Flexor Pollicis Longus Tenosynovitis - Cause, Symptom, Treatment

Table of Contents

Description

Flexor pollicis longus tenosynovitis, also known as de Quervain’s tenosynovitis, is a condition characterized by inflammation of the tendons that control the movement of the thumb. It usually affects the flexor pollicis longus and abductor pollicis longus tendons on the thumb side of the wrist.

Causes of Flexor Pollicis Longus Tenosynovitis

The exact etiology or cause of flexor pollicis longus tenosynovitis (also known as de Quervain’s tenosynovitis) is not fully understood. However, several factors likely influence its development. They include:

Repetitive movements of the hand and wrist:

Repetitive movements of the thumb and wrist, such as repeated gripping, squeezing, or twisting, can strain the tendons and their sheaths, causing inflammation and irritation.

Overuse or strain:

Making repetitive or forceful movements with the thumb and wrist, especially when they are combined with inadequate rest or recovery can increase the risk of tenosynovitis.

Anatomical factors:

Some people may have anatomical variations or abnormalities in the tendons or their sheaths that predispose them to tenosynovitis. For example, a tight or narrow tendon sheath can make the tendon more susceptible to inflammation and irritation.

Hormonal changes:

Hormonal changes, especially during pregnancy, are suggested to contribute to tenosynovitis. Hormonal fluctuations can cause increased fluid retention, which can lead to swelling and inflammation of the tendon sheaths.

Inflammatory diseases:

Certain inflammatory conditions, such as rheumatoid arthritis, can increase the risk of tenosynovitis. In these cases, the underlying inflammation of the joints and surrounding tissues can extend to the tendons and their sheaths.

Trauma or injury:

Direct injury or trauma to the thumb or wrist, such as a fall or collision, can damage the tendons and their sheaths, causing inflammation and tenosynovitis.

It is important to note that although these factors are often associated with the development of flexible wrist prolapse with tenosynovitis, the condition can occur without an identifiable cause.
In addition, individual sensitivity may vary and several factors may contribute to its occurrence.
A consultation with a doctor can help determine the underlying cause and guide appropriate treatment.

Related anatomy

To understand flexor pollicis longus tenosynovitis, it is important to know the relevant clinical anatomy. Here are the main anatomical structures:

Flexor Pollicis Longus (FPL) Tendon:

The flexor pollicis longus is a forearm muscle. It originates from the middle of the ulna and passes through the fibro-osseous tunnel on the palmar side of the wrist.
The tendon then runs along the palmar side of the thumb, passes under the fibrous sheath, and attaches to the distal phalanx (skull) of the thumb.
The main function of the FPL tendon is to flex the thumb.

Abductor Pollicis Longus (APL) Tendon:

The Abductor pollicis longus is another muscle located on the forearm that runs parallel to the FPL muscle.
It also passes through the same fibro-bony tunnel and runs down the palm to the thumb.
The APL tendon helps in the abduction and extension of the thumb.

Tendon protection:

The tendons of the FPL and APL muscles are surrounded by a synovial sheath, which is a protective layer.
consists of two layers: the inner synovium and the outer fibrous layer.
The tendon guard facilitates the smooth gliding of the tendons as they move through the fibro-osseous tunnel and onto the thumb side of the palm.

Fibro-osseous tunnel:

The fibro-osseous tunnel, also known as the first back, is a passage formed by a combination of bones and ligaments on the thumb side of the wrist.
The FPL and APL tendons pass through this tunnel with their synovial sheaths.
When inflammation occurs in the tendon sheath and surrounding structures, such as flexor pollicis longus tenosynovitis, it can cause pain, swelling, and limited motion in the thumb.
Understanding the anatomy helps healthcare professionals effectively diagnose and treat flexor pollicis longus tenosynovitis by targeting the affected tendons and surrounding structures.

Epidemiology

Flexor pollicis longus tenosynovitis, or de Quervain’s tenosynovitis, is a relatively common disease, especially in certain populations. Here are some key points about its epidemiology:

Occurrence:

Flexor pollicis longus tenosynovitis is more common in women than men, with a female-to-male ratio of approximately 4:1.
It usually affects people between 30 and 50 years of age, although it can occur at any age.

Occupation:

Certain occupations that involve repetitive hand and wrist movements or activities that require a strong thumb flexor pollicis longus tenosynovitis occurs more during movements.
For example, craftsmen, healthcare laborers, musicians, assembly line workers, and people who do repetitive activities such as gardening or knitting.

Pregnancy:

The condition is more common during pregnancy, probably due to hormonal changes and fluid retention.
Increased fluid content in tissues can contribute to inflammation and irritation of tendons and their sheaths.

Bilateral involvement:

Flexor pollicis longus tenosynovitis can affect one or both wrists, but bilateral involvement is relatively common.
It is estimated that up to 50% of cases involve both hands.

Risk factors:

As previously mentioned, repetitive hand and wrist movements, overload, anatomical factors, hormonal changes in pregnancy, and certain medical conditions, such as rheumatoid arthritis, can increase the risk of developing flexor pollicis longus tenosynovitis.

Symptoms

Symptoms of flexor pollicis longus tenosynovitis usually include:

Pain and tenderness on the thumb side of the wrist may radiate to the forearm.
Swelling with inflammation at the base of the thumb.
Difficulty grasping or pressing objects. A “sticky” or “clicking” feeling when moving the thumb.
Thumb weakness or difficulty moving the thumb.

Recurrence:

Although many cases of flexor pollicis longus tenosynovitis can be successfully treated with conservative measures, the condition tends to recur, especially if the underlying cause is not treated or if repetitive activities continue without change.

It is important to note that the epidemiology of flexor pollicis longus tenosynovitis can vary in different populations and geographic areas. Correct diagnosis, treatment, and preventive measures can help manage the condition effectively and reduce the risk of recurrence.

Diagnosis

Diagnosis of a patient with symptoms and symptoms of De Quervain’s tenosynovitis starts with a thorough history, observed by a physical examination.

History

Wrist pain
Overuse injury versus acute trauma
History of symptoms
Repetitive movements of the upper limbs during work or daily living (ADL)
Manual control
Pregnant or currently postpartum

Pain:

The primary complaint is radial wrist pain (base of the thumb and dorsolateral aspect of the wrist near the radial styloid process) that radiates to the forearm when the thumb is grasped or extended.
Mostly as a “continuous painful, burning sensation”.
Repetitive lifting, grasping, or twisting movements of the arm make it worse (eg, opening a jar lid).

Medical examination

On examination, tenderness at the base and/or first dorsum of the thumb are some important findings.
Extensor tendons on the thumb side of the wrist, especially over the radial styloid process [Swelling in the anatomical snuff Decreased range of motion (ROM) of abduction of the first digit of the carpometacarpal (CMC) Conscious thickening of the first dorsal extensor sheaths and crepitus of the extensor tendons.

Other possible findings are include

Weakness and paresthesia in the hand
Provocative Finkelstein test
During this test, the thumb is bent and held in a fist. The patient actively rotates the wrist toward the ulna. This causes sharp pain in the first dorsal compartment of the radial wrist.

Differential diagnosis of flexor pollicis longus tenosynovitis

When evaluating a patient with symptoms suggestive of tenosynovitis pollicis longus, it is important to consider other possible diseases that can cause similar symptoms. Here are a few differential diagnoses to view:

Intersection syndrome:

Intersection syndrome involves inflammation at the junction of the tendons of the extensor muscles of the wrist and the tendons under the muscles of the forearm.
This can cause pain and swelling in the forearm, about two inches above the wrist joint.
Sometimes flexor pollicis longus can be confused with tenosynovitis because of its proximity etc.

Carpometacarpal (CMC) arthritis of the thumb:

Arthritis affecting the CMC joint of the thumb can cause pain, swelling, and decreased range of motion at the base of the thumb.
It can be distinguished from tenosynovitis by the location of the pain, which is directed more toward the joint itself than the thumb of the wrist.

Rheumatoid arthritis (RA):

RA is a chronic autoimmune disease that can affect several joints, including the wrists and hands.
The inflammatory changes associated with RA can cause swelling, pain, and stiffness in the affected joints.
Differentiating RA from flexor pollicis longus tenosynovitis may require a thorough evaluation of the patient’s medical history, additional physical examination findings, and laboratory tests.

Osteoarthritis:

Osteoarthritis, a degenerative joint disease, can affect the CMC joint of the thumb, causing pain, swelling, and limited range of motion.
It usually develops gradually over time and may have typical signs such as bone enlargement or joint wrinkling.

Trigger Thumb:

Trigger thumb, also known as constrictive tenosynovitis, involves inflammation and narrowing of the tendon sheath of the flexor thumb.
This can cause pain, a popping or sticking sensation, and difficulty extending or bending the thumb.
A thumb trigger is characterized by the thumb being stuck in a flexed position and then suddenly released (triggered) to the ear.

Ganglion cyst of the wrist:

A ganglion cyst is a non-cancerous fluid-filled lump that usually occurs around the wrist joint or tendons.
This can cause pain and swelling in the affected area.
Although ganglion cysts are not usually associated with tenosynovitis, they may have similar symptoms and may need to be differentiated.
To make an accurate diagnosis, a doctor must perform a thorough, including comprehensive, evaluation of medical history, physical examination, and any imaging studies such as x-rays or ultrasounds.

Treatment:

Surgical intervention: If conservative measures fail to provide relief, surgery may be considered. Procedural involves loosening the contracted tendon sheath to allow the tendons to move more freely. It is important to consult a doctor to obtain an accurate diagnosis and discuss the most appropriate treatment options for your condition.

1-Nonsurgical treatment of flexor pollicis longus tenosynovitis

Non-surgical treatments are often the first line of treatment for flexor pollicis longus tenosynovitis. These conservative approaches aim to relieve symptoms, reduce inflammation and promote healing. Here are some of the more common non-surgical treatments:

Rest and activity Modification:

Avoiding or modifying activities that worsen symptoms is key.
Resting the injured hand and avoiding repetitive motion of the thumb and wrist can help reduce inflammation and allow the tendons to heal.
It is recommended to change jobs or leisure activities that affect the condition.

Immobilization:

Immobilization of the thumb and wrist with a splint or brace can support and limit tendon movement.
This immobilization helps reduce stress on the inflamed tendons and allows for recovery.
A splint is usually used for several weeks and the duration can vary depending on the severity of symptoms and response to treatment.

Cold treatment:

Using ice packs or cold compresses on the affected area can help reduce pain and inflammation.
Cold treatment can be done for 15-20 minutes at a time several times a day.
It is important to wrap the ice pack in a thin cloth to protect the skin and avoid direct contact.

Medicines:

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can be used to relieve pain and reduces inflammation.
These medicines should be taken according to a doctor’s instructions and be careful of possible side effects or contraindications.

Hand care and exercises:

A physical or occupational therapist can guide you through specific exercises and stretching techniques to improve mobility, strength, and flexibility in your thumb and wrist.
They can also provide training on ergonomic principles and posture changes to prevent recurrence and promote overall hand health.

Corticosteroid injections:

In cases where symptoms are severe or persist despite conservative measures, a corticosteroid injection may be recommended.
Injections are made directly into the tendon sheath to reduce inflammation and provide short-term pain relief.
However, it is important to note that repeated corticosteroid injections can cause side effects and should be used with caution.

It is very important to consult a doctor for an accurate diagnosis and a proper treatment plan
customized for your space. They can guide the most appropriate non-surgical treatments and follow up on your progress during the healing process.

2-Physical therapy management

The development of exercise therapy is as follows:

Strength exercises can be started by patients when pain has reduced to a manageable level, with strengthening being gradually criticized.
Place the patient on a strengthening program only if he can tolerate its current strength program for at least 1 week.
It is important to go slowly and for patients to get stronger without pain to prevent the worsening of symptoms.
Below are examples of strengthening exercises.
Abductor pollicis longus Strengthening the abductor pollicis longus muscle can help improve thumb strength, stability, and function.
Here are some exercises commonly used to target and strengthen abductor pollicis prolapse:

Thumb abduction with resistance band:

Attach the other end of the resistance band to a stationary object.
Hold the other end of the tape with the affected hand.
Place your hand with thumbs up.
Gently pull the thumb away from the fingers by stretching the band and grasping the thumb.
Keep the position for some time and then release gradually.
Do 10-15 repetitions and gradually increase the resistance.

Abduction of the thumb against resistance:

Place the affected forearm on a table or other flat surface, palm down.
Hold a small ball or towel.
Hold your thumb against your palm.
Try to hold the ball or towel lightly, keeping your thumb away from your fingers.
Keep the contraction for a few seconds and then relax.
Repeat 10-15 repetitions, gradually increasing the resistance.

Thumb abduction with thumb extension:

Start with your arm in a relaxed position.
Place the uninjured hand in the palm of the affected hand so that the thumb of the uninjured hand is over the thumb of the affected hand.
Try to keep the injured thumb away from your fingers, if the thumb is healthy, offer gentle resistance.
Hold the contraction for some time and then release.
Do 10-15 repetitions and gradually increase the resistance.

Dumbbell Thumb Abduction:

Hold a light dumbbell (or a small household object such as a can or water bottle) in your affected hand.
Raise your forearm on a table or other flat surface, palm down.
For support, place your thumb against the side of the dumbbell with your fingers around it.
Gently lift your thumb away from your fingers, keeping your thumb against the resistance of the dumbbell.
Hold the contraction for a few seconds, then lower your thumb back down.
Do 10-15 repetitions and gradually increase the weight of the dumbbell.
It is important to start with a comfortable resistance level and gradually increase it as your strength improves.
If you experience pain or discomfort during or after these exercises, reduce the resistance or consult a physical therapist for guidance.

Isometric thumb extension

Isometric exercises affect muscle contractions without visual movement in the joint. For the abductor pollicis slang, an isometric exercise can be done to extend the thumb. Here’s how you can do an isometric thumb extension exercise:

Sit or stand in a comfortable position with the affected arm relaxed, palm down.
Place the uninjured hand on the back of the affected hand above the joint of the thumb so that the thumb is higher than the thumb of the affected hand.
Try to extend your thumb against the obstacle. Hold the contraction for 5-10 seconds, maintaining a constant and controlled effort without letting the thumb move.
Relax and rest for a few seconds.
Repeat the exercise a total of 10-15 times.
During the exercise, focus on contracting the abductor pollicis longus muscle while keeping the rest of the hand and forearm engaged. muscles relaxed.
It is important not to overdo it and always work without pain.
If you experience discomfort or pain, reduce the resistance or contact your doctor or physical therapist for further instructions.

Radial deviation isometric

To perform an isometric radial deviation exercise that targets the muscles responsible for moving the wrist toward the thumb, you can follow these steps.

Sit or stand in a comfortable position so that the affected arm rests comfortably on the table or in your lap.
Place the affected hand with the palm facing down and the thumb towards the ceiling.
Place the unaffected hand on top of the affected hand, above the wrist joint.
Apply gentle resistance with the uninjured hand while trying to move the injured hand toward the thumb (radial deviation).
Engage the muscles on the thumb side of your wrist and press against the resistance of your intact hand.
Hold the contraction for 5-10 seconds, maintaining a constant and controlled effort without allowing any real movement in the wrist joint.
Relax and rest for a few seconds.
Repeat the exercise a total of 10-15 times.
During the exercise, concentrate on working the muscles on the thumb side of the wrist.
Remember to use gentle and controlled force and avoid straining or causing pain.
If you feel uncomfortable or anxious, it is recommended that you consult a health professional or physiotherapist for proper guidance and to ensure that the exercise is right for you.