We see many people at our practice with a long medical history of thumb pain and thumb pain treatments. These people would up seeing us because their long medical history of conservative care treatments, possibly surgery or surgical recommendation did not help them and they are seeking stem cell therapy or PRP platelet rich plasma therapy as options. Perhaps as options and an alternative to some type of hand surgery.
Thumb pain is often confused with wrist pain and carpal tunnel pain. The confusion with Carpal Tunnel Syndrome is the belief that there is some type of tendon involvement. The confusion with the wrist pain can lead to the belief that there is a ligament or osteoarthritis involvement. As an added layer of confusion doctors may find it difficult to determine if the person’s pain is coming from the wrist or thumb.
Is it De Quervain’s Tenosynovitis?
- Tenosynovitis refers to the inflammation of the synovium that surrounds the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. These tendons move the thumb. Both of these tendons pass within a sheath called the synovium. Tenosynovitis is the Tendon-synovium-itis or inflammation. The tendons are being squeezed within this sheath.
- Is it flexor carpi radialis? Some people who report overuse, which is a common characteristic of thumb and wrist pain, will suggest a wrist pain when they flex their wrist. The pain center point being a spot behind the wrist. The flexor carpi radialis is one of the tendons that helps flex the hand at the wrist. When this tendon suffers from overuse it can swell and cause chronic pain and tenderness. Flexor carpi radialis and Quervain’s Tenosynovitis can be confused or can be occurring simultaneously.
The Finkelstein test
A diagnosis of De Quervain’s Tenosynovitis is usually made after a Finkelstein test. The test goes like this:
- Your thumb is bent into your hand and you make a fist.
- You then bend your wrist towards your pinky side.
- If you have pain at the back of your thumb you will probably be diagnosed with De Quervain’s Tenosynovitis
De Quervain’s Tenosynovitis is also referred to as Mommy Thumb. This is an overuse injury unique to new mothers who frequently pick up and hold their new babies. You may know or knew a new mom who wore wrist braces.
- Splints. Many people find splinting helpful, especially at night time when a painful thumb may awaken them or to prevent a numb thumb in the morning. Splints may help the thumb heal over time. The people I see have a long history of splint usage that was not effective for them.
- Anti-inflammatory medication (NSAIDs). Sometimes these will help with pain and discomfort but if the person is suffering from wear nd tear type injury, the NSAIDs will not heal it. NSAIDs will only mask the pain.
- Avoiding activities that make the pain worse. Usually the people I see are at the point now where they can no longer do these activities because of pain. Some do tell me that they did go through long periods of “rest” and the pain just returned when the resumed their work or activity.
Here is a study that was recently published in the journal Musculoskeletal surgery.(1) It spells out the current concerns with cortisone injections.
“Steroid injection has been described as first line of management over many decades, but it is associated with some significant complications like depigmentation of skin, atrophy of subcutaneous tissue, suppurative tenosynovitis and even tendon rupture. Animal studies have also reported increased risk of peritendinous adhesions with steroid injection.”
A PRP review study from October 2023 (5) writes: “De Quervain’s tenosynovitis is frequently managed with corticosteroid injections with evidence supporting its use, but limited studies exist on the role of PRP. In a trial performed on 40 patients, the corticosteroid group produced better pain relief, improved hand function and ultrasound findings in the short term, but PRP was found to be statistically superior to corticosteroids at mid-term follow-up.”
Manual manipulation in the treatment of De Quervain’s Tenosynovitis
An April 2022 study (4) reported on three patients diagnosed with De Quervain’s Tenosynovitis treated with manual therapy. Many patients as summarized by the researchers do not respond to splinting, activity modification, medications, corticosteroid injections, physical therapist management, and surgery. These three patients underwent a multi-modal treatment regimen including carpometacarpal thrust and non-thrust manipulation, end range radiocarpal mobilization, mobilization with movement, strengthening exercises, and grip proprioception training.
The study investigators found that all three patients showed definitive improvements in standardized pain and functional outcome scores. That the patients were able to achieve these results with ten visits or less. Further, all three patients were able to return to their usual daily tasks without pain. The improvements were maintained at six month follow-up.
1 Mangukiya HJ, Kale A, Mahajan NP, Ramteke U, Manna J. Functional outcome of De Quervain’s tenosynovitis with longitudinal incision in surgically treated patients. Musculoskeletal surgery. 2019 Dec;103(3):269-73.
2 Shafaee-Khanghah Y, Akbari H, Bagheri N. Prevalence of Carpal Tunnel Release as a Risk Factor of Trigger Finger. World Journal of Plastic Surgery. 2020 May;9(2):174.
3 Leong NL, Kator JL, Clemens TL, James A, Enamoto‐Iwamoto M, Jiang J. Tendon and ligament healing and current approaches to tendon and ligament regeneration. Journal of Orthopaedic Research®. 2020 Jan;38(1):7-12.
4 Young SW, Young TW, MacDonald CW. Conservative management of De Quervain’s tendinopathy with an orthopedic manual physical therapy approach emphasizing first CMC manipulation: a retrospective case series. Physiotherapy Theory and Practice. 2020 Jun 1:1-0.
5 Pretorius J, Habash M, Ghobrial B, Alnajjar R, Ellanti P. Current Status and Advancements in Platelet-Rich Plasma Therapy. Cureus. 2023 Oct 17;15(10).