Approach
The basic common features of all stenosing tendinopathies are pain, swelling, and tenderness at the point where an extrinsic tendon enters its retinacular sheath. Symptoms increase with active motion and more so with resisted motion. Lack of motion associated with increased pain may signify locking.
Diagnosis can be confirmed by injection of local anesthetic (lidocaine) combined with corticosteroid into the corresponding sheath, resulting in resolution of symptoms.[1][2]
Trigger finger
Digital flexor tendon tendonitis at the A1 pulley in the hand (trigger finger) typically presents with painful catching or popping of the flexor tendon, which occurs as the patient flexes and extends the digit. The digit may be locked in flexion. Passive manipulation into extension may release the locking. Prolonged neglect will result in flexion contracture of the finger. A tender nodule may be palpable at the level of the metacarpal head in the palm.[10]
True joint locking (rare), extensor tendon subluxation, and locking under the A2 pulley in the finger (rare) should be ruled out using physical exam, MRI, or CT scan.[31][32]
de Quervain disease
Defined as tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons as they pass through the first dorsal compartment sheath of the wrist at the radial styloid process. de Quervain disease presents with pain, tenderness, and swelling localized to the radial side of the wrist 1 to 2 cm proximal to the radial styloid. It is aggravated by thumb movement. Pain is exacerbated by ulnar deviation of the wrist when the thumb is clasped in the palm (Finkelstein test).
Basilar thumb arthritis (presenting with direct tenderness over the basilar thumb joint; positive grind test) and radial sensory nerve neuritis (Wartenberg syndrome presenting with direct tenderness, sensory changes, and positive Tinel sign over the radial sensory nerve) should be ruled out.[31][32][33]
Intersection syndrome
Tenosynovitis of the second dorsal compartment tendons (extensor carpi radialis longus/extensor carpi radialis brevis) results in intersection syndrome. It is thought to be the result of friction between the muscle bellies of the abductor pollicis longus and the extensor pollicis brevis (first compartment), and the radial wrist extensor tendons (second compartment). It presents as pain and swelling 4 cm proximal to the wrist joint. In severe cases, redness and palpable crepitus (that may sometimes be audible) are noted on exam. Pain is greatly increased by resisted wrist extension.[34]
Extensor pollicis longus tenosynovitis
This is rare but requires early diagnosis and treatment to prevent rupture. Pain, swelling, and tenderness at Lister tubercle are presenting features. Thumb interphalangeal joint motion causes pain at Lister tubercle.[28][35][36]
Extensor carpi ulnaris tenosynovitis
This common condition is one of the causes of ulnar-sided wrist pain. Pain is increased with all motions of the wrist. Pain with extension/ulnar deviation against resistance is suggestive. Extensor carpi ulnaris subluxation can also present with reactive synovitis. It is important to distinguish between tenosynovitis and instability because surgical management differs. Triangular fibrocartilage complex tear or dorsal sensory branch of ulnar nerve irritation should be ruled out using MRI or CT scan.[31]
Flexor carpi radialis tenosynovitis
Presents with pain at the palmar wrist crease over the scaphoid tubercle and along the length of the tendon. Increased pain with resisted wrist flexion and radial deviation is pathognomonic. Localized swelling and a ganglion cyst may be present.[29]
Role of imaging
Diagnosis of the vast majority of cases of tendonitis and tenosynovitis pathologies is clinical. The single most useful and accurate diagnostic investigation for all the stenosing tendinopathies is a high-resolution ultrasound scan.
Ultrasonography
Can be used to diagnose both sterile and purulent tenosynovitis, as well as a number of other hand and wrist pathologies. Improvements in high-resolution ultrasound are producing increasingly high-quality images of superficial structures, expanding the indications for this imaging modality in the hand and wrist.[37][38][39]
Other imaging modalities
Imaging studies that may be used to rule out other diagnoses if highly suspected, but are not routinely used, include:[31][32]
Plain radiographs: helpful to evaluate for occult wrist fractures, arthritis (basilar thumb and radiocarpal arthritis), and calcific tendonitis, among others.
CT or MRI: helpful if clinical suspicion persists and plain x-rays prove unhelpful (e.g., to rule out occult scaphoid fracture, subretinacular ganglion cysts, tendon degeneration, reactive synovitis). MRI is also useful to characterize swelling or masses around tendons or tendon sheaths.
Blood studies
Blood studies (CBC, ESR, CRP) do not have a direct role in the diagnosis of stenosing tendinopathies. They help to establish or rule out other diagnoses, such as rheumatoid arthritis, gout, and infection (septic tenosynovitis, cellulitis, septic arthritis).
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