Tendons are like ropes which connect muscles to bones and are enclosed within a sheath (covering) that allows smooth movement. De Quervain’s Tenosynovitis is caused by painful irritation of the sheath of two tendons as they travel from the wrist towards the thumb. These tendons travel in close proximity to each other and are involved in thumb movements (such as bringing the thumb away from the hand as it lies flat in the plane of the palm). When their sheath becomes thickened or irritated, the tendons have less space for movement resulting in pain and other symptoms. Some experts attribute the degeneration of tendon and deposition of fibrous tissue as the cause for the condition.

What are the symptoms of De Quervain’s Tenosynovitis?

De Quervain’s tenosynovitis presents with

• Pain and swelling at the base of thumb, wrist
• Pain during thumb movements such as griping or pinching
• Sometimes a snapping/ sticking sensation may be felt  with thumb movement 

Image 1: Area of pain in De Quervain’s Tenosynovitis

What causes De Quervain’s Tenosynovitis?

This condition occurs most often between the ages of 30 -50 years. Quite often the cause is unknown although tendon sprain and overuse during repetitive movements can predispose to the development of this condition. Some of the risk factors include:

• Women, especially mothers with young infants are more likely to be affected due to a combination of overuse, hormonal changes and fluid retention. Improper lifting technique can specially predispose to the development of this condition and it is also addressed as Mothers Thumb.
• Professions or hobbies involving repetitive wrist or hand motions such as with musicians, dental hygienists, golfers, mountain bikers, typists, video game players. Other commonly used names used for the same condition include texting thumb, gamers’ thumb, washerwoman’s sprain and designer’s thumb.

How is De Quervain’s Tenosynovitis diagnosed?

A simple test used for diagnosis involves making a fist around the thumb placed in the palm on the affected side (Image 2). The patient is then asked to bend the wrist towards the little finger as shown in the image 3. If this makes your pain worse, then the test is considered positive

An ultrasound scan may help identify thickening of the tendons, increased fluid surrounding the tendons, increased blood flow, narrowing of the canal/ passage for tendons, anomalies in tendon slips and thus help confirm the diagnosis. MRI is useful for detecting mild disease where ultrasound in inconclusive. An x-ray of the wrist is sometimes requested to rule out other conditions with similar presentation.

How is De Quervain’s Tenosynovitis managed

The treatment option will vary depending on multiple factors such as the duration of symptoms, severity & impact on your daily activities, previous treatments and their results. It can be self-limited and may resolve without intervention. For most individuals non surgical treatment options suffice with very few requiring surgery. Treatment options include-

Rest. This includes avoidance of provoking activities and heavy work with the affected hand for several weeks. Rest provides an opportunity for the symptoms to settle. In mothers with young infants, changing the lifting technique and breast feeding position can make a difference.

Icing – Ice can help in reducing the pain and swelling.  Avoid applying the ice directly to the skin. Ice can be wrapped in a towel and used for a few minutes (as tolerated), a few times in a day.

Splinting – The splint may be required to be worn for a few weeks. It works by restricting the movement of thumb thereby providing an opportunity for healing to occur. The combined use of splints and steroid injections has been found to be more effective than splinting alone.

Medications – Pain killers can provide temporary relief and may include anti-inflammatory medications. It is important to use these medications as directed by your doctor.

Physiotherapy– This involves a combination of stretching and strengthening exercises to improve the hand function. Exercises are best learned under supervision of an experienced therapist. Once you have learned the correct technique, you can continue with these at home. Exercises have been shown to improve the duration of pain relief when used in combination with steroid injection and splinting.

Steroid injections In case the pain does not settle, then your doctor may consider injections. Steroids are effective anti-inflammatory medicines and are commonly used treatment modality with near complete relief with one or two injections.

Sometimes septae (partitions) may be present in the intended injection compartment. Using ultrasound can help not only in verifying the diagnosis but also in visualizing these septae and accurately guiding the injection into the tendon compartments. There are studies highlighting the role of ultrasound in increasing injection accuracy and citing success rates of 91% after up to two injections.

Surgery– if the problem persists despite the above treatments then surgery can be considered.

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Epidural injections are a pain management option for patients with leg or arm pain originating from the spine. This is also known as Radicular pain or Radiculopathy. The pain usually radiates away from the irritated nerves. For Example – the pain could be originating from lower spine and may be felt far away in the legs. Pain specialists offer non-surgical options like this one for pain relief. As the techniques used are minimally invasive, and do not involve surgical incision or prolonged recovery, the risks involved are less.

One of the causes nerve pain is the narrowing (stenosis) of the space for these nerves in the spine or narrowing of the space from which these nerves exit the spine. This may be secondary to a slip disc or rupturing of the discs.

Depending on the problem different techniques /routes may be utilised to perform epidural injection. Nerve root block /transforaminal epidural, caudal epidural, interlaminar epidural are all epidural injections. Different names are used to indicate the technique used and route of entry. The route or the technique used can have an impact on where the maximum amount of drug is deposited.

How the epidural Injection works

Generally a combination of local anaesthetics and steroid are uses in these injections. The resulting pain relief can last for a few months although some people can experience long lasting relief from these injections. Corticosteroids serve dual purpose as an analgesic as well as have anti-inflammatory property. So, they help to control both pain and inflammation.

Immediately after the injection the injection site can feel sore although this is not troublesome for most people. This is mainly because of the mechanical process of inserting needle or at time also due to irritation resulting from the injected medication. But you need not worry about this as it will fade away soon and the pain relief would become apparent as the steroids start to work.

Benefits of Epidural Steroid Injection

There are numerous benefits of epidural pain injection over oral corticosteroids:

• Epidural injection delivers the medication close to the problem as a result more drug reaches the site of action compared to when it is taken orally.
• Side effects of the epidural injection are less compared to oral corticosteroids.
• The duration for which the effect of epidural steroid injection is generally longer. This period can be effectively utilized by the patient to engage in physiotherapy and strengthen the supporting muscles.
• Epidural steroidal injections help in providing quick pain relief in case of severe pain

Epidural injection works very well in case of pain originating from lower back (thoracic spine), neck (cervical spine) and mid back (thoracic spine). You should take expert advice from experienced pain specialists in Delhi as they can give you advice regarding the most appropriate therapy for you. Generally epidural injections are more beneficial in cases where the pain travels (radiates) towards arms or legs. Discuss this option with your specialist to find out if this is the right treatment for you.

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Some common causes include –

• Muscle sprain, spasm/ increased tension
• Poor posture and work ergonomics
• Incorrect positioning of the neck while sleeping
• Aging: Degenerative disc disease and spinal osteoarthritis become more common as we age
• Injuries/ Whiplash: Whiplash neck involves sudden jolting of neck forwards and backwards and is commonly observed in vehicular accidents. This can cause excessive stretching of neck muscles, ligaments or other injuries which can be associated with neck pain.

Neck pain can be a part of more widespread medical issues such as in fibromyalgia, arthritis, ankylosing spondylitis, infections, cancer etc. You can approach Pain Management Specialists in Delhi for diagnosing your problem and suggesting suitable solutions

It is advisable to seek early medical attention if you experience any of the following

• Persisting symptoms or severe pain not responding to usual care or medications
• Pain starting after fall, injury
• New onset numbness, weakness or tingling in arms
• Gait or balance problems
• Loss or urine or stool control
• Signs of infection/ meningitis
• Pain worse at night time/interfering with your sleep

Some of the pain management techniques for neck pain include:

Lifestyle changes: Incorrect/ ignored posture while working on laptops mobiles etc can put excessive cervical spine strain leading to pain. Certain professions can be more prone to develop neck pain. Simple posture awareness and improvement, taking regular breaks can go a long way in reducing symptoms.

Medications: Anti-inflammatory drugs such as ibuprofen or naproxen and pain relievers like acetaminophen may initially be prescribed by your doctor. Sometimes medications like muscle relaxants or stronger painkillers may also be suggested by your doctor.

Physical Therapy: Regular exercise, good posture, stretching can help to reduce/ prevent to prevent unwanted stress and tension to your neck muscles. Heat or cold application may be used during the initial phases of injury to facilitate your recovery and physical exercise. Depending on the severity, time since injury and your recovery the specialist may recommend limiting normal physical activity or slow range-of-motion exercises or strengthening exercises.

There is research evidence supporting the use of specific strengthening exercises as part of a routine practice for chronic neck pain, cervicogenic headache and radiculopathy.

Ergonomics & Posture
Simple posture changes and better workplace ergonomics can help in preventing/reducing neck pain. Measures include adjustment of furniture height and computer position such that

• Eyes point directly at the top third of the screen
• Forearm is parallel to floor
• Feet should be flat on the floor with thighs parallel with the floor

While sitting in office chair it’s a good practice to have back aligned against the back of the office chair and avoid slouching. Avoid sitting in one place for too long. Taking regular breaks to walk around and stretch is a good practice.

Relaxation techniques: relationship between stress and increase pain is well known and easily appreciated by most patients. Measures to deal with stress and anxiety help in more effective pain management.

Massage Therapy: The evidence supporting the use of massage therapy is limited although some people do find it useful in the short term. Massage can help in relaxing, loosening of muscles but it is important to remember that wrongly done massage can lead to harm.

Acupuncture: Certain people find Acupuncture helpful in neck pain management. When performed correctly it is a low risk procedure. The traditional acupuncture is based on the theory of restoring the energy balance in body and removing any blockages to the flow of energy.

Injections/ other interventions such as Radiofrequency ablation: These would depend on the cause of neck pain and actual pathology. They have been explained in more detail in the neck & arm pain section under treatments, on my website- removemypain.com

Ignoring persisting symptoms can aggravate the situation leading to chronic pain with reduced functionality. So, if your pain persists and does not respond to usual lifestyle changes and painkillers then seek medical opinion on time.

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