Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Tenosynovitis

Basics
Description
  • Tenosynovitis is the painful inflammation of a tendon and its surrounding synovial sheath.
  • It affects long tendons, most commonly in the fingers, wrist, or ankle.
  • The inflammation may be related to an acute injury, chronic overuse, a systemic inflammatory disease (rheumatoid arthritis) or infection, or it may be idiopathic in origin.
  • The condition is rare in children and is most common in early to middle adulthood.
  • Classification:
    • By duration:
      • Acute: Few days’ duration of symptoms; usually resolves promptly with rest and NSAIDs
      • Chronic: Duration of symptoms >2-3 weeks; may have more changes in tendon and its sheath; more difficult to cure
    • By common locations:
      • Posterior tibialis tenosynovitis
      • Flexor tenosynovitis
      • Biceps tenosynovitis
      • de Quervain tenosynovitis (of the thumb extensor and abductor tendons)
  • Synonym: Tendinitis
General Prevention

In general, it is difficult to predict who will be affected by tenosynovitis, making prevention in the general population difficult.

Epidemiology
  • 1 of the most common musculoskeletal problems affecting the general population
  • Most people experience at least 1 episode of tenosynovitis in their lifetime.
  • Females are affected slightly more frequently than are males.
Risk Factors
  • Systemic inflammatory diseases such as rheumatoid arthritis
  • Previous episodes of tenosynovitis
  • Unclear if repetitive motion is linked
Etiology
  • Excessive use or constriction of a tendon causes inflammation of the sheath (tenosynovium), which then becomes thickened.
  • Females in the 30-50-year age group who are engaged in activity involving repetitive motion constitute most of the noninfectious, nonrheumatologic cases.
  • Rheumatoid arthritis, lupus, or other inflammatory arthritides can manifest as tenosynovitis.
  • Infectious causes of tenosynovitis are associated with a cut or break in the skin that extends deep into the flexor sheath.
Pregnancy Considerations
Pregnancy can precipitate tenosynovitis, especially de Quervain.
Associated Conditions
  • Rheumatoid arthritis
  • Inflammatory arthropathies
Diagnosis
Signs and Symptoms
  • Pain over the affected tendon:
    • May be acute or insidious
    • Usually follows a period of unusual or new activity
    • Worse with continued use
  • De Quervain tenosynovitis:
    • Tender on the radial side of the wrist
    • Worse with ulnar deviation
  • Some patients may develop a trigger finger, in which inflammation and scarring of the long flexor tendons of the fingers causes a locking or snapping sensation as the tendon passes through the pulley systems along the palmar aspect of the fingers.
Physical Exam
  • Tenderness in a longitudinal distribution, along the course of the involved tendon
  • Tenderness can be mild, moderate, or severe.
  • Possible associated swelling along the tendon sheath
Tests
Lab
  • Laboratory studies may be useful to rule out infection, including complete blood count, sedimentation rate, and C-reactive protein.
Imaging
  • Radiographs are needed:
    • If a history of penetrating trauma is present
    • To assess the presence of arthritis in adjacent joints or to exclude other possible causes of the patient’s symptoms, such as fractures
  • MRI and ultrasound may show inflammation in the tendon sheath and can be useful in confirming the diagnosis.
Pathological Findings
Localized inflammation and thickening of the tendon sheath are revealed microscopically by the presence of acute inflammatory cells (polymorphonuclear leukocytes).
Differential Diagnosis
  • Infection of the tendon sheath
  • Trauma to tendon (e.g., strain or tear)
Treatment
General Measures
  • Relative rest: Avoidance of offending activities and gentle ROM exercises
  • Short-term splinting can be used for complete immobilization in extreme cases.

Special Therapy

Physical Therapy
  • Physical and occupational therapists manage these problems, making use of:
    • Splints
    • Strengthening and stretching exercises
    • Job and activity modification
Medication
  • NSAIDs are the mainstay of treatment.
  • Corticosteroid injection for de Quervain tenosynovitis
  • Tenosynovitis associated with systemic inflammatory diseases such as rheumatoid arthritis may respond to disease-modifying agents or to systemic anti-inflammatory medications.
  • Infectious causes of tenosynovitis must be treated aggressively with antibiotics.
Surgery
  • Indicated in patients for whom nonoperative measures have failed
  • Release of the tendon sheath around the inflamed area, along with excision of tenosynovitis and tendon debridement
  • de Quervain tenosynovitis may require complete release of the abductor pollicis longus, followed by splinting.
  • For septic tenosynovitis: Release of the tendon sheath, decompression of purulence, and removal of inflamed/infected synovium
Follow-up
Disposition
Issues for Referral
Patients with tenosynovitis secondary to a systemic inflammatory condition such as lupus or rheumatoid arthritis should be referred to a rheumatologist for medical management (including disease-modifying agents).
Prognosis
  • Most cases resolve with nonoperative measures.
  • The PTT and the Achilles tendon are especially prone to disease recurrence.
Complications
Tenosynovitis may fail to resolve, usually because of chronic changes in the tendon.
Patient Monitoring
Patients are followed at 4-6-week intervals to check ROM and healing of the tendon.
Miscellaneous
Codes
ICD9-CM
727.0 Tenosynovitis
Patient Teaching
Activity
Patients should be instructed to avoid exacerbating activities.
Prevention
Patients should avoid repetitive manual activity or a sudden increase in activity.

FAQ
Q: What is tenosynovitis?
A: Tenosynovitis is an inflammation of the tendon and the tendon sheath. It can be caused by acute injury, overuse, systemic inflammatory diseases, or infection.
Q: How do you treat tenosynovitis?
A: Treatment depends on the causes. Infections are treated with antibiotics and even surgical decompression. Overuse injuries are treated with anti-inflammatory medications and relative rest of the affected area. Systemic diseases leading to tenosynovitis may require a more aggressive medical regimen for treatment.
Q: What is de Quervain tenosynovitis?
De Quervain tenosynovitis is an inflammation of the tendons of the 1st dorsal compartment of the wrist, namely the extensor pollicis brevis and abductor pollicis longus.

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