De quervain's tenosynovitis - A detailed study
De Quervain's tenosynovitis is an inflammation of the tendons that run along the thumb side of the wrist and connect to the base of the thumb. This happens when the tendons are restricted by the sheath that they pass through to get from the wrist to the palm. This medical condition is named after Swiss surgeon Fritz de Quervain, who initially diagnosed it in 1895.
Tendons are rope-like structures that connect muscle and bone, allowing the muscle to pull and move the bone. Tendons are protected soft tissue covering known as synovium. This layer nourishes the tendons and allows them to move freely through the sheath that surrounds them. Any swelling of the tendons and/or thickening of the sheath may cause the tendons to no longer fit properly inside the sheath.
De Quervain's tenosynovitis affects both the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. These are two of the thumb's primary tendons that help move the thumb away from the index finger (APL) and straighten the thumb joints (EPB).
This condition is commonly known as the Mother's thumb or Mommy wrist. New mothers with small babies appear to be especially vulnerable, which could either be due to hormonal changes after pregnancy or repetitive lifting of the baby.
Causes
1. Primarily seen to affect women especially during pregnancy and breast feeding stage.
2. Any activity resulting in the overuse of wrist and thumb. Eg Use of keyboard, texting, golfing, knitting etc.
3. Acute injury to the wrist
4. Inflammatory conditions like rheumatoid arthritis
Symptoms
1. Pain on the thumb side of the wrist which can develop suddenly or gradually.
2. Severe pain during hand movements such as lifting or moving the thumb.
3. The pain originates in the wrist and can progress up the forearm. It can also be associated with swelling in the wrist.
Diagnosis
1. Patient history is evaluated.
2. Physical examination including tests such as Finkelstein/Eichhoff test. The Finkelstein's Test involves placing the thumb in the palm, grasping it with the other fingers, and bending the wrist toward the little finger. Pain during the maneuver denotes a positive test for De Quervain's tenosynovitis.
Treatments
- 1.Avoiding or modifying activities causing pain
- 2. Wearing a thumb spica splint especially during night which helps place the thumb in a comfortable position
- 3. Physiotherapy
- 4. NSAIDs (nonsteroidal anti-inflammatory drugs)
- 5. Corticosteroid injections for pain relief
- 6. If everything else fails wrist surgery may be required.
Exercises
The exercises presented are intended to be preventative and should only be performed once the symptoms have subsided. The purpose is to strengthen and train the thumb and wrist while also improving hand function. If any workout causes pain, seek medical attention.
Exercises should be conducted with the elbow resting on a tabletop with a towel to pad underneath, shoulder flexed to 90 degrees, elbow fully extended, or elbow at the side and flexed at 90 degrees. The exercises can be done in two or three sets, with three to five repetitions each.
Ayurvedic view
Snayu is a fibrous connective tissue found in the human body. It takes numerous forms according to the body's functioning requirements. The human body contains various forms of the Snayu, including tendons, aponeurosis, fascia, peripheral nerves, and ligaments. Thus, even though in Ayurveda Kandara is the term used to specify tendon, it can be considered to fall under the bracket of Snayu based on functionality.
Furthermore, there are four types of Snayu according to Acharya Susrutha; Pratanvatya, Vrutta, Pruthula and Sushir snayu.
Analyzing the references regarding the types of Snayu it can be stated that
1) Pratanvatya snayu prakara- Nerves, tendons and ligaments
2) Pruthu snayu prakara- Aponeurosis (flat tendons)
3) Vrutta snayu prakara- Tendons
Thus, the symptoms and treatment aspects of Snayugata vata can be used to compare De quervain's tenosynovitis.
In Ayurveda, Snayugata Vata is explained under the concept of Vatavyadhi. The Vata Dosha vitiation occurs through various reasons such as over-exertion, exercising beyond one's limit, overuse of body parts or repetitive activities along with consuming food that is dry, light, devoid of necessary fats, etc to name a few. Among the five types of Vata explained, Vyana is the one that is responsible for different body movements such as Gati, akshepana, utkshepana, nimesha, and unmesha.
In Snayugata Vata, the general symptoms as mentioned by Acharya Susrutha are:- Shoola (Pain), Kampa(Tremors), Akshepa (convulsions), and Stambha(stiffness). In the context of De quervain's tenosynovitis vitiated vyana vata settles down in the Snayu of the wrist and hand region causing pain and stiffness apart from difficulty in moving the thumb.
According to different Acharyas Snehana Karma, Swedana Karma, Upanaha, Bandhana, Agnikarma are explained under the treatment modalities for Snayugata Vata
1. Snehana and swedana - This method of applying heated medicated oil to the affected part along with sudation can decrease the pain, and inflammation and nourish the tendons. Oils such as Dhanwantharam taila, murivenna, karpooradi taila, kottamchukkadi taila etc can be used externally as and when prescribed by an Ayurvedic practitioner. These oils have different properties and their use will vary depending on the condition. Swedana methods such as nadi sweda, churna pinda sweda, seka can also bring relief.
2. Upanaha - Upanaha is a type of swedana where a medicated drug paste is applied and tied over the affected region. This again can help in relieving the pain and inflammation.
3. Bandana - Bandana or bandaging helps to immobilize the area or restrict the full range of movements, helping the tendons to recover and thereby reducing the pain.
4. Agnikarma - Thermal cautery can be performed at the affected region which can relieve the pain. it is normally conducted using specialized Agni karma salakas or yantra. Thermal cautery using heated honey has also shown promising results.
Apart from these Vatasamana drugs should be consumed internally along with Rasayana drugs which can help in the complete recovery and rehabilitation of the affected tendons and also to prevent the reoccurrence of the same.
By
Dr Archana V
BAMS, M.D
References
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