Summary
Noninfectious tenosynovitis is inflammation or thickening of a tendon and/or its synovial sheath due to repetitive use injury or chronic inflammation from systemic disease. It typically presents with pain and swelling across the affected tendon. Noninfectious tenosynovitis commonly affects the hands (e.g., trigger digit, De Quervain tenosynovitis), but can also occur in other tendons throughout the body. Diagnosis is clinical. Diagnostic studies and imaging are reserved for suspected underlying systemic disease or diagnostic uncertainty. Initial treatment is conservative and includes glucocorticoid injection, splinting, physical therapy, occupational therapy, and oral NSAIDs. Surgical release is typically reserved for severe or refractory symptoms.
See also “Infectious tenosynovitis” and “Insertional tendinopathy”.
Definitions
Etiology
- Repetitive use of the involved tendon [1][2]
- Systemic disease (e.g., rheumatoid arthritis, sarcoidosis, diabetes mellitus, gout, thyroid disease) [1][2]
Clinical features
Clinical features differ depending on which tendons are involved. See “Trigger finger” and “de Quervain tenosynovitis” for clinical features specific to those conditions. [1][2][3]
- Pain along the affected tendon that worsens with movement and typically improves with rest
- Swelling
- Tenderness, nodules, and/or crepitus upon palpation
- Decreased range of motion
The presence of clinical features of infectious tenosynovitis is a medical emergency.
Subtypes and variants
Trigger finger [1][2][3]
Epidemiology
- The most common tendon pathology, affecting
- ∼ 2% of the general population [1][2]
- ∼ 20% of individuals with diabetes [1][2]
- ♀ > ♂ (∼ 6:1) [2]
- Incidence highest in children < 8 years old and adults 40–60 years old [4]
Pathophysiology
Fibrocartilaginous metaplasia of the tendon sheath of the A1 annular pulley → loss of smooth gliding of the finger flexor tendons under the annular pulley → finger catching or becoming locked in a flexed position
Clinical features
- Most often affects the ring finger or thumb [1]
- Pain, tenderness, and/or palpable nodule at the palmar base of the affected finger
- Palpable crepitus with movement
- Catching or locking in a flexed position with painful popping on flexion or extension
- Often concurrent with carpal tunnel syndrome [2]
Individuals with diabetes often have involvement of multiple fingers. [1]
Management
See “Diagnostics of noninfectious tenosynovitis” and “Treatment of noninfectious tenosynovitis.”
De Quervain tenosynovitis [1][2][3]
Epidemiology
- ♀ > ♂ (∼ 3:1) [1]
- Age of onset: 40–59 years [1]
-
More common in
- Golfers, tennis players [5]
- Individuals who frequently text or play video games
- Caregivers for infants or pets (“mother's thumb”)
- Pregnant, postpartum, and lactating individuals
- Individuals with rheumatoid arthritis [6]
Pathophysiology
Repetitive and/or prolonged abduction and extension of the thumb → noninflammatory thickening (i.e., myxoid degeneration and fibrosis) of the abductor pollicis longus and extensor pollicis brevis tendons
Clinical features [2]
- Pain and/or swelling of the dorsoradial wrist and base of the thumb overlying the radial styloid
- Pain exacerbated by movement of the thumb and/or wrist (e.g., when grasping objects)
- Pain may radiate proximally to forearm
Diagnostics
- Diagnosis is clinical.
-
A positive Finkelstein test on examination supports the diagnosis. ; [2][7]
- Description: The examiner grasps the thumb of the affected hand and exerts longitudinal traction, passively pulling the thumb across the palm to cause ulnar deviation of the wrist.
- Test is positive if pain or discomfort is elicited over the dorsoradial wrist (very high specificity) [7]
- See also “Diagnostics of noninfectious tenosynovitis.”
Treatment
See “Treatment of noninfectious tenosynovitis.”
Diagnosis
- Noninfectious tenosynovitis is a clinical diagnosis.
-
If concern for underlying systemic disease or diagnostic uncertainty, consider:
- Laboratory studies as indicated (e.g., serological testing in rheumatoid arthritis)
- Imaging [8]
- X-ray: recommended initial evaluation for chronic symptoms in patients with hand or wrist involvement
- MRI or ultrasound: can be used to evaluate the tendon and synovium
Diagnostic studies are not usually necessary for the diagnosis of noninfectious tenosynovitis. [3]
Treatment
Initial management of noninfectious tenosynovitis is conservative. Refer patients with severe or refractory symptoms for surgical evaluation.
Conservative management [1][3][9]
-
Glucocorticoid injection into the affected tendon sheath (may be performed under US guidance) [10]
- Effective in up to 90% of patients with trigger finger and ∼ 80% of patients with De Quervain tenosynovitis [1][2]
- Repeat doses may be necessary. [3]
- Adverse effects include atrophy of subcutaneous fat and tendon degradation.
-
Splinting (immobilization) of the affected area
- Trigger finger: MCP extension (preferred) or DIP extension splint for 4–6 weeks [1][3]
- De Quervain tenosynovitis: thumb spica splint for 3–4 weeks [1][9]
- Occupational and/or physical therapy (e.g., hand therapy) [10]
- Oral NSAIDs
Glucocorticoid injection should be offered as an initial treatment for most patients. [3][9][11]
Surgery [1][3][9]
-
Indications [4]
- Severe symptoms
- Refractory symptoms despite 6 weeks of conservative management
- Trigger digit in individuals with diabetes
-
Methods: usually involve release of the affected compartment, e.g.,
- Trigger finger: release of the A1 annular pulley of the affected finger
- De Quervain tenosynovitis: release of retinaculum of the first dorsal (extensor) compartment