Radial side wrist pain – De Quervain Tenosynovitis / Mummy’s thumb / Gamer’s thumb

Introduction

De Quervain disease (DQD) is tenosynovitis or inflammation which affects the tendons that control the movement of the thumb, specifically the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). These tendons run through a narrow tunnel known as the wrist’s first extensor compartment (there are six extensor compartments). It is a fibro-osseous sheath that becomes constricted and inflamed in De Quervain’s tenosynovitis. Fritz De Quervain, a Swiss surgeon, first reported this painful thumb phenomenon in 1895. 

What are the symptoms?

DQD occurs when these 2 tendons around the base of your thumb become inflamed and swollen. The swelling causes the fibro-osseous sheaths or the “casings” covering the tendons to become inflamed.  When the swollen tendons rub against the narrow tunnel they pass through, it causes pain at the base of your thumb and into your forearm.

This causes pain and discomfort when moving the wrist and thumb in specific motions that involve repetitive hand and wrist movements such as grasping, twisting, or pinching when doing activities i.e. wringing out wet cloths, lifting a baby or opening a jar.   

How common is this condition?

DQD is a common condition and may be caused by overuse of the thumb and wrist.  Repetitive movements day after day cause irritation and pain. One common movement that causes it is lifting a child, and lifting heavy grocery bags by the handles. 

Other causes / differential diagnoses of radial side wrist pain are:

•  injury / trauma to the wrist or 

• arthritis i.e. osteoarthritis of the first CMCJ – carpometacarpal joint or thumb MCPJ – metacarpophalangeal joint, rheumatoid arthritis, and uncommonly;

• intersection syndrome – inflammation of extensor tendon sheaths of the 1^st and 2^nd compartment

• Superficial radial nerve problems i.e. Wartenberg syndrome, Neuroma
  

Who is commonly affected?

It typically affects women between 30 and 50 years of age especially those who use repetitive hand or wrist motions in their daily activities. However, it can also occur in men and women of any age group who engage in activities that strain the tendons in the wrist and hand, such as playing sports or using hand tools for extended periods. 

If you use your thumbs or wrists a lot in any kind of activity, that increases the likelihood that you will get de Quervain’s tenosynovitis/DQD.  Among the things that can put you at risk are: 

• Parenting young children; new parents
• Working with young children; daycare, nursery 
• Hobbies; knitting, gardening, or gaming, 
• Using smartphones; thumbs to type/gaming
• Sports; golf, skiing, rowing, badminton, tennis

How to diagnose DQD?

To diagnose de Quervain’s tenosynovitis, your doctor may do a simple clinical test. It is called the Finkelstein’s test. The doctor will bend your thumb across your palm. This movement stretches your tendons. If it hurts on the thumb side of your wrist (tip of radial styloid process), you probably have de Quervain’s tenosynovitis.

You might get X-rays to look for other underlying problems like osteoarthritis.

Ultrasound by a musculoskeletal radiologist may also be a useful diagnostic tool, especially to identify anatomical variations before surgery.

How to treat DQD?

The management of DQD is typically conservative, with escalation to steroid injections before surgery is indicated.

Treatment for de Quervain’s tenosynovitis focuses on reducing pain and swelling. It includes:

• Applying ice to the affected area
• Taking a nonsteroidal anti-inflammatory drug (NSAIDs). These include ibuprofen or naproxen 
• Wearing a splint for 4 to 6 weeks to rest your thumb and wrist

• Avoiding activities that cause pain and swelling. 
• Injections of steroids and local anesthetic (numbing medicine) into the tendon sheath. 

A physical therapist or occupational therapist can show you how to change the way you move your wrists and hands; for example in new mothers diagnosed with DQD, avoid holding your baby by the armpits as it forces repeated extension of the thumb and wrist.  Instead hug the baby using the stronger brachioradialis and biceps i.e. using the forearm and elbow.  This can reduce stress on your wrist and thumb. 

You might need surgery if other treatments do not relieve your pain. During outpatient surgery, the surgeon makes a small cut in the sheath around the swollen tendons. This provides more room for the tendons to move.

After surgery, you will need to do physical therapy to strengthen your wrist and thumb. This will help keep the problem from coming back. Once the area has healed and returned to full strength, you should have normal use of your hand.

How long to recover from DQD?

In my practice as an orthopaedic surgeon in Kuala Lumpur, Malaysia, most DQD cases resolve after splinting and physiotherapy.  Most people notice improvement after 4 to 6 weeks of treatment. They are able to use their hands and wrists without pain once the swelling is gone.  It may take 6 to 12 weeks for your hand to heal completely. After you heal, you may be able to move your wrist and thumb without pain. How soon you can return to work depends on your job. If you can do your job without using your hand, you may be able to go back after a few days. 

Can the disease come back?

The disease can recur if you continue stressing your wrist and thumb in the same manner as when you first had the pain.  It is important to get diagnosed and learn how to change or modify the way you move or hold your tools. This can reduce stress on your wrist.  You need to do physical therapy to strengthen your wrist and thumb. This will help keep the problem from coming back

The best way to prevent DQD is by avoiding repetitive movements. Change your actions to reduce the stress on your wrists. Take frequent breaks to rest if you are using your wrists a lot. Wear a brace or splint on your thumb and wrist, if necessary. Follow the exercise routine suggested by your doctor or physical therapist. 

Take home message?

When you have de Quervain’s tenosynovitis, you develop painful inflammation around the tendons in your thumb. The most common cause is repetitive activities that overwork those tendons. Rest, medication, and using a splint can help you recover. Reduce overuse and learn correct form and posture for wrist motions. In rare cases, you might need surgery.  Most important is to get diagnosed so treatment can be started promptly.