De Quervain’s “Tendonitis” Syndrome
What is De Quervain’s “Tendonitis”?
In fact, strictly speaking, this is not a “tendonitis”, as tendons are not inflamed, but the tunnel through which they pass becomes thickened and painful. The tendons of Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB) are located over the side of the wrist, where they pass through a tunnel. These tendons pull the thumb up and out, as if trying to stretch out around a large object. The tendons do not have much room, and the tunnel can become narrowed, causing a “vicious circle”.
What are the symptoms?
There is intense pain on using the thumb, felt on the thumb side of the wrist. There may be swelling in that area. Stiffness of the thumb may develop, or the thumb may “trigger” or “catch” in and out on movement.
Why does it happen?
The cause is unknown, but it occurs more commonly in women, often during or after pregnancy, so hormones are probably involved.
What can be done?
The best treatment initially is anti-inflammatory medication, rest from any activity that worsens the inflammation, and often a neoprene splint, which must include the thumb. Hand therapy is often helpful.
The next step on the ladder of treatments is a steroid injection. This is helpful in around 60-80% of cases, and can be repeated once or twice. The main side-effect is a thinning of the skin over the injection site, which can look unsightly.
If those treatments do not work, then an operation to release the tunnel in which the tendons run may be indicated.
What does the operation involve?
The operation can be done under local or general anaesthetic. A tourniquet (like a blood pressure cuff) is worn on the upper arm during the procedure to prevent bleeding.
One small incision is required, approximately 3cm on the back of the wrist. The EPB and APL tendons are located, and the tunnel fully released all around the tendons.
The wounds are closed with a dissolveable suture, and a soft bandage applied.
What happens after the operation?
The operation is nearly always done as a “daycase”, with a hospital stay of just a few hours. The hand must be elevated, particularly for the next 48 hours.
After 10-14 days, the bandages will be removed, and the wound is usually fully healed.
Over the next few weeks, our hand therapist will supervise a carefully graduated exercise programme to allow increasing strengthening and movement, whilst protecting the released tendons from further inflammation.
Are there any risks?
This is generally a very safe and effective procedure, with few problems. However, there are a few potential risks, as with any operation.
- Wound infections occur in less than 1% of cases, and usually quickly resolve with antibiotics.
- The scar may be tender. This usually improves with scar massage.
- There can be some stiffness in achieving full flexion of the thumb into the palm. This usually improves with hand therapy, and further treatment is not generally needed.
- Grip strength can also take some months to return to normal.
- Numbness over the back of the thumb, caused by damage to a branch of the nerve.
- This rarely causes any functional problems, but there is often discomfort, and this is associated with scar tenderness. This is treated with scar massage.
- Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which very slowly improve.
- Very rarely, the condition can recur, and the operation need to be re-done.
- Any operation can have unforeseen consequences and leave a patient worse than before surgery. This is rare for De Quervain’s tendon release.