a lesson in pronunciation: de Quervain's tenosynovitis

Before I delve into this article, let me give you a little background on my athletic prowess

I was the girl whose parents threw her into every “sport”: softball, soccer, ballet, swimming, horseback riding, gymnastics, basketball, and yes, even tap-dancing (that one ended with an embarrassing public urination episode that is still not spoken of to this day). In high school, I finally accepted the notion that my hand-eye coordination couldn’t exactly compete with the average student (note: the only point I ever scored during basketball was for the opposing team), and so I turned to running.

hand-eye coordination was never a strong suit...

example: I always feared having to use hand-eye coordination

Even though I lacked the speed required to “make it big” (ok, I lacked the speed to even just qualify for state in a 2A school in Mississippi), I loved the feeling that running gave me. I’ve recently learned that not everyone shares this feeling; many athletes see running as punishment, since it is often used for that purpose in their training. But running became therapeutic for me—a release. I imagine running offers a similar outlet to me as other sports do to their respective athletes.

Since high school, I have continued to be fascinated by the human body and especially how it can be so challenged in the athletic population. I’ve hungrily absorbed books, articles, lectures and videos on the subject. And, having a disadvantage as far as Sports Trivia (upbringing = Indian father, hippie mother), this was extremely important. I took a lot of heat in my first job when I showed up with the following book:

But what perhaps has driven me to this field the most is my own experience with injury. As most runners will, I encountered several overuse injuries over the years, a few which brought me to physical therapy. Even though I wasn’t a professional level athlete and never experienced an injury that affected me for more than a month at a time, I understood the debilitating effect an injury can have on an individual. In some cases, when the sport defines the athlete, it can be akin to losing a job. It is, in some cases, a loss of identity. (A blog on sports psychology to be posted in the future).

Overuse injuries are extremely common among the athletic population. The specific statistics vary by sport, but have been estimated to be between 37% in sports such as skiing to 68% in sports like running (DiFiori et al ). There are many factors that predispose athletes to overuse injuries, and many of these factors can be prevented. Often, overuse injuries involve tendons.

A tendon is a part of the body that connects the muscle to the bone. When muscles contract, they send energy into the tendons to be stored to help either begin or control a movement. If an athlete is not allowed sufficient time to rest, or consistently performs a certain movement with poor mechanics, the tendon may become subject to high loads that eventually leads to injury.

One such injury that is common yet less devastating than many others is known as de Quervain’s tenosynovitis.

When first learning about this injury, I could not for the life of me remember how to pronounce “de Quervain’s”. A scholarly google search reminds me it is pronounced dih-kwer-VAINS (I prefer dih-KWER-vens). So for my sake, let’s refer to it as DQ from here on out.

DQ (now I’m craving an oreo blizzard) refers to an overuse injury that involves some of the muscles responsible for moving the wrist and thumb, specifically the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles. These tendons run under a sort of 'tunnel' or sheath, and both the tendons and sheath can become irritated and thickened with repetitive use.

*Contrary to popular belief, evidence suggests that inflammation is not always involved [Clarke et al 1998]. DQ is a degenerative, rather than an inflammatory, disease.

So why write about a subject I can barely pronounce? There are several reasons that DQ is an important topic for the Sports PT:

1) DQ affects a wide range of populations and is not limited to the athletic population. In fact, DQ is commonly associated with new mothers who repeatedly lift their toddlers. In the sports population, it is common among athletes who consistently use their wrists or are involved in gripping activities. Think golf, racquet sports, baseball, bowling, wrestling, weight lifting, and even volleyball (Rossi et al 2005). DQ has also shown to be increasing in prevalence among younger populations due to frequent SMS text messaging (Ali et al 2014). In addition, any occupation that involves lifting or repetitive wrist/hand movements (i.e. typing) may be more predisposed to developing DQ.

2) Despite its fairly common prevalence among a wide range of populations, evidence regarding DQ in athletes is lacking. Few studies exist that provide high level evidence in DQ management and rehabilitation (Cavaleri et al 2016). Perhaps this can be attributed to the fact that DQ is a self-limiting injury that often only requires conservative care and does not lead to high medical costs. Most of the time, DQ can be effectively treated with rest (including the use of ice), short-term NSAIDs and potential corticosteroid injections, and a gradual return to activity. However, improving the early detection of DQ through wide-spread education of the injury may prevent time out of sport, or at the very least, prevent unnecessary pain.

3) Finally, I do have a few selfish motivations for writing on this subject. This past winter I developed the condition. I attribute the development to a combination of the repeated use of manual therapy techniques in the clinic, repeated application of athletic tape in the training room and at sporting events, and repeated lifting in the gym with, more than likely, improper mechanics. Fortunately, working in a PT clinic has many advantages and the injury quickly subsided (when I finally practiced what I preach and made some modifications to my daily routine).

Additionally, researching de Quervain's is forcing me to delve deeper into the anatomy and biomechanics of the hand, my least favorite part of the human body. (Why can't we leave it to the hand specialists?) In my mind, learning about the hand was just as difficult as it would be for my mom to vote for Donald Trump.

Finally, why not write about a condition that I have difficulty pronouncing? After all, who can pronounce the name "Asha," especially in a southern state such as Mississippi?

An athlete that develops DQ often complains of pain near the radial styloid of the thumb (that protruding bone at the wrist). Often, moving the thumb or wrist or bearing weight through the upper extremity exacerbates pain. Athletes will sometimes complain of swelling which may be visible, and may report a catching sensation when attempting to move the thumb.

Other pathologies, such as a condition known as 'intersection syndrome,' may present similarly to DQ. In the case of 'intersection syndrome,' the location of pain differs slightly. Though knowing the exact pathology can be helpful, it is usually more important to pay attention to the individual athlete and treat his/her signs/symptoms rather than treating the diagnosis.

Treatment, as stated earlier, often consists of conservative measures such as rest, ice, splinting/taping/orthotics, therapy and short term NSAIDs (such as aspirin and ibuprofen). Often, an athlete may be referred to a physician to receive a corticosteroid injection for pain relief. A recent meta-analysis found that the combination of therapy and corticosteroid injection/orthotic use is more effective than either treatment in isolation (Cavaleri et al 2016). Neither isolated hand therapy nor isolated corticosteroid injections/use of orthotics had significant advantage over the other in providing pain relief (Cavaleri et al 2016).

Fortunately, a diagnosis of DQ does not often prohibit an athlete from engaging in sport. With proper taping or bracing (i.e. the use of a thumb spica, seen below) and education, an athlete may participate relatively comfortably in their sport. However, it is important that the athlete allow the tendons time to rest to avoid acquiring a chronic condition that will prolong healing time. A Sports PT should evaluate the athlete's specific wrist and hand biomechanics during their sport and make any modifications necessary to prevent DQ from recurring. Athletes should be conscious of any increase in their training, change in environment, or handling of any new equipment. Improper handling of equipment may lead to athletic injuries such as DQ (Karthik et al 2013).

In worst-case scenarios, athletes may require surgery when conservative treatment fails (usually after about 4-6 months). Surgery often consists of 'releasing' the sheath that the tendons run under to decrease pressure. Results following surgery tend to be favorable and athletes may be able to return to play as soon as they regain normal range of motion and strength, typically around 6 weeks post-operatively (Goel, Abzug 2015).

Additional Information (derived from Orthopaedic Rehabilitation of the Athlete, 2015)

Physical therapists treating an athlete with de Quervain's tenosynovitis must, as always, take a good patient history, complete a comprehensive examination, and develop an appropriate and timely plan of care in conjunction with the patient's goals. The following will outline a typical case presentation. Keep in mind that each athlete will vary and, as is often the case, will deviate from the 'typical' presentation.

Patient History- Patient will likely report the following:

Pain at or near radial styloid process of the wrist (may radiate into thumb or forearm)
History of repetitive overuse (though rarely may report a single acute episode, including a traumatic blow to the wrist)
Pain with thumb extension and abduction and wrist radial deviation
History of swelling may or may not exist

Patient Examination:

+ Finkelstein's test:

Note that this test has little evidence to support its reliability; one study suggests that the test has a specificity of only 50 and a sensitivity of 81 (Cook, Hegedus 2013). Often this test is positive in a normal, healthy population due to its fairly aggressive nature.

Pain with resisted thumb abduction, extension
Tenderness to palpation at first dorsal compartment (EPB, APL)
Potential crepitus or 'catching' sensation with thumb movements
Erythema or edema possible

The goals of rehab should include regaining pain-free range of motion and strength, if appropriate. Rehab goals should also address identifying the cause of the injury; for instance, identifying any biomechanical deficits or ill-fitting equipment that may put the athlete at risk for reoccurrence of DQ.

With proper care and early detection, DQ is an easily treated injury that should not cause any major concern to the athlete and his/her rehabilitation team.

References and Resources:

Articles/Books

Aggarwal R, Ring D. de Quervain tendinopathy. UpToDate. 2016.
Ali M, Asim M, Danish SH, Ahmad F, et al. Frequency of de Quervain's tenosynovitis and its association with SMS texting. Muscles, Ligaments, Tendons Journal. 2014; 4(1):74-78.
Cavalry R, Schabrun SM, Te M, Chipchose LS. Hand therapy versus corticosteroid injections in the treatment of de Quervain's disease: A systematic review and meta-analysis. Journal of Hand Therapy. 2016; 29(1): 3-11.
Cook CE, Heeds EJ. Orthopedic Physical Examination Tests: An Evidence-Based Approach. 2nd Edition. Pearson Education, Inc, 2013.
DiFiori J, Benjamin H, Brenner J, Gregory A, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clinical Journal of Sports Medicine. 2014; 24(1): 3-20.
Goel R, Abzug JM. de Quervain's tenosynovitis: a review of the rehabilitative options. Hand. 2015; 10(1): 1-5.
Huisstede BM, Coert JH, Friden J, Hoogvliet P. Consensus on a multidisciplinary treatment guideline for de Quervain disease: results from the European HANDGUIDE study. American Physical Therapy Association. 2014.
Ilyas AM, Ast M, Schaffer AA, Toder J. De quervain tenosynovitis of the wrist. Journal of American Academy of Orthopaedic Surgeons. 2007; 15(12): 757-764.
Karthik K, Carter-Easdale CW, Vijayanathan S, Kochar T. Extensor pollicis brevis tendon damage presenting as de Quervain's disease following kettlebell training. BMC Sports Science Medical Rehabilitation. 2013; 5(13).
Rettig A. Athletic Injuries of the Wrist and Hand. Part II: Overuse injuries of the wrist and traumatic injuries to the hand. The American Journal of Sports Medicine. 2003; 31(6): 262-273.
Rossi C, Colloco P, Margaritondo E, Bizzarri F, Costanzo G. De Quervain disease in volleyball players. American Journal of Sports Medicine. 2005; 33(3): 424-427.
Stahl S, Vida D, Meisner C, Stahl AS, Schaller HE, Held M. Work related etiology of de Quervain's tenosynovitis: a case-control study with prospectively collected data. BMC Musculoskeletal Disorders. 2015; 16: 126.