De Quervain’s Syndrome

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What is De Quervain’s Syndrome?

This is a painful condition that affects tendons where they run through a tunnel on the thumb side of the wrist. It is usually aggravated especially by lifting the thumb when using scissors or in the hitchhiker position.

What causes it?

There is often no obvious cause, in many cases. Mothers of small babies seem particularly prone to it, but whether this is due to hormonal changes after pregnancy or due to lifting the baby repeatedly is unclear. There is little evidence that it is caused by work activities, but the pain can certainly be aggravated by hand use at work, at home, in the garden or at sport.

What are the symptoms?

  1. Pain on the thumb side of the wrist. Usually aggravated by lifting the thumb.
  2. Tenderness if you touch the site of pain
  3. Mild swelling on the area of pain
  4. Snapping or clicking of the tendons may occur.

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What Treatments can help?

Although De Quervain’s syndrome is not harmful, it can be painful and irritating. Some mild cases can recover over a few weeks with no treatment. If your symptoms persist treatment begins with POLICE.

POLICE.

Previously we used RICE (Rest, ICE, Compression, Elevation) for injury management. However, rest can be harmful and inhibits recovery. Recent research has now advised we use the acronym POLICE

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  • Protection
  • Optimal-Load
  • Ice
  • Compression
  • Elevation

The key term is Optimal-load, this replaces Rest.

Modifying your normal activities, by reducing prolonged activities using your hands is a form of optimal loading. This activity modification will be specific to you but will help reduce your levels of pain and speed up your recovery. You may need to speak to your physiotherapist to discuss what your optimal load is. When you achieve activity modification it enables the tendons and their sheath to recover whilst not affecting your normal day to day living.

Splint

Using a wrist/thumb splint, which can often be obtained from a sports shop or a physiotherapist, which will protect the area and allow optimal load. It may need to immobilise the thumb as well as the wrist.

Mild – To wear a splint for irritating activities up to 4/52. Either thumb spica or thumb/wrist futura

Moderate/Severe – To wear continuously for 4/52 24hrs pm, then wean out if pain is settling

Thumb/wrist futura or custom-made thermoplastic splint (OT or ESP physio can supply this)

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Steroid injection

A Steroid injection can help relieve the pain in about 70% of cases. The risks of injection are small, but it very occasionally causes some thinning or colour change in the skin at the site of injection. It is essential however, to continue with activity modification and exercise to ensure your symptoms don’t return and you are able to get a lasting improvement.

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Flare ups

An increase in pain or ‘flare up’ is common with De Quervains syndrome. The key is to manage this effectively and efficiently. By using POLICE this can help reduce the initial pain. During a flare up managing your optimal load is important. You may need to reduce the stresses at the thumb and hand, reduce the amount of exercises and daily activities that you do. Over time gradually increase your activity back to previous levels.

How long will it take to get better?

Unfortunately, there is not definite answer to this question. There are no quick fixes and it requires active participation from the patient throughout the process. Due to the biology of tendons and their sheaths, they tend to take longer to improve. Conservative management has been proven to be the most effective treatment.

The Exercises.

An appropriate specific exercise program is designed to gradually increase the load going through your tendons, which will gradually reduce your pain and any swelling.  These exercises can take between 6 – 9 months to significantly improve symptoms, however it can improve more quickly. If your symptoms don’t improve within 6 – 9 months, other treatment options can be discussed with your physiotherapist.

It is very important to note that you may experience an increase in pain as you begin this program, however this is normal but you should not exceed 3-4/10 where 0 is no pain and 10 is the worst pain you could imagine. The pain will gradually reduce as you continue your rehabilitation plan.

 

Level 1: Range of movement and tendon glides

Reps 12 - 15
Sets 3 – 5
Rest 30seconds

 

  1. Ulna Deviation with thumb resting in abduction

With your palm on a table top, slide your hand in the direction of your little finger as shown, with the thumb relaxed away from the palm.

 https://www.youtube.com/watch?v=CBFHo0m19r8

  1. Thumb opposition working into extension

With the side of your hand supported on a table as shown, slowly flex your thumb as shown.  As this becomes more manageable, begin to work into extending the thumb as shown.

https://www.youtube.com/watch?v=nalwO-2jSQ4 

  1. Full Ulna deviation with hand flat working into thumb adduction

With your palm on a table top, slide your hand in the direction of the little finger, then slide the thumb over to meet the palm as shown.

https://www.youtube.com/watch?v=vmsT4oFIU1Q 

  1. Combined UD with thumb opposition

With your forearm supported on a table and hand over the edge, move your hand down as if bringing the little finger towards the floor, then flex your thumb towards the little finger as shown

https://www.youtube.com/watch?v=P7mBAoaEi0Q

Level 2: Muscle activation

 

Reps 10 - 45 seconds
Sets 3 – 5
Rest 30seconds

 *Unless stated* 

  1. Isometric thumb extension

With your forearm supported on the edge of a table and hand over the edge, gently push your affected thumb up against resistance from your other hand as shown

https://www.youtube.com/watch?v=4qdVfRWZbFU 

  1. Isometric thumb abduction

With your forearm supported on the edge of a table and hand over the edge, gently push your affected thumb out to the side against resistance from your other hand as shown.

https://www.youtube.com/watch?v=eYhcXIQl0rY 

  1. Isometric wrist radial deviation

 

With your forearm supported on the edge of a table and hand over the edge, gently push your affected hand up against resistance from your other hand as shown.

https://www.youtube.com/watch?v=zXz5HDeZggg 

  1. Dart thrower’s motion

This exercise is aimed at improving control around the wrist and glides the tendons affected in De Quervain’s Syndrome. It is a movement which we regularly perform during daily tasks e.g. lifting cup to mouth, pouring water from a kettle or writing.

*Repeat 15 – 25 time, 3 sets*

https://www.youtube.com/watch?v=EXw3egZbELg

Level 3: Strength

 

Reps 1, 2 & 5 = 15 3 & 4 = 8 - 12
Set 3-5
Rest 60 seconds

 NB: Consider sustained hold at end of range if normal activities/job requires the strength or posture and can’t be adapted.

 

  1. Theraband - eccentric radial deviation

With a yellow theraband looped around your hand as shown, the other end fixed with your other hand, or under your foot.  Use your unaffected hand to lift the hand up, followed by slowly lowering the hand under tension of the band.

https://www.youtube.com/watch?v=t62ccGhd0kQ 

  1. Weighted (dumbbell) eccentric radial deviation

With your forearm supported and hand over the edge of a table, holding onto a light weight (max 1kg). Use your unaffected hand to lift the hand up, followed by slowly lowering the hand in a controlled motion.

https://www.youtube.com/watch?v=b-tIVwwsdDU 

  1. Theraband – concentric radial deviation (with eccentric radial deviation)

With a yellow theraband looped around your hand as shown, slowly lift your hand from the wrist against resistance, then lower as shown.

https://www.youtube.com/watch?v=q5kaYk5SRNk 

  1. Weighted (dumbbell) combined eccentric and concentric radial deviation

With your forearm supported and hand over the edge of a table, holding onto a light weight (max 1kg). Slowly lift and lower your hand at the wrist as shown.

https://www.youtube.com/watch?v=Kcl4ScXcFx8 

  1. Dart thrower’s motion with weight

This exercise is aimed at improving control around the wrist and glides the tendons affected in De Quervain’s Syndrome. It is a movement which we regularly perform during daily tasks e.g. lifting cup to mouth, pouring water from a kettle or writing. Complete with a light weight and as this gets easier, increase the size of weight.

https://www.youtube.com/watch?v=sRh462xvPkw 

Level 4. Functional rehab.

This maybe individualised to the patient, depending on the demands of occupation, sports or other hobbies.  You can discuss with your physiotherapist about the best rehabilitation plan to ensure that you return to your normal activities. This plan will also include exercises to ensure the risk of re-injury is minimised. Later stage rehabilitation may include plyometric type exercises, weight bearing exercise, posterior kinetic chain work including shoulder (rotator cuff control), for example:

 Ball bounce            5.jpghttps://www.youtube.com/watch?v=7rx_Oz43N5gThrowing/catching6.jpgOverhead press with resistance. 7.jpghttps://www.youtube.com/watch?v=0JfYxMRsUCQLogos.jpg

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