Approach

Most primary stenosing tendinopathies in adults can be successfully treated nonsurgically. Splinting can be attempted for a period of 4 to 6 weeks initially. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be recommended for some patients.

Corticosteroid injection

In most cases, corticosteroid injection may be offered initially in place of, or in addition to, NSAIDs and splinting. Alternatively, it may be used after NSAIDs and splinting have been tried.

Opinion varies as to the choice of corticosteroid and its preparation. Methylprednisolone, triamcinolone, and betamethasone are among the most commonly used.[6][7][8][23][43][44][45][46][47]​ The corticosteroid is mixed with a local anesthetic, most commonly 1% lidocaine.[48] Some treating physicians add sodium bicarbonate in a 1:10 mixture. Total volume injected is about 1 to 3 mL depending on the site and preference. A small needle is preferred (e.g., 25- or 27-gauge). The injection may be repeated on several occasions, but caution should be exercised after multiple injections due to risk of skin thinning, fat atrophy, or tendon rupture.[7][47][49]​​

Surgery

Reserved for patients who fail or refuse conservative management.

Patients may refuse injection therapy if they believe that the discomfort of the injection itself would be greater than the described symptoms. A correctly administered corticosteroid injection (with or without imaging guidance) should cause no more than mild discomfort. Patients may also refuse injection therapy if they have had a previously unsuccessful corticosteroid injection at this site or elsewhere in the past.

Surgery consists of incising and dividing the stenosed sheath. Synovectomy is performed when needed. NSAIDs and ice application may be useful adjuncts in some conditions.

Trigger finger

Treatment starts with a trial of flexor tendon sheath corticosteroid injection. Several techniques exist; all involve injecting the mixture into the flexor tendon sheath. A randomized trial of blind versus ultrasound-guided injection of corticosteroid showed faster resolution of symptoms and return to work in the ultrasound cohort, but no differences in patient-reported outcomes measured at 12 and 24 weeks.[50] A 2021 meta-analysis of the role of NSAIDs in the treatment of trigger digit showed minimal benefit, especially when compared with corticosteroid injection.[51] 

Injection of hyaluronic acid as an alternative treatment for trigger digits has been studied and has shown equivalent outcomes compared with corticosteroid injections in a randomized trial.[52]​ Another randomized trial has shown equivalent outcomes of hyaluronic acid and corticosteroid injections, although corticosteroid seemed to have a greater impact on relief of pain and inflammation.[53] However, a 2023 meta-analysis of hyaluronic acid use for soft tissue diseases included studies on trigger finger and concluded that outcomes showed uncertain benefit.[54]

If surgery is necessary, such as when injection fails or the digit cannot be unlocked, open surgery or percutaneous techniques can be used to incise the A1 pulley, allowing the flexor tendons to glide freely.[33][55][56][57][58][59][60][61][62][63]

In the presence of rheumatoid arthritis, synovectomy rather than pulley release is preferred to avoid bow-stringing and further ulnar deviation of the digits.

de Quervain disease

Treatment commonly starts with splinting and NSAIDs for a period of 4 to 6 weeks. A trial of first dorsal compartment injection can be performed next.[2][5]​​[22][46][64][65]​ Corticosteroid injection combined with splinting has also been described.[66][67]​ Thumb and wrist immobilization (with a thumb spica splint) is used for comfort and resting.[9][22]

If surgery is necessary, such as when injection fails, the first dorsal compartment is incised longitudinally, allowing the extensor tendons to glide freely. It is imperative to positively identify the extensor pollicis brevis (EPB) because it might be in a separate subsheath, separate from the abductor pollicis longus, which is frequently formed of multiple slips.[17][22] Failure to recognize and release an EPB subcompartment can be a cause of treatment failure or recurrence.[68][69][70] Endoscopic release of the first dorsal compartment has been described.[71]

In pregnancy and lactation, nonoperative treatment is highly effective, and the condition tends to resolve after cessation of lactation.[14][72][73]

Extensor pollicis longus tenosynovitis

Urgent surgical exploration (within days to weeks), third dorsal compartment release, and tendon transposition are crucial to avoid attritional rupture of the tendon. NSAIDs and splinting can be offered for pain relief for a period of 4 to 6 weeks.

Extensor carpi ulnaris tendon tenosynovitis

Conservative management with splinting, immobilization, and injection is attempted initially.[40][41][74][75][76] If this is unsuccessful, surgical treatment consists of release of the sixth dorsal compartment.

Tenosynovectomy and retinacular sheath repair and/or reconstruction may be deemed necessary intraoperatively.

All other tenosynovitides

Conservative management with a trial of NSAIDs and splinting can be attempted for a period of 4 to 6 weeks initially. A trial of corticosteroid injection is also frequently attempted early on. An injection is often offered as a first-line treatment and is considered coequal to NSAIDs by many. This applies to all categories that do not require urgent intervention.

Following the trial injection, follow-up is scheduled within 1 month for repeat exam. If the injection fails, a second injection may be given or the patient may be referred to surgery. Surgery consists of surgical release of the corresponding compartment.[34]

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