De Quervain Tendinopathy

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De Quervain Tendinopathy

De Quervain tendinopathy is a common cause of wrist pain in adults, involving the tendons and tendon sheaths of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) as they pass through a fibro-osseous tunnel near the radial styloid. The tendon sheaths have an outer fibrous layer and an inner synovial layer. The synovial layer produces fluid that nourishes the tendons and facilitates smooth, friction-free movement.

Tendinopathy is a broad term encompassing various conditions that involve degeneration, damage, or inflammation of a tendon. In the case of De Quervain tendinopathy, the condition is primarily due to degenerative changes rather than acute inflammation. These changes include fibrous tissue deposits and increased vascularity within the synovial lining of the tendon sheath, which causes thickening of the sheath, leading to entrapment of the tendons. This process can result in pain, swelling, and restricted movement in the affected tendons, particularly during thumb and wrist movements.

While the exact cause of Quervain tendinopathy remains unknown, it is generally attributed to overuse or repetitive wrist and thumb movements. The condition most commonly affects adults between the ages of 30 and 50 and is more prevalent in women than men. Notably, it has been observed in a subset of postpartum women, possibly due to the repetitive lifting of infants, often referred to as “mother’s thumb.” Additionally, it is frequently seen in individuals engaged in activities requiring repetitive thumb and wrist motions, such as racquet sports, tennis, bowling, and rowing.

The affected tendons, abductor pollicis longus (APL) and extensor pollicis brevis (EPB), control radial abduction, which involves moving the thumb away from the hand in the plane of the palm.

• Pain localized over the radial side of the wrist, specifically at the radial styloid
• Pain worsens with thumb or wrist movement, especially with repetitive activities
• Pain triggered by gripping, pinching, or twisting objects, such as opening a jar or making a fist
• Pain that may radiate along the thumb or extend up the forearm

• Swelling may be present over the radial styloid
• Pain with active extension and radial thumb abduction
• Pain with ulnar deviation of the wrist, particularly during resisted motion
• Tenderness on palpation over the radial styloid
• Positive Finkelstein test
• Positive Wrist Hyperflexion and Abduction of the Thumb (WHAT) test
• Positive Eichhoff test

The diagnosis of De Quervain tendinopathy relies primarily on clinical assessment, focusing on the patient’s history and physical examination. Although plain radiography does not confirm the diagnosis, it is useful in differentiating De Quervain tendinopathy from other conditions causing radial wrist pain, such as carpometacarpal (CMC) joint osteoarthritis.

Advanced imaging techniques, such as ultrasound and MRI, can provide further diagnostic clarity. Both modalities enable direct visualization of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, which may appear thickened or inflamed in De Quervain tendinopathy. These imaging tools also offer a dynamic, real-time assessment of tendon movement, which can be valuable for confirming the diagnosis, guiding treatment decisions, and monitoring treatment response.

Ultrasound, in particular, is often preferred as a first-line imaging tool due to its availability, cost-effectiveness, and ability to capture dynamic tendon function. MRI, although less frequently used, may be beneficial when soft tissue pathology needs further evaluation or if ultrasound findings are inconclusive.

The following are examples of red flags for patients presenting with wrist pain:

• A history of significant injury
• Severe pain
• Unrelenting pain
• Nocturnal pain
• Unexplained weight loss
• Fever
• Deformity
• Significant swelling
• Presence of tingling, numbness, burning, or other neurological impairment
• Significant loss of range of motion
• Severe tenderness on palpation or severe pain with any examination procedure

If any of these ‘red flags’ are identified during history taking or clinical examination, it is crucial to refer the patient for urgent medical evaluation and further investigation.

Key Differentiators in Differential Diagnosis

Intersection Syndrome

• Pain is typically located 4-6 cm proximal to the wrist, where the Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB) cross over the Extensor CarpiRadialis Longus (ECRL) and Extensor CarpiRadialis Brevis (ECRB) tendons.

Wartenberg’s Syndrome (Superficial Radial Nerve Entrapment)

• Symptoms include numbness, tingling, or burning along the dorsal-radial wrist and thumb.
• Symptoms can be aggravated by wrist flexion or tight wristbands.
• Neurological involvement without swelling.

Osteoarthritis of the Thumb Carpometacarpal (CMC) Joint

• Pain located at the base of the thumb which is aggravated by pinching and gripping.
• Positive Thumb Grind test.

C6 Radiculopathy

• Pain, tingling, and numbness radiate from the neck to the radial side of the hand.
• Symptoms aggravated with neck movements.
• May have motor deficits.
• Positive special tests (e.g., Maximum Cervical Compression, Cervical Distraction, and Shoulder Abduction tests)

Extensor Carpi Radialis Longus/Brevis Tendinopathy

• Pain localized over the radial dorsum of the wrist, which is worsened by resisted wrist extension.
• No pain on thumb movement.

Scaphoid Fracture

• Pain and tenderness in the anatomical snuffbox following trauma (e.g., fall on outstretched hand).
• Fracture confirmed by imaging.

Rheumatoid Arthritis (RA)

• Pain, swelling, and stiffness in the wrist.
• Systemic symptoms (e.g., morning stiffness, fatigue).
• Other joints are typically affected (fingers, toes, elbow, shoulder, knee, hip and upper cervical spine).

Ganglion Cyst

• Visible lump near the wrist, causing discomfort or limiting movement.
• Palpable mass, typically fluctuant, without significant inflammatory signs.

Myofascial Pain Syndrome

Myofascial pain syndromes may present as pain in the thumb and along the radial side of the wrist (see examples below). Trigger points associated with myofascial pain syndrome can develop anywhere within a muscle and its fascia, so examining the entire muscle thoroughly is essential. However, based on clinical experience, the most common locations for trigger points are highlighted below.