Wrist Pain: De Quervain’s Syndrome

El Paso, TX. Scientific chiropractor Dr. Alexander Jimenez discusses an unusual injury incurred by a skilled powerlifter...

The Patient

A 29-year-old powerlifter presented to the clinic. The pain was a continuous annoyance with sharp pain episodes during weight training. It had started insidiously as a vague ache that was intermittent. As he had previously been able to train through the pain, he'd noticed it penalizing over a couple of week she was unable to strongly grip during sessions. He maintained that as this seemed to exacerbate the issue, he had been forced to rest the wrist from movements that were heavy and that medications did help. No wrist trauma had been suffered by him, but he'd suffered a strain on the side.
On the radius, he had a somewhat inflamed lateral wrist upon demonstration. The and the pain place appeared to be concentrated around abductor pollicis longus and the extensor pollicis brevis. All his movements of radial extension and ulnar deviation and wrist flexion appeared to be normal and all thumb movements appeared to be normal also. The location of the pain was highly suspicious. He was provocative on the 'Finkelstein test' and this proved positive (see diagram of test right). Palpation of the tendons provoked pain and palpation of the scaphoid bone proved unremarkable.

Upon questioning the patient about adjustments to his training program, he had fluctuated his loadings as per his normal program and denied that he had incorporated any movements in his sessions. He denied any change in behavior or work pattern aside from possibly working because of the birth of his second daughter and worked as a fitness expert.

It had been discovered that he was helping his wife frequently and nappy-changing the youngest whilst spending more and more time with the older child. When asked if he had been picking up the infant and older sister he agreed that this was certainly true. He explained how he picked up child and the infant as putting the hands to lift with the horn abducted and extended. He concurred that the pain had started after his daughter was born.

The pathology of the injury and the factors that were mechanical were explained to the patient. It was explained that this would settle in 4-6 weeks if the offending movement was removed and time was spent managing the tendon pain. He asked a quicker fix, as the patient had a lifting competition fast approaching. There was A sports doctor consulted as well as an ultrasound guided corticosteroid injection into the tendon sheath was administered. He was back lifting in the gym pain-free. He wore a protective strap and he altered his way of picking up his kids to avoid the radial deviation movement of the wrist.

What Is De Quervain's Syndrome?

Also known as 'mummy thumb' and 'Blackberry thumb', the condition is an overuse inflammation of the tendon sheaths of the extensor pollicis brevis and abductor pollicis longus tendons. It is classified as a tenosynovitis. It generates an situation whilst the thumb is held in abduction/extension. This is normal in activities like picking up a baby, using bigger screen phones such as iPhones Blackberrys and other phones and gaming consoles.

Signs & Symptoms

The patient will complain of pain, swelling and tenderness on the side of the wrist just above the 'snuffbox' .
It will most likely be a onset with the patient not remembering the activity. Strength will be affected and the Finkelstein test will be positive. This test is performed moving the wrist to ulnar deviation that was active and by gripping the thumb.

Causes/Pathophysiology

The cause of the problem is repetitive wrist extension with deviation. It's a common overuse or repetitive strain injury which affects computer/mouse consumers, some athletes such as tennis players and rowers, players, mothers and tradesmen such as carpenters. Women appear to be more affected than men.

Both tendons involved in the pathology would be the tendons of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) muscles. Both of these muscles and cross the wrist joint to fit into the thumb and their joints run down the surface of the wrist. The function of these muscles is to move the thumb abduct and extend. When the sheath of the tendon becomes inflamed then this pathology is called 'tenosynovitis'.

The tendons are covered in sheaths which prevent friction between the bones and the tendon below and contain them. This allows the tendons to function with no friction between bone and the tendon.
Evaluation of specimens shows a thickening and myxoid degeneration consistent with a degeneration.

Treatment

The usual time course for an acute tenosynovitis is if the individual protects and knowingly rests the tendon. They need to prevent the thumb extension/abduction moves in a radial deviation position.
Treatment usually includes rest, a thumb splint that avoids the movements and shields the tendons. Local treatment to manage the inflammation includes icing the tendon (best performed with two cubes of ice in a wet tea towel), neighborhood anti inflammatory gel application, managing the muscle tone through the EPL and APL through massage and dry needling and gradual restrengthening of the wrist away from maximum radial deviation. When the steroid is injected into the sheath area rather than the tendon, corticosteroid injections have been demonstrated to be effective in handling the inflammation.

Conclusion

This case study presents a instance of an injury affecting an sportsman. Even though active participation in the sport that is chosen not itself caused the injury, the case study highlights how the athlete can be impacted on by activities of daily living and masquerade as a 'sports injury'.