Tenosynovitis, Radial Styloid

Radial styloid tenosynovitis occurs when the tendons that move the thumb outward (away from the index finger) become painful and swollen (tenosynovitis), most commonly from the irritation caused by repetitive gripping and twisting motions.

Two commonly affected tendons are extensor pollicis brevis and abductor pollicis longus. These tendons pass over the end of the radius (radial styloid) at the wrist. Normally, they slide through a canal (extensor retinaculum) without difficulty. Motion of the thumb and wrist become painful and difficult when the tendons become thickened and do not slide smoothly. This process is sometimes labeled as trauma of repetitive use.

The cause of tenosynovitis is unknown (idiopathic), but can be associated with repetitive grip, grasp, and vibration with the thumb positioned against the fingers while the wrist is moved toward the palm (flexed) and toward the little finger side of the hand (ulnarly deviated), as may occur when lifting or twisting. The problem is similar to trigger finger.

Risk Individuals who use repeated gripping and twisting motions of their hand and wrist, such as chefs or cooks, checkout clerks, and carpenters, seem to be more susceptible to this condition. The condition is not uncommon in mothers and day care workers (often in both hands) who repeatedly lift 6- to 12- month-old babies. Adults are most commonly affected with females being at considerably greater risk than males.

Incidence and Prevalence The two most common entrapment tendinitis conditions in the hand and wrist are trigger finger and radial styloid tenosynovitis; however, trigger finger occurs 20 times more often (Meals).

History Individuals complain of pain at the base of the thumb with wrist or thumb motion. There may be a visible swelling or a lump on the thumb side of the wrist, and at times a catching or snapping sensation. Individuals may complain of inability to grip.

Physical exam The exam reveals swelling and tenderness along the thumb side of the wrist (tip of radial styloid over the first dorsa compartment that contains the tendons of the extensor pollicis brevis and the abductor pollicis longus). Pain is made worse with simultaneous flexion of both of the interphalangeal joint and the metacarpal phalangeal joint of the thumb with simultaneous ulnar deviation of the wrist (Finkelstein test). Swelling or fullness may be felt over the tendon. Active contraction against resistance of the involved thumb extensor tendon increases the pain.

Tests No invasive tests are required and x-rays are usually normal. X-rays are useful, however, in ruling out arthritic changes in the thumb and wrist.

Modifying the aggravating activity, and using nonsteroidal anti-inflammatory drugs (NSAIDs) as analgesics are only effective in very mild cases. Immobilization of the thumb with a protective splint or cast may be necessary to provide rest for the tendons, which decreases the pain. However, individuals frequently remove the splint because of the restriction it imposes, and there is some question about its benefits when used alone. Injection of corticosteroid and an anesthetic provides relief in more difficult cases. If conservative measures fail, surgery may be necessary to decrease pressure over the tendon (tenosynovectomy). There are few studies that prove the effectiveness of various treatment options, but steroid injection tends to offer the best relief outside of surgery, whereas rest with NSAIDs are more useful for individuals who refuse steroid injection therapy.

Physical and occupational therapy modalities to decrease the pain and swelling and adaptive splints may be recommended.

Most individuals will recover with injections or rest. Pain may decrease quickly, while swelling is slower to resolve. Those who require surgery (tenosynovectomy) can expect recovery from symptoms. Permanent impairment after surgery is rare unless nerve injury occurs (superficial radial nerve).

Common clinical practice for the conservative (nonoperative) management of radial styloid tenosynovitis begins with three goals. The first goal is to decrease pain and swelling with a trial of continuous splinting in a thumb spica splint and corticosteroid injection. The next goal addresses potential causes of the problem. An ergonomic assessment is useful to examine workplace modifications that may reduce the risk factors associated with this condition. The final goal is to restore mobility and strength, and educate the individual in ways to protect the wrist {ACOEM}.

The duration of therapy depends on the severity of the symptoms and the response to treatment. If the initial pain and swelling subside and motion becomes pain free, the rehabilitation process may warrant less direct observation and guidance of the therapist, being continued independently through a home exercise program. If symptoms persist, iontophoresis with corticosteroids as well as topical or oral NSAIDs may be used {ACOEM}. According to the individual’s response during rehabilitation, corticosteroid injections may also need to be repeated {ACOEM}.

As pain subsides, stretching and strengthening exercises of specific wrist and elbow muscles are emphasized. If work tasks are suspected as contributing to the condition, ergonomic recommendations should be implemented to reduce the risk factors associated with the symptoms.

If radial styloid tenosynovitis requires surgical release, some restrictions may be placed on the progression of range of motion and strengthening exercises with certain movements. These restrictions vary according to the degree or type of surgery that was performed and will be guided by the treating physician.

Work restrictions include modified use of affected thumb, restricted lifting, gripping and twisting during early stages of treatment. Individuals may need to wear protective splinting for aggravating activities.

Previous injury that altered the anatomy of the wrist would make treatment more difficult. Corticosteroid injections may cause changes in skin color and cannot be repeated more than one or two times.

Dominant hand use, job requirements, ability to avoid aggravating activity, tolerance to immobilizing devices (splints), and complications of treatment would all affect length of disability.

Some individuals may not be able to return to the same job unless tasks can be modified.

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

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