Tenosynovitis

By admin Last updated Mar 11, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Tenosynovitis

Tenosynovitis

Gregory Gebauer MD, MS

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 (1)
  - Flexor tenosynovitis
  - Biceps tenosynovitis
  - de Quervain tenosynovitis (of the thumb extensor and abductor tendons) (2)
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.

P.443

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 (2)
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 débridement
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.

References

1. Bare AA, Haddad SL. Tenosynovitis of the posterior tibial tendon. Foot Ankle Clin 2001;6:37–66.

2. Weiss APC, Akelman E, Tabatabai M. Treatment of de Quervain’s disease. J Hand Surg 1994;19A:595–598.

Additional Reading

Coughlin MJ. Disorders of tendons. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, 7th ed. St. Louis: Mosby, 1999:786–861.

Froimson AI. Tenosynovitis and tennis elbow. In: Green DP, ed. Operative Hand Surgery, 3rd ed. New York: Churchill Livingstone, 1993:1989–2006.

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.