De Quervain's tenosynovitis causes pain on the thumb side of the wrist. It is common, it is not dangerous, and most people get better without an operation. This guide explains what it is, how it is diagnosed, what splints and injections can do, and what to expect if you need surgery.

What is De Quervain's tenosynovitis?

Two tendons move your thumb away from your hand and straighten its base. They run side by side through a short tunnel at the wrist, just above the bony bump on the thumb side. This tunnel is called the . One tendon is the . The other is the .
In the roof of the tunnel and the lining around the tendons thicken. The tendons no longer glide freely, and moving the thumb hurts. It is a form of , like trigger finger.
The tunnel is not the same in everyone. In many people a thin wall splits it into two smaller tunnels, and the tendons often come in several strands. In a study of 300 wrists, about 4 in 10 had a full or partial wall inside the tunnel1. A wall like this is more common in people who have the condition than in people who do not2. This matters for injections and for surgery, as you will see below.

Who gets it?

It is much more common in women and in middle age. In the US military, women were affected almost 5 times as often as men: 2.8 against 0.6 new cases per 1,000 people a year. People over 40 were affected more than 3 times as often as people under 203. In a large insurance database, the peak age was 40 to 59. Diabetes, rheumatoid arthritis and an underactive thyroid were linked with a higher risk4.
It often starts in late pregnancy or in the months after a baby is born. In South Korea, about 2 in 100 women developed it during pregnancy or after the birth5. In a large US study, new mothers were about 5 times as likely to be diagnosed with it as women who had not been pregnant6.
It is often blamed on work or on a single strain. No study has shown that heavy hand use at work or an injury causes it7. Using the hand can make the pain worse, but that is not the same as causing it.

What are the symptoms?

The main symptom is pain over the thumb side of the wrist. It is worse when you lift, grip or pinch with the thumb, for example when you pick up a baby, pour from a kettle or wring a cloth. The area may be swollen and tender to press. Some people feel a creak or catch as the thumb moves.

How is it diagnosed?

Usually by examination alone. Your surgeon will press over the tunnel and ask you to move your thumb.
The usual check is the . The examiner holds your thumb and gently tilts your wrist towards the little finger. Many textbooks describe a different version, in which you tuck the thumb into a fist first. That version can give a false result and lead to the wrong diagnosis89. In a study of 72 healthy wrists, the examiner-held test gave fewer false alarms and was less painful10.
In the , you bend your wrist forward and push your thumb out against the examiner's hand. It picked up 99 in 100 cases in one study, but it was also often positive in people whose ultrasound showed something else11.
An X-ray is not usually needed. An ultrasound scan can show the thickened tunnel and whether it is split by a wall2.

Will it get better on its own?

Often, especially when it starts around pregnancy. In a small trial of women who were pregnant or breastfeeding, 8 of the 9 who wore a splint got better by themselves when they stopped breastfeeding12. In another study, only 1 of 30 women whose symptoms began after giving birth needed an operation, against 25 of 30 other women given the same simple treatment13. How often it settles by itself in other people is not well known.

Treatment without surgery

Rest and a splint

A thumb splint holds the thumb and wrist still and can ease the pain. In a trial of 83 people, wearing the splint all the time was no better than wearing it when you wanted to. The authors concluded that a splint eases symptoms but does not cure the condition14.

A steroid injection

A into the tunnel is the usual first treatment. In a review of 16 trials with 1,206 people, an injection worked better than a splint. An injection and a splint together worked better than either alone15. A larger review found that adding 3 to 4 weeks in a splint after an injection gave only a small benefit, too small to matter much to most people16. In a small trial, the splint added nothing to the injection17.
In a database of over 33,000 people, one injection was enough for about 7 in 10. A second injection worked for about 2 in 3 of those who had one, and a third for about 6 in 104. An injection may help less when the tunnel is split by a wall. In one study, 22 of 30 wrists that needed surgery after an injection had a separate tunnel for one of the tendons18. Guiding the needle with ultrasound places the medicine more accurately2. Whether that means fewer repeat injections or operations is less clear19.
The injection can thin the fat under the skin and leave a pale patch at the injection site20.

If you are pregnant or breastfeeding

A steroid injection can be given in late pregnancy and while breastfeeding21. In the trial of pregnant and breastfeeding women, all 9 who had an injection had full pain relief, although in one the pain later came back. None of the 9 who used a splint had full relief12. Many women prefer to wait, because the condition often settles when breastfeeding stops.

When is surgery considered?

Surgery is for pain that keeps coming back or does not settle despite a splint and one or more injections. It is a small, planned operation and it is not urgent.

What happens during the operation?

The operation is called a first extensor compartment release. It is done as a day case under local anaesthetic. Numbing medicine is injected around the wrist, and a cuff on the upper arm stops the bleeding while I work.
I make a cut about 2 to 3 cm long along the line of the tendons. A small sensory nerve, the , often runs right across this area. Its branches are found and kept out of harm's way. The roof of the tunnel is opened along its back edge. A flap of the roof is left on the palm side to help stop the tendons slipping forward when the wrist bends22. I then look for a second, hidden tunnel around the extensor pollicis brevis and open it too. If a hidden tunnel is missed, the pain can carry on after surgery1.
The skin is closed with a dissolving stitch under the skin and paper strips. There are no stitches to remove.

Recovery

You go home the same day with a soft, bulky dressing, and your thumb stays free. Usually no splint is needed: in a trial, keeping the wrist still after surgery gave no better result than moving it early23. If the tendons are loose at the end of the operation, you wear a removable thumb splint for 2 weeks.
  • Keep the hand up when you can and start moving the thumb, fingers and wrist straight away.
  • Take regular paracetamol and an anti-inflammatory for the first 2 to 3 days, if they are safe for you.
  • The bulky dressing is reduced at 2 to 3 days. Keep the wound dry until it is checked at 10 to 14 days.
  • You can use the hand for light tasks from the first day.
  • Most people return to desk work within the first week and to manual work after 3 to 4 weeks.
  • You can drive when you can grip the wheel comfortably and are off strong painkillers, usually after 1 to 2 weeks.
  • Once the wound has healed, massage the scar to soften it.
  • I see you in clinic 6 weeks after the operation.

How well does surgery work?

For most people, well. In a review of 21 studies with 939 patients, about 5 in 100 still had some pain afterwards24. In a study of 707 people, pain scores fell by about 44 points on a 100-point scale by 3 months25.

What are the risks?

In the review of 21 studies, about 11 in 100 people had a complication of some kind24.
  • Tingling or numbness on the back of the thumb from handling the small nerve. It is usually temporary. In one trial, 9 of 25 people had temporary nerve symptoms after the open operation26.
  • A tender or thick scar. Scar tenderness may take about 3 months to settle.
  • Tendons that slip forward over the wrist bone when the wrist bends. In a study of 130 operations, the tendons sat on the edge of the bone in about 9 in 100 at the end of the operation. They slipped out fully in fewer than 1 in 10027. Leaving the flap of the tunnel roof is meant to prevent this.
  • Pain that carries on because a hidden tunnel was not opened, which may need a second operation.
  • Infection, bleeding or stiffness, as after any hand operation.
Complex regional pain syndrome is an uncommon reaction after any hand operation. It causes pain, swelling and stiffness that seem out of proportion. Tell your surgeon early.

When to seek help

See your GP, or go to the emergency department, if you have:
  • a fever, or spreading redness, warmth or discharge at the wound;
  • pain that gets worse instead of better after the first few days;
  • numbness or tingling that does not settle, or a very tender spot over the nerve;
  • a snapping of the tendons over the wrist when you bend it.

Summary

De Quervain's tenosynovitis is a common cause of pain on the thumb side of the wrist, especially in women in middle age and in new mothers. It often settles with time, a splint or a steroid injection. One injection is enough for most people. If the pain keeps coming back, a short day-case operation under local anaesthetic opens the tight tunnel, and most people do well.