A look at the symptoms and treatments for de Quervain’s disease.

The human body performs daily activities with the cooperation of different body parts. For the body to function, all of its parts are very important. When these parts are deficient, they can make a person feel like his or her life is on hold.

Oftentimes, we do not appreciate how valuable our two healthy hands are until they are injured. From the beginning to the end of the day, our hands are actively involved in different daily chores. What makes the human hand unique is the thumb. The human hand’s ability to oppose the thumb to the small finger enables it to grip and gives it stability and strength. When the thumb is impaired, either by injury or amputation, the hand appears useless while performing day-to-day tasks—even when the other fingers are present. One should never ignore any problems affecting the thumb, because many medical problems are related to the thumb. However, this article will concentrate on the diagnosis of de Quervain’s disease.

Signs and Symptoms
de Quervain’s disease is the stenosing tenosynovitis of the first dorsal compartment of the wrist involving the extensor pollicis brevis and abductor pollicis longus tendons as they pass through the osteoligamentous tunnel of the radial styloid and transverse fibers of the dorsal carpal ligament. The inflammation in this first dorsal compartment causes pain, swelling, and range-of-motion (ROM) limitations in the thumb and wrist joints. Women are affected 3 to 10 times more frequently than men.

Clinically, de Quervain’s disease can be diagnosed by: Finkelstein’s test; magnetic resonance imaging studies, which reveal thickened tendons of the first dorsal compartment of the wrist and synovial edema; and ultrasound.

Differential diagnoses include: Intersection syndrome, involving the second dorsal compartments (extensor carpi radialis longus and extensor carpi radialis brevis), with patients experiencing pain and swelling 4 cm proximal to the first dorsal compartment; and Wartenberg’s syndrome, where patients may show entrapment of the sensory branch of the radial nerve in the forearm and have a positive result in Tinel’s test.

Causes of de Quervain’s disease include repetitive motion while performing activities of daily living (ADL), such as grasping, pinching, squeezing, and wringing, as well as sudden trauma to the thumb or wrist, such as by a fall, the use of tools, or an automobile accident.

Some metabolic abnormalities, such as diabetes, hyperuricemia, hypothyroidism, pregnancy, and rheumatoid arthritis, may be associated with de Quervain’s disease.

Depending on the cause of injury, de Quervain’s disease may start with either soreness or pain, and swelling in the radial styloid area. As the friction in the tendons increases, it causes crepitus and swelling in the area, and it becomes more painful for patients to grasp any object. The pain is aggravated by ulnar deviation of the wrist, and by flexion and adduction of the thumb. Supination has been reported to be more frequently painful than pronation. The pain may occasionally radiate into the forearm.

Treatment Options
Generally, patients start with anti-inflammatory medication, as well as a thumb-spica splint to immobilize the wrist and the thumb and to decrease pain and swelling of the tenosynovium. If these measures fail to control the symptoms, the next step is steroid injections. Therapy may be offered before or after the steriod injections.

The patient’s first visit to the physical therapy clinic to receive treatment for de Quervain’s disease is very important. Take a complete assessment of a patient’s hand and arm ROM, sensation, edema, pain, strength, splinting, and ADL status from morning to nighttime while the patient performs different activities at home or at work. The assessment of ADL is very crucial for patients with de Quervain’s disease, because they need to be informed about what to do or not to do, or to be cautious while using their hands with or without thumb involvement due to the thumb-spica splint.

Treatments may include:

• Thermal modalities;

• Anti-inflammatory modalities (a check for contraindications in necessary);

• Ice (in the acute stage);

• Transverse friction massage;

• Splinting;

• Edema control;

• Sensory evaluation;

• Therapeutic exercises—starting with ROM exercises, and as the patient progresses, adding strengthening exercises;

• Ergonomic workstation assessment as needed;

• Educating the patient to either avoid or decrease repetitive hand motions, such as pinching, wringing, turning, twisting or grasping; and

• A home-exercise program.

The patient plays a major role in his or her recovery process. The PT’s job is to guide the patient through the long healing process, which takes several months if the patient follows the proper guidelines with patience.

If treatment goals—decreased or eliminated inflammation, and the prevention of reoccurrence—are not met, then the referring physician may recommend the patient for surgery. Sometimes, patients develop complications such as continued pain, edema, joint stiffness, subcutaneous fat atrophy, tendon deterioration, and skin depigmentation.

Surgery for this condition can be performed as an outpatient procedure, under general, regional, or local anesthesia. Recovery can take weeks or months after surgery.

Postsurgical treatment options include:

• Complete assessment of the hand and arm on the first day after surgery to check for pain sensation, ROM, scar condition, edema, and the ability to perform ADL;

• Thumb-spica splint. This may be prescribed for 3 days or up to 2 weeks, depending on the physician’s recommendation. Some physicians prefer not to immobilize the thumb in a splint at all;

• Scar management after the stitches are removed;

• Edema control;

• Therapeutic tendon-gliding and ROM exercises, as tolerated before and after the stitches are removed;

• Therapeutic strengthening exercises; and

• Home-exercise programs.

Patients may develop complications after surgery, such as neuromas, adhesions in the scar area, volar subluxation of the tendons, and hypertrophy of the scar. When the patient is seen for physical therapy for the first time after surgery, the PT must discuss hand positioning and precautions when using the involved hand in ADL or at work for approximately 4 to 10 weeks postsurgery, depending on the condition of the hand.

Overall, there are three treatment categories:

1) Conservative, nonoperative therapy only;

2) Postoperative therapy only; and

3) Conservative, nonoperative treatment and injections, administered first, and then postoperative therapy.

Results from these treatment options depend on the patient’s hand condition, the therapist’s and physician’s expectations, the extent of the patient’s involvement in the healing process, and the patient’s insurance coverage.

The healing process depends on the patient’s desire to heal, faith in himself or herself and in his or her therapist, and willpower to cooperate with the prescribed treatments. The patient’s attitude—positive or negative—also reflects in the progress or loss of hand function. That is why a combination of physical and psychological components is very important to achieve the goals set by the patient and the PT during the patient’s first visit to the clinic for assessment. The PT’s role is to provide individual attention to his or her patient and to be an empathetic listener while focusing on the patient’s rehabilitation goals.

Patients with de Quervain’s disease should work toward the goal of recovery. As the patient progresses, he or she will need less and less therapy at the clinic and may need an independent home-therapy program for strengthening, weaning himself or herself off the brace, and involving the hand in daily functional activities.

It may be a good idea to start a home-therapy program from the patient’s first clinical visit, as this allows appropriate modifications as the patient progresses in his or her recovery process. While treating a patient with de Quervain’s disease, the PT should always provide him or her with realistic expectations for functional outcomes.

Ravinder K. Sohi, OTR/L, CHT, currently practices at Congress Medical Associates in Pasadena, Calif.

Recommended Reading
Amadio PC, Hentz VR. Year Book of Hand Surgery. Philadelphia, Pa: Elsevier; 1997.

Clark GL, Wilgis EFS, Aiello B, et al. Hand Rehabilitation: A Practical Guide. 2nd ed. Philadelphia, Pa: Elsevier; 1997.

Hunter JM, Mackin, EJ, Callahan AD. Rehabilitation of the Hand: Surgery and Therapy. Philadelphia, Pa: Elsevier; 1995.

Reiner M. The Illustrated Hand. 2nd ed. St Paul, Minn: Minnesota Hand Rehabilitation Inc. 2004.