Painful thumb - De Quervain syndrome

Do you feel pain on the outer side of the thumb or wrist? You cannot grasp objects firmly enough because of the pain? Is the area of your thumb swelling and painful on the touch? The cause of the problems can be de Quervain disease. In this article we will try to explain this syndrome as well as explaining the possible modern treatment options.

DE QUERVAIN SYNDROME

This syndrome was first described in detail by swiss surgeon Fritz de Quervain from Switzerland in 1895. Even though the exact mechanism of the syndrome was not yet described, we know that it is inflammatory disability, affecting ligaments of the extensor pollicis brevis muscles and the extensor pollicis longus muscle. That leads to thickening (hypertrophy) of the synovial pouch, which carries the two mentioned muscles, and this thickening irritates muscles and tendons, and it makes their movement impossible in certain movements in the thumb and wrist. This irritation cause pain and swelling on the inner side of the wrist and pain when grasping for specific objects.

FORMATION OF THE SYNDROME

This syndrome is partly caused by the chronic overloading of the wrist and hand by a stereotypical movement. Before, this syndrome was typically occurring by women who were cutting fabrics - overloading the thumb with a long lasting stereotypical holding of the scissors led to chronic damage of the ligaments. Nowadays this syndrome affects hairdressers, but it is not an exception when it affects people who constantly write messages on their phone, where the thumb is exposed in the same convulsive position.

Intensity of the pain can gradually grow. People try to ignore it at first, but within several weeks or even months, the pain grows, till it becomes impossible to grasp and hold any object. The pain is localized on the wrist close to the thumb, by the root of the thumb and in the lower radial bone. The problems increase during combined movement of the thumb and wrist to the sides. Another symptom is restricted strength during handshake.

DIAGNOSIS - HOW TO DISTINGUISH DE QUERVAIN’S SYNDROME?

The most used test for confirming the de Quervain syndrome is Finkelstein test: the examined patient should place his whole thumb into the palm and cover it with three fingers, subsequently bend the wrist to the side of the pinky joint. During this exercises you may feel ligament irritation in the above mentioned muscles, and if it is accompanied by unpleasant pain in the area of the lower thumb, the disability of ligaments and its sheath is confirmed. Finkelstein’s can be be also accompanied by creaking in the area of the ligaments, wrist, thumb, which later causes edema in the given area.

In diagnosis of the pain in the area of the thumb and wrist it is important to keep in mind the possibility alternative other diseases and exclude them, such as arthritis of the thumb joint, fracture of the scaphoid bone of the wrist, arthrosis in the wrist area, rheumatoid arthritis etc…

TREATMENT

Conservative treatment

Classical conservative therapy immobilizes the thumb with a splint, and continues with rehabilitation. This option of treatment is often supplemented with using non-steroid antirheumatics (anti-inflammatory drugs) in form of pills and creams. If the syndrome is already in a chronic phase, doctors may use cortisone injections (hormones) and apply it in the area of the ligaments - but it cannot be applied directly into the ligament, because there is a risk that the ligament can be damaged or even torn apart. For this reason it is not recommended to repeat this treatment. After the cortisone injection, you will continue to wear the splint and in better case you may be ordained to do a rehabilitation.

Operative treatment

If the classical conservative treatment fails, the doctor steps towards surgical treatment, which lies in releasing the ligaments in the bony-ligamentous canal - cutting through the “eyelet” through which go the enlarged ligaments. Unpleasant complication of the surgical treatment can be disruption of the nerve, which is responsible for the sensitivity on the back of the hand and thumb, index finger and middle finger. The damage is manifested by tingling and lowered sensitivity in this area, therefore it is necessary to sew this nerve together. Post-operational therapy starts with early rehabilitation and both active and passive exercising of the wrist. Reliving the soft tissues in the area of the thumb is necessary for elimination of swellings and restricting the adhesion - here it is important to care for the scar correctly.

WHAT DOES THE TREATMENT LOOK LIKE BY US?

In our clinic we approach de Quervain’s syndrome complexly. It is very important to run a detailed diagnosis in the area of the thumb joint and wrist, but to examine also their functional continuity on the elbow, shoulder girdle and cervical spine. If the therapy won’t be focused also on the seemingly distant muscles, there is a risk that the problems may return back.

FOCUSED SHOCKWAVE THERAPY

The most modern therapy nowadays includes application of high-energy focused shock wave therapy. It can penetrate deep into the affected area, where it starts the natural repairing mechanism and at the same time metabolism. These factors lead to recovery of the natural elasticity of the affected soft tissues. Care for the disabled muscles is important just as taking care for the functionally connected muscle groups, in which can appear the painful trigger points. This increased tension of the soft tissues can be very effectively removed by the radial shock wave therapy, which we apply directly after the focused shockwave therapy. Therapy is then always ended with vibrating massage with a V-Actor headpiece, which helps for ideal regeneration of the muscles and other soft tissues.

By this diagnosis, 3 to 4 applications of the focused shock wave are necessary in a period of 7 to 14 days. Improved mobility and lowered pain often come after first therapy.

To support the effects of the focused shockwave therapy, we apply the after therapy functional kinesio tape elastic cotton band, which helps to relax the affected muscles and at the same time it can relieve the painful area. This service is welcomed and valued by our clients.

When will you be able to fully work again?

Within 2 months after last application of the shock wave, most patients (according to the study 80-95% success) had a significantly lowered pain or it completely disappeared, the mobility in the thumb and wrist was recovered. Thanks to that, the client can return back to work and social activities without any restrictions.



Author:
 Mgr. Iva Bílková, FYZIOklinika fyzioterapie Ltd, Prague, Czech Republic

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