De Quervain's tenosynovitis

Two tendons lift the thumb away from the hand and straighten it. On the thumb side of the wrist they run together through a short tunnel, lined by a slippery sheath. In De Quervain's the tunnel and the tendons' lining thicken, so the tendons no longer slide freely, and every movement of the thumb pulls on a sore, crowded space.

It often appears with no obvious cause. Some groups seem to get it more:

• New mothers and women late in pregnancy, particularly in the months after the birth; whether hormonal change or the repeated lifting of a baby is to blame is not known
• People who grip, pinch or wring a great deal, at work, at home, in the garden or in sport; work has not been shown to cause it, but hand use can certainly make the pain worse

Women are affected more often than men, most commonly in middle age.

The pain is felt where the thumb meets the wrist, on the thumb side, and the thumb's own movements set it off. The usual signs are:

• Pain over the thumb side of the wrist, worst when you lift the thumb, as in a hitchhiker's thumb, or use scissors
• Pain on gripping, lifting or turning the wrist, such as opening a jar or picking up a baby
• Tenderness when you press on the spot, and sometimes a swelling there that you can see by comparing the other wrist
• Now and then a click or a snap as the tendons move

What you describe and an examination usually settle it: the tender spot over the tendons, any swelling, and a test in which folding the thumb into the palm and tilting the wrist towards the little finger brings on the pain. Arthritis at the base of the thumb, a tendon problem elsewhere in the wrist and a trapped nerve can all cause pain nearby, so telling them apart matters.

A scan, usually done during the appointment, can show the two tendons and their thickened sheath, and the same picture can steer an injection; the ultrasound clinic page goes into the scan more fully.

De Quervain's is not harmful in itself, though the pain can be severe. A mild case may clear within a few weeks untreated; for the rest, treatment goes step by step:

• Less of what hurts. Cutting down on the lifting, gripping and pinching that bring on the pain gives the tendons a chance to settle.
• A thumb and wrist splint. To work, a splint has to hold the thumb as well as the wrist still. It is worn during the activities that hurt and often at night. Simple painkillers and a cold compress can help while it settles.
• A steroid injection. If the pain persists, steroid injected into the sheath around the tendons gives relief to about 70% of people. Very occasionally the skin over the spot thins or turns paler, but the risks are small. Under ultrasound guidance the needle can be seen entering the sheath, and if the first injection only partly helps, a second is sometimes given.
• An operation. If injections do not end the pain, a small operation widens the tendon tunnel by opening its roof, through a short cut over the thumb side of the wrist, taking care of the small nerve branches under the skin. The anaesthetic may be local, the whole arm may be numbed, or a general anaesthetic may be used. Pain relief is usually quick; the scar can be sore for several weeks, numbness on the back of the hand or thumb now and then follows for a while, and infection or stiffness are uncommon risks.

Here, the assessment, the scan and, if you and Dr Borukhson decide it is right, an ultrasound-guided injection can usually all happen at one appointment: you go home with a diagnosis and, if it is needed, treatment under way.

You and Dr Borukhson settle the plan together.

Between appointments, your own care makes a real difference to how well the tendons settle:

• Share the load. Change how you lift and grip so the thumb is spared, and break up long spells of gripping, pinching or wringing.
• Wear the splint as advised, during the tasks that hurt and at night if it helps.
• Ease a flare with a cold compress wrapped in a cloth and simple painkillers.
• Build back up step by step as the pain settles, neither resting the hand completely nor taking everything on again in one go.

De Quervain's tenosynovitis does no harm in itself, and thumb-side wrist pain is rarely dangerous: most of it is for a GP or a booked assessment. Some pictures need more, and the two lists below give their routes; examples are a feverish illness that could be sepsis, a wrist hurt in a fall or a blow, an infected hand, sudden weakness or numbness in a hand or arm, sight lost suddenly in one eye, and tingling that has come on with a painful neck.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• After an injury, a crack heard as it happened, or skin around it that has turned blue, grey or cold, since these can be signs of a broken bone
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time, and a hand or an arm that has suddenly gone weak or numb, with no injury behind it, is one of these signs
• An eye that suddenly and completely loses its sight
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• A lump, a finger or the palm that has turned very painful, hot or red, or hand pain with feeling hot, cold or shivery, since an infection in the hand can show itself this way and has to be found the same day, at A&E or through NHS 111 if a fever comes with it or you feel ill, short of the signs that follow; a lump, or the skin of a finger or the palm, turned hot or red, with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, which may be less obvious on black or brown skin, feeling dizzy or faint, confusion, or skin that is cold, clammy or pale, is a 999 or A&E emergency: call 999 and do not drive yourself to A&E
• Tingling in a hand, or numbness or weakness there that has come on gradually, with neck pain, since a nerve trapped at the neck can bring it on, and seeing someone that day tells it apart from pressure on the spinal cord, as our neck pain guide explains

See a GP if thumb-side wrist pain has not improved after two weeks of care at home, is stopping you doing normal activities, or is worsening or returning, or if tingling or a loss of feeling comes and goes with it, with no injury and no neck pain; with diabetes, see one at any stage. Numbness that will not clear, dropping things, a hand that has weakened over time or a pad at the base of the thumb that is shrinking needs a GP within days, since that can point to a trapped nerve, such as carpal tunnel syndrome. A wrist that is warm, swollen and stiff, hands stiff for longer than half an hour each morning, or a finger swollen all along its length needs a GP within days as well, since an inflammatory arthritis may be starting. If the neck hurts as well, those nerve signs are for the same-day list, and weakness or numbness that comes on suddenly, or numbness that follows an injury, is for the first list. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. A wrist or thumb bent to an odd angle or knocked out of shape by a fall or blow, or a wound with bone visible in it, is a 999 or A&E emergency; where a knock or a fall has left pain, with none of those or of the first list's signs, but a bone could still be broken, NHS 111 can say whether you need an X-ray. If you cannot tell how urgent something is, asking is never a mistake.

Treated, De Quervain's usually does well, while left untreated the pain often limits the hand; one visit can usually confirm it, rule out the problems that mimic it and begin treatment. If the thumb side of your wrist hurts and is not settling, that is the visit to book.

What tells a doctor it is De Quervain's?

Your account of where it hurts and what sets it off, then an examination, usually settle it: the tender spot over the tendons, any swelling, and a test in which folding the thumb into the palm and tilting the wrist towards the little finger brings the pain on. An ultrasound scan, usually at the same appointment, can show the tendons and their sheath, and an X-ray is added where the thumb's base joint needs checking.

What is the treatment, and does it have to be an injection?

Not always. Mild cases can settle over a few weeks with less of the lifting and gripping that hurt and a splint that holds both the thumb and the wrist still. If the pain lasts, a steroid injected around the tendons, inside their sheath, brings relief to about 70% of people. If an injection does not hold, a small operation that opens the roof of the tendon tunnel usually ends the pain.

Can the diagnosis and the injection happen at the same appointment?

Usually. Examination, scan and, if you and Dr Borukhson agree it is the right step, a guided injection into the sheath can all be done at one appointment. No referral is needed, and next-working-day appointments can almost always be arranged.

It started after my baby was born. Will it get better?

It often does. New mothers seem particularly prone to it, though whether hormones or the constant lifting of the baby is to blame is not known. Changing how you lift and grip so that the thumb is spared, a thumb and wrist splint, and treatment if the pain persists, can all help. See a GP or book an assessment if two weeks of care at home have not eased it, or if it is stopping you looking after the baby.

Could it be thumb arthritis or carpal tunnel syndrome instead?

De Quervain's hurts on the thumb side of the wrist, over the tendons, and is worst when you lift the thumb or grip. Thumb-base arthritis hurts inside the joint, deeper than the tendons. Carpal tunnel syndrome is a nerve problem: the fingers tingle or lose feeling, typically at night, rather than one spot hurting. Examination usually separates the three, with a scan or an X-ray where it is needed.