL) and extensor pollicis brevis tendon (EPB).
Signs and Symptoms	Acute Localized edema over the first dorsal compartment, pain with grasp and prehension, and tenderness over APL/EPB are evident. Chronic Pain, weakness, and muscle atrophy are evident.
Applied Anatomy	The abductor pollicis longus tendon (APL) and extensor pollicis brevis tendon (EPB) are located in the first dorsal compartment at the level of the radial styloid. Thumb extension, thumb abduction, and wrist ulnar deviation may elicit pain, particularly during active or resisted motion.
Physical Examination	History Determine the mechanism of injury, the effect on function, and the duration of symptoms. Initial Inspection Assess for edema and abnormal posturing of thumb and wrist. Objective Assessment (Special Tests) Examination reveals point tenderness and swelling to the first dorsal compartment. A positive Finkelstein's test is frequently observed. The test involves ulnar deviation of the wrist with the thumb adducted in the palm. Resisted thumb extension and abduction should also elicit pain. Finkelstein's test Image courtesy of the authors.
Rehabilitation Goals	Short Term To resolve pain and inflammation, restore pain-free thumb and wrist motion, restore unrestricted and pain-free pinch and grip strength. Long Term Return to pre-morbid activity level and return to sport.
Rehabilitation Management	Conservative treatment includes the use of supportive modalities to decrease inflammation and immobilization using a forearm-based thumb spica splint commonly leaving the IP joint of the thumb free. Once pain has subsided, progress the patient accordingly with ROM and strengthening exercises for the hand and wrist. If surgical decompression is required, post-operative therapy may include pain, edema, and scar management in addition to hand/wrist ROM exercises and progressive pinch and grip strengthening. Patient education should be included in both scenarios to minimize the risk of recurrence.
Patient Self Care	If wearing a splint, monitor for any skin irritation that may be caused by wearing the splint.
Return to Competition	In non-surgical cases depending on the sport and the patient's tolerance, the patient may remain in competition with the use of a protective splint. In general, symptoms should resolve with conservative management within 4-6 weeks. In the case of surgery, once sutures are removed, the athlete may return to the sport, however, this again will vary with each sport, athlete's tolerance, and the severity of post-operative complications such as pain, edema, scar sensitivity, and loss of mobility of the thumb and wrist.
Complications	Persistent symptoms of de Quervain's tenosynovitis may require surgical management to release the tendon sheath. Complex regional pain syndrome may manifest if the dorsal radial sensory nerve is involved.