De Quervain's Tenosynovitis Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for De Quervain's Tenosynovitis. It is designed to guide treatment progression based on pain levels, functional limitations, and individual patient response. It's crucial to remember that this is a general guideline, and treatment must be individualized based on the patient's specific needs and progress.

Pathophysiology

De Quervain's tenosynovitis is a condition affecting the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles at the radial styloid. It involves inflammation and thickening of the tendon sheaths that surround these tendons as they pass through the first dorsal compartment of the wrist. Repetitive hand and wrist movements, particularly those involving gripping, twisting, and thumb abduction/extension, are common contributing factors. This leads to friction, irritation, and subsequent pain at the radial side of the wrist. Swelling and tenderness are characteristic findings.

Common Special Tests

• Finkelstein's Test: The patient makes a fist with the thumb tucked inside the fingers. The examiner then ulnarly deviates the wrist. A positive test elicits sharp pain along the radial aspect of the wrist (over the APL and EPB tendons). This is the most sensitive and specific test.
• Eichhoff's Test: Similar to Finkelstein's test, but the patient actively makes a fist with the thumb inside. The examiner then passively ulnarly deviates the wrist.
• Wrist Circumference Measurement: Measure the wrist circumference at the level of the radial styloid to assess for swelling. Compare to the uninvolved side.
• Grip Strength Testing: Using a dynamometer, measure grip strength to assess for weakness and monitor progress throughout rehabilitation.
• Pinch Strength Testing: Assessing the strength of pinch grip.

Phase I: Protection (Acute Phase - Approximately 0-3 Weeks)

The primary goals of this phase are to reduce pain and inflammation, protect the affected tendons, and prevent further aggravation.

• Goals:
  • Reduce pain and inflammation.
  • Protect the APL and EPB tendons.
  • Prevent further aggravation.
• Interventions:
  • Splinting: Thumb spica splint worn continuously (24/7) to immobilize the wrist and thumb in a neutral position. The splint should include the IP joint of the thumb.
  • Rest: Avoid activities that exacerbate symptoms. Modify daily activities to minimize stress on the wrist and thumb.
  • Ice: Apply ice packs to the affected area for 15-20 minutes, several times a day, to reduce inflammation.
  • Education: Patient education on proper body mechanics, activity modification, and the importance of splint compliance.
  • Gentle Range of Motion (ROM): Gentle, pain-free ROM exercises for the fingers and elbow to prevent stiffness. This should NOT include active thumb abduction or extension against resistance.
  • Edema Management: Elevate the hand above heart level to reduce swelling. Gentle massage can also be considered.
  • Modalities: Ultrasound or phonophoresis (with appropriate medication) may be used to reduce pain and inflammation. Iontophoresis may also be used.
  • Isometric Exercises (Limited): Very gentle isometric exercises for wrist flexion/extension and radial/ulnar deviation, performed within a pain-free range. Avoid thumb abduction/extension isometrics in the initial stages.
• Progression Criteria:
  • Decreased pain at rest and with gentle movement.
  • Reduced swelling and tenderness over the radial styloid.
  • Improved pain-free ROM of the fingers and elbow.

Phase II: Loading (Subacute Phase - Approximately 3-6 Weeks)

The goals of this phase are to gradually increase tendon loading, improve strength and endurance, and restore functional use of the hand and wrist.

• Goals:
  • Gradually increase tendon loading.
  • Improve strength and endurance.
  • Restore functional use of the hand and wrist.
• Interventions:
  • Splinting (Weaning): Begin weaning from the thumb spica splint during the day, as tolerated. Continue wearing the splint at night and during activities that may aggravate symptoms.
  • Active Range of Motion (AROM): Progress to AROM exercises for the wrist and thumb, focusing on full pain-free ROM.
  • Strengthening Exercises: Introduce gentle strengthening exercises, starting with isometric exercises and progressing to isotonic exercises with light resistance (e.g., using theraband or light weights). Examples include:
    • Thumb abduction/extension isometrics, progressing to active.
    • Wrist flexion/extension with light weight.
    • Radial/ulnar deviation with light weight.
    • Pinch grip strengthening.
  • Tendon Gliding Exercises: Perform tendon gliding exercises to improve tendon excursion and reduce adhesions.
  • Soft Tissue Mobilization: Gentle soft tissue mobilization to the APL and EPB tendons and surrounding tissues to improve tissue mobility and reduce adhesions.
  • Ergonomic Assessment: Evaluate the patient's workstation or activities to identify and modify contributing factors.
• Progression Criteria:
  • Decreased pain with activity and splint weaning.
  • Improved ROM and strength.
  • Ability to perform light functional tasks without increased pain.

Phase III: Return to Function (Chronic Phase - Approximately 6-12 Weeks)

The goals of this phase are to restore full functional use of the hand and wrist, improve endurance, and prevent recurrence.

• Goals:
  • Restore full functional use of the hand and wrist.
  • Improve endurance.
  • Prevent recurrence.
• Interventions:
  • Splinting (Discontinuation): Discontinue splinting as tolerated. Consider wearing a supportive brace during strenuous activities.
  • Progressive Strengthening Exercises: Continue strengthening exercises, gradually increasing resistance as tolerated.
  • Endurance Training: Incorporate endurance exercises, such as sustained grip or repetitive movements, to improve the ability to perform functional tasks for longer periods.
  • Functional Activities: Gradually return to normal activities, modifying as needed to avoid symptom exacerbation.
  • Work Simulation: If applicable, perform work simulation activities to prepare for return to work.
  • Proprioceptive Exercises: Implement proprioceptive exercises to improve joint stability and coordination.
  • Patient Education: Reinforce proper body mechanics, activity modification, and self-management strategies to prevent recurrence.
• Progression Criteria:
  • Full pain-free ROM and strength.
  • Ability to perform all desired functional activities without pain or limitation.
  • Successful return to work or recreational activities.

Important Considerations: Pain should be the primary guide throughout the rehabilitation process. If pain increases, modify the exercises or activities accordingly. Close communication with the patient and regular reassessment are essential to ensure optimal outcomes.