0008-3194/2012/112–120/$2.00/©JCCA 2012 Conservative management of De Quervain’s stenosing tenosynovitis: a case report John A. Papa, DC, FCCPOR(C)* Objective: To chronicle the conservative treatment and Objectif : Rendre compte du traitement et de la prise en management of a 32-year old female patient presenting charge conventionnels d’une patiente âgée de 32 ans with radial wrist pain of 4 months duration, diagnosed souffrant de douleurs au bord radial du poignet depuis as De Quervain’s stenosing tenosynovitis. 4 mois, qui avait reçu le diagnostic de ténosynovite Clinical features: The primary clinical feature is wrist sténosante de De Quervain. pain at the radial styloid with resultant impairment of Caractéristiques cliniques : La principale wrist, hand, and thumb function. caractéristique clinique est la douleur au poignet au Intervention and outcome: The conservative niveau de la styloïde radiale ayant pour conséquence treatment approach consisted of activity modification, une défaillance de la fonction du poignet, de la main et Graston Technique®, and eccentric training. Outcome du pouce. measures included verbal pain rating scale, QuickDASH Intervention et résultat : L’approche conventionnelle Disability/Symptom Score, and a return to activities du traitement a inclus un changement de ses activités, of daily living (ADLs). The patient attained symptom la technique Graston® et un entraînement excentrique. resolution and at 6 month follow-up reported no Dans les indicateurs de résultats, on a pris en compte recurrence of wrist pain. notamment l’échelle verbale d’évaluation de la douleur, Conclusion: A combination of conservative le questionnaire QuickDASH/Symptom Socre, et la rehabilitation strategies may be used by chiropractors to reprise de ses activités de la vie quotidienne (AVQ). Les treat De Quervain’s stenosing tenosynovitis and allow symptômes de la patiente ont disparu et, après six mois for an individual to return to pain free ADLs in a timely de suivi, elle n’a constaté aucune réapparition de ses manner. douleurs au poignet. (JCCA 2012; 56(2):112–120) Conclusion : Les chiropraticiens peuvent avoir recours à une combinaison des stratégies conventionnelles de réadaptation afin de traiter la ténosynovite sténosante de De Quervain et permettre aux patients de reprendre rapidement leurs activités de la vie quotidienne sans souffrir. (JCCA 2012; 56(2):112–120) k e y w o r d s : radial wrist pain, stenosing m o t s c l é s : douleurs au niveau du bord radial tenosynovitis, De Quervain’s, Graston Technique®, du poignet, ténosynovite sténosante, De Quervain, eccentric training technique Graston®, entraînement excentrique. * Private Practice, 338 Waterloo Street Unit 9, New Hamburg, Ontario, N3A 0C5. E-mail: [email protected]. © JCCA 2012 112 J Can Chiropr Assoc 2012; 56(2) JA Papa Introduction icle the conservative treatment and management of a 32- De Quervain’s stenosing tenosynovitis (DQST) is a dis- year old female patient presenting with chronic pain at the order that is characterised by wrist pain and tenderness radial styloid diagnosed as DQST. at the radial styloid.1,2 It is caused by impaired gliding of the tendons of the abductor pollicis longus (APL) and Case report extensor pollicis brevis (EPB) muscles.1 These musculo- A 32-year old, right hand dominant female presented with tendinous units control the position and orientation, force gradual onset over four months of right-sided radial wrist application and joint stability of the thumb. The impaired pain. The patient was a stay at home mother. Her pain gliding is believed to be as a result of thickening of the started after pulling her two children (boys aged seven extensor retinaculum at the first dorsal (extensor) com- months and three years old) in a wagon during her daily partment of the wrist, with subsequent narrowing at the walks. She originally felt only mild discomfort in the fibro-osseous canal.3–7 Severe cases of DQST have been right wrist and base of the thumb that did not limit any associated with extensor retinaculum thickening that is of her activities of daily living (ADLs). Over the follow- three to four times greater than normal.3,5 ing weeks, she noticed a gradual increase in her wrist and The term “tenosynovitis” implies the presence of an thumb pain, especially after holding her seven-month old inflammatory condition. However, the pathophysiology son at her side. She visited her family physician who pro- of DQST does not involve inflammation and has histo- vided a diagnosis of “tendonitis.” The physician recom- pathological findings similar to those of other tendinop- mended over the counter medication (ibuprofen), and a athies such as fibrocartilagenous metaplasia, deposition thumb spica splint to manage her symptoms. She found of mucopolysaccharide,8,9 and neovascularization.10 the thumb spica splint to be cumbersome and impractical Neo vascularization is known to be accompanied by an during participation in most household chores and child in-growth of nerve fascicles that have both sensory and minding activities, and therefore discontinued use. sympathetic components capable of transmitting pain.11 The patient rated her current pain level on the Verbal Thus, the mechanical impingement of the APL and EPB Pain Rating Scale (VPRS) where 0 is “no pain” and 10 tendons in the narrowed fibro-osseous canal is the likely is the “worst pain that she had ever experienced”. She re- stimulus of nociceptors and pain.7,8 This creates resultant ported her pain as ranging from 3/10 at rest to 8/10 when impairment of wrist, hand, and thumb function with activ- aggravated by activity. Evaluation of her disability was ities such as lifting, pushing, pulling, and gripping. completed using the QuickDASH (disability of the arm, In a large community based study from the United shoulder and hand). Her QuickDASH Disability/Symp- Kingdom, the prevalence of DQST was found to be 0.5% tom Score (QDDSS) was 80 out of a possible score of in men and 1.3% in women.12 Epidemiological studies in 100. The pain was described as a constant ache that be- industrial settings have shown a point prevalence of 8% came sharp in character with use of her right hand. This when wrist pain and a positive Finkelstein’s test, with or resulted in functional limitations with many of her ADLs without tender ness to palpation of the radial wrist were (i.e. meal preparation, carrying laundry and groceries, used as diagnostic criteria.13,14 The highest prevalence of home cleaning duties, vacuuming, picking up her chil- DQST has been reported among subjects 30–55 years of dren). She did not report any other previous history of age.1,3,5 There are no reports available that definitively de- significant right upper extremity injury. A systems review scribe the natural history of untreated DQST.2 and family health history was unremarkable. According to the National Board of Chiropractic Exa- Upon examination, inspection did not reveal any swell- miners 2005 Job Analysis of Chiropractic, the chief pre- ing of the right wrist, hand, or thumb. A cervical spine senting complaint on initial visit of 8.3% of chiropractic screen and neurological screen (reflex, motor, sensory patients in 2003 was in an upper extremity.15 Chronic ten- testing) for the upper extremities were within normal lim- don pathology is a soft tissue condition commonly seen its. Radial nerve tension testing as described by Magee18 in chiropractic practice.16 Chiropractors offer a number of and Butler19 was unremarkable. Provocative joint test- conservative interventions that can be employed to treat ing and range of motion (ROM) for the right elbow joint tendinopathy.17 This case study was conducted to chron- were within normal limits. Active wrist ROM revealed J Can Chiropr Assoc 2012; 56(2) 113 Conservative management of De Quervain’s stenosing tenosynovitis: a case report nique® (GT®) was administered by a certified provider using GT® protocols to all the affected soft tissues of the right upper extremity. Care was taken in the initial stages to not administer treatment over the painful first dorsal compartment at the radial styloid. The patient was initially prescribed exercises con- sisting of static stretching for the thenar muscle group (Figure 1) and forearm extensors/flexors. In addition, ec- centric unweighted hammer curl exercises with no con- centric component were prescribed (Figure 2 A–C). The patient was instructed to assist with the other hand dur- ing the concentric (radial deviation) movement phase. In week 3, eccentric thumb extension and abduction exercis- es with an elastic band (Figure 3 and 4), were introduced. At the beginning of week 5, eccentric wrist extension and Figure 1 Stretching for the thenar muscle group flexion exercises with a dumbbell (Figure 5 and 6), along with eccentric forearm pronation and supination exercises with theraband® (Figure 7 and 8) were introduced. All ec- discomfort at end ranges of flexion, extension, and radial centric exercises were performed without the concentric deviation. Ulnar deviation as well as active thumb exten- component permitted. A summary of the full rehabilita- sion and abduction movements were limited by 50%. In tive exercise treatment protocol is included in Table 1. addition, Finklestein’s test (deviating the wrist to the ul- The patient was seen twice a week for 4 weeks and nar side while grasping the thumb) was positive for pain. then once per week for 4 weeks. At the end of week 8, the The first CMC joint grind test18 did not reproduce the pa- patient reported a VPRS score of 0/10 consistently at rest, tient’s symptoms. There was no reported tenderness with and 1–2/10 with functional activities formerly reported as joint play of the metacarpals and no evidence of instabil- painful. The patient began gradually resuming her previ- ity.