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TYPE
Original Research
PAGE NO.
50-57
10.37547/tajmspr/Volume07Issue01-07
OPEN ACCESS
SUBMITED
18 October 2024
ACCEPTED
20 December 2024
PUBLISHED
21 January 2025
VOLUME
Vol.07 Issue01 2025
CITATION
Bianca Gabriella de Oliveira, Manoel Machado Pereira, Eric Zaneti Teixeira
Baptista, Pedro Augusto Espírito Santo de Carvalho, & Lisse Veronica Rocha
Salazar. (2025). Therapeutic evaluation of quervain tendonitis - systematic
review with meta-analysis systematic review with meta-analysis of
randomized clinical trials. The American Journal of Medical Sciences and
Pharmaceutical Research, 7(01), 50
–
57.
https://doi.org/10.37547/tajmspr/Volume07Issue01-07
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Therapeutic evaluation of
quervain tendonitis -
systematic review with
meta-analysis systematic
review with meta-analysis
of randomized clinical
trials
Bianca Gabriella de Oliveira
Acadêmica de Medicina pela Universidade Salvador, Salvador,BA, Brasil
Manoel Machado Pereira
Médico residente em Ortopedia e Traumatologia pelo Hospital Aroldo
Tourinho, Montes Claros, MG, Brasil
Eric Zaneti Teixeira Baptista
Médico residente em Ortopedia e Traumatologia pelo Hospital Alvorada
Moema, São Paulo, SP, Brasil
Pedro Augusto Espírito Santo de Carvalho
Médico residente em Ortopedia e Traumatologia pelo Centro Médico de
Campinas, Campinas, SP, Brasil
Lisse Veronica Rocha Salazar
Médico residente em Ortopedia e Traumatologia Hospital Santo Amaro,
Guarujá, SP, Brasil
Abstract:
Objective: The aim of this study is to summarize
the treatment of De Quervain's tenosynovitis, from a
conservative point of view, by means of corticosteroid
injection
versus
corticosteroid
injection
with
immobilization of the thumb, establishing criteria for
prognostic evaluation and a systematic review with meta-
analysis.
Methodology: Systematic review with meta-analysis
registered under the prolific ID CRD42024557767. The
research questions were defined using the PICOS model
in accordance with the PRISMA guidelines.
Results: 207 patients were included, of whom 103
underwent
corticosteroid
injection
and
104
corticosteroid injection with immobilization. The studies
analyzed in this systematic review showed better results
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in the Disabilities of Arm, Shoulder and Hand (DASH)
assessment in the corticosteroid injection with
immobilization group.
Conclusion: Even though corticosteroid injections alone
are considered a promising choice of conservative
treatment, current evidence points to a multimodal
approach, employing various non-surgical modalities
associated with better results, studies show that the
combination
of
thumb
immobilization
with
corticosteroid injection is a first-line treatment for
patients with De Quervain's tenosynovitis.
Keywords:
Tenosynovitis; Tenosynovitis De Quervain;
Conservative treatment; De Quervain's disease.
Introduction:
Popularly known as De Quervain's
syndrome, stenosing tenosynovitis of the extensor
pollicis brevis and abductor pollicis longus tendons is
caused by biomechanical and functional overload due
to ergonomics, although this occasionally occurs in
association with rheumatoid arthritis. Marked by
severe pain in the wrist and thumb which improves at
rest and with hypersensitivity near the radial styloid
process over the site of the tendon sheaths involved, it
most frequently affects women aged between 30 and
50. 1,2
The diagnosis is made on symptomatic presentation
and confirmed by physical examination, especially the
Finkelstein test. It is performed so that the patient
performs adduction and wraps the thumb with the
fingers. It is positive if the passive ulnar deviation of the
wrist results in severe pain in the sheaths of the
affected nerves. In addition, evaluation of the active
maneuver of resisted extension of the thumb with a
pain response also confirms the diagnosis. 1,2,3,4,5,6
The therapeutic approach consists of inflammatory
control and acute pain through the use of a splint, local
moist heat and doses of non-steroidal anti-
inflammatory drugs. With pharmacological evolution,
corticosteroid infiltration of the flexor tendon sheath
can be inserted along with the use of a splint, which
can provide safety: a possibility of an agile response to
the pain and shortening component. In the event of
therapeutic
failure,
operative
release
is
recommended, such as performing a fascial-fatty
neighborhood flap, which provides proper coverage of
tissue, tendons and nerves, as well as treating the
disease and providing a reduced and aesthetic
scar.2,3,4,5,6,7 The aim of this study is to summarize
the treatment of De Quervain's tenosynovitis, from a
conservative point of view, using corticosteroid
injection
versus corticosteroid
injection
with
immobilization of the thumb, establishing criteria for
prognostic evaluation and a systematic review with
meta-analysis.
METHODOLOGY
The systematic review was carried out according to the
recommendations of Khan et al considering: 1) framing
the questions for a literature review; 2) identifying the
relevant research; 3) assessing the quality of the studies;
4) summarizing the evidence; 5) interpreting the results.
The research questions were defined by the PICOS
model in accordance with the PRISMA guidelines, as
follows:
1. Population: Patients with de Quervain's tendonitis.
2. Intervention: Conservative treatment
3. Comparator: Comparing recovery intervals of
different lengths
4. Results: Corticosteroid injection with thumb
immobilization versus injection alone
5. Study design: Randomized controlled designs,
counterbalanced crossovers or repeated measures
designs that investigated the effects of the recovery
interval.
Database search method During the period from March
to MAY 2024, records were analyzed from 3 electronic
databases (Pubmed, Biblioteca Virtual da Saúde BVS,
Ebsco Sportdiscus). The keywords were obtained using
the PubMed "mesh terms" query. The search was
conducted with the English terms for: QUERVAIN
TENDINITIS with a combination of "AND" and "OR". The
study protocol was drawn up and registered in the
Prospective Register of Systematic Reviews (ROSPERO)
database under the identification IDCRD42024557767.
Inclusion and exclusion criteria
The inclusion criteria for the articles were:
(01) studies evaluating surgical techniques for the
treatment of De Quervain's tenosynovitis (2) studies
older than 15 years (2) studies evaluating ultrasound-
guided (USG) or blind corticosteroid injection (3) studies
addressing patients diagnosed with De Quervain's
tenosynovitis treated with corticosteroid injection and
thumb immobilization.
Studies with the following criteria were excluded: (1)
experimental studies using animal models (2) non-
original studies - literature reviews (3) opinion studies
(4) studies which dealt with management after infection
had been established, i.e. which did not discuss
prevention and diagnosis of the infection (5) studies
published more than five years ago (6) studies which did
not meet the other inclusion criteria mentioned above.
The search and selection of studies was carried out by
two reviewers who independently analyzed the studies.
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Initially, studies published in the last five years (2017-
2022) were selected using the aforementioned DECS
and Boolean operators, followed by an analysis of titles
and abstracts. At this stage, studies using animal
models, opinion articles and literature reviews were
excluded.
Once this stage was completed, the full texts of the
articles were retrieved to analyze the other inclusion
and exclusion criteria. Duplicate citations and studies
not corresponding to the proposed review parameters
were also excluded. Possible disagreements were
resolved by discussion with a third reviewer, and
inclusion was decided after consensus with the two
main reviewers.
In order to prioritize methodological quality, studies
classified as "Good" after the NIH quality assessment
were included, with studies with more than nine items
ticked being considered suitable for inclusion.
Epidemiological and demographic data was extracted
using a Microsoft Excel spreadsheet, including
parameters such as number of patients, surgical
approach, risk factors described and infection
prevention strategies.
RESULTS
A total of 32 articles were selected during the search
process, and after excluding those published more
than 15 years ago, 28 remained. Analysis of the title
and abstract allowed the exclusion of 15 papers that
did not correspond to the objective of this study. A
complete reading of 13 articles was carried out, 10 of
which were excluded because they did not meet the
inclusion criteria, and 03 of which were selected for
this article (Figure 1).
The three articles selected featured patients diagnosed
with De Quervain's tenosynovitis who had undergone
treatment
with
corticosteroid
injection
or
corticosteroid injection with immobilization of the
thumb. The Disabilities of the Arm, Shoulder and Hand
(DASH) functional assessment was carried out, in
addition to the VAS (pain analogy assessment) scale
reported in the studies. 207 patients were included, of
whom 103 underwent corticosteroid injection and 104
corticosteroid injection with immobilization.
Table 1 sho
ws the articles selected and their results⁵
﹐
⁹
﹐
¹
⁰
Table 2 shows the functional assessment score of the
Disabilities of the Arm,
Shoulder and Hand (DASH) after 06 months of
treatment⁵
﹐
⁹
﹐
¹
⁰
﹐
Figure 2 shows the Forest graph with the analysis of the
Disabilities of the Arm, Shoulder and Hand(DASH) scale
of the studies analyzed⁵
﹐
⁹
﹐
¹
⁰
In the prospective randomized trial by Ippolito et al, 20
patients took part in the study, 09 in the corticosteroid
injection (CSI) group and 11 in the CSI with thumb
immobilization group. Pain intensity, assessed by the
Visual Analog Scale (VAS) score, was 1.1 ± 0.9 in the CSI
group and 1.4 ± 1.9 in the CSI with immobilization group
(p=0.797). The Disabilities of the Arm, Shoulder and
Hand (DASH) score, which analyzes functional outcome,
was 8.4 ± 9.4 in the CSI group and 9.7 ± 14.4 in the CSI
group with immobilization (p=0.864). Patients in the CSI
group had greater resolution of radial wrist pain than
the CSI group with immobilization (100%[9/9] versus
63%[7/11]; p=0.043). The CSI group with immobilization
had better results when it came to resolving sensitivity
to palpation (p=0.202) and the negative Filkelstien test
(p=0.822).
In the Mardani-
Kivi⁹ randomized clini
cal trial, 34
patients underwent CSI and 33 underwent CSI with
immobilization. 01 patient in the CSI group and 02 in the
CSI with immobilization group were lost to follow-up
before the first appointment after 03 weeks, due to a
plane crash, death and a change of city, respectively.
Five patients were excluded from the study for taking
analgesics, one from the CSI group with immobilization
and four from the CSI group. The success rate assessed
at the first return was considerably higher in the CSI
group with immobilization, successful in 32 of the 33
patients (97%), while in the CSI group it was higher in 26
of the 34 patients (p=0.027). The 09 patients with poor
results repeated the treatment and were seen 03 weeks
later, all with successful results and at the 06-month
follow-up.The final result was good in 28 of the 30
patients in the CSI with immobilization group (93%) and
in 20 of the 29 patients in the CSI group (69%) (p=0.021).
All the patients who did not improve had tenderness
and pain in the first dorsal compartment. VAS scores
were 0.37 ± 0.4 in the CSI immobilization group and 1.7
± 1.5 in the CSI group (p=0.001). Both groups had good
results in reducing pain, however, combined therapy
was significantly more effective (p=0.001). VAS scores
were reduced by 96% and 80% in the CSI with
immobilization and CSI groups, respectively. DASH
values in the CSI group with immobilization were 10 ± 9
and 19 ± 2 in the CSI group, with reduction rates of 87%
and 76%, respectively.
In Kumar¹⁰'s study, 60 patients unde
rwent CSI and 60
underwent CSI with thumb immobilization. At the first
visit, 4 weeks after the intervention, the treatment was
successful in 58 of the 60 patients in the CSI with
immobilization group (96.67%) and in 48 of the 60 in the
CSI group (81.67%) (p=0.037). The 14 patients who did
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not have positive results were re-treated and assessed
4 weeks later, all of whom had good results. At the final
follow-up (at 6 months), the values were the same and
all those who didn't respond to treatment had pain and
tenderness in the first dorsal compartment. As for the
VAS score, in the CSI group it was 2.3 ± 1.79 and CSI
with immobilization was 0,44 ± 0,65(p<0,001). The
DASH values were 20 ± 21 in the CSI group and 11.2 ±
1.3 (p<0.001) in the CSI group with immobilization. The
average reduction in the DASH score was greater in the
CSI group with immobilization (75 ± 18) than in the CSI
group (68 ± 23) (p,0.001). The tendency towards pain
relief was also greater in the CSI group with
immobilization.
DISCUSSION
The Disabilities of the Arm, Shoulder and Hand (DASH)
is a form of clinical and functional assessment for
upper limbs. In all the studies used for analysis,
patients in the CSI group with immobilization had a
better score when compared to the CSI group. CSI with
immobilization was also associated with a better VAS
(pain analogue scale) score after therapeutic
intervention, resolution of sensitivity to palpation and
a negative Finkelstein test⁵
﹐
⁹
﹐
¹
⁰.
Conservative treatment of De Quervain's tenosynovitis
differs based on the severity of the disease. Options
include corticosteroid injections ¹¹, the use of non-
steroidal anti-inflammatory drugs and immobilization.
Based on information in the literature, the
effectiveness of conservative treatments varies, with
plaster being 36% effective, immobilization 19% and
corticosteroid injections between 60-90%¹².
Some studies state that corticosteroid injection has
been considered one of the main interventions in
conservative
treatment
for
De
Quervain's
tenosynovitis¹³. According to anatomical studies, this
technique can be employed in two ways, as a one-point
injection or a two-point injection.That said, the two-
point injection technique is performed on the tendon
of the extensor pollicis brevis and the abductor pollicis
l
ongus, leading to a more desirable result¹⁴ is
significantly better than the one-point injection
technique. For this reason, research suggests that if the
one-point injection technique is performed, a proximal
injection is advised rather than a distal injection,
because of its greater likelihood of infiltrating both
compartments
of
a
septated
first
dorsal
compartment¹⁵.
Corticosteroid injections have been found to be very
effective in resolving pain, function and grip strength¹³,
with a short-term success rate after two or fewer
injections of over 70%¹⁴. However, the use of
corticosteroids presents notable risks, including skin
hypopigmentation, tendon ruptures, skin atrophy,
temperature sensitivity, skin fragility¹⁵ and in type 1
diabetics and/or insulin-dependent diabetics, elevated
serum glucose levels for two days after an injection¹⁴.
Therefore, corticosteroids should be used with caution
and in properly selected patients, avoiding patients with
contraindications and comorbidities such as diabetes¹⁵.
As for immobilization, another conservative treatment
option, the results were excellent and the treatment
safe. That said, there are a few types of immobilization
technique, all of which have an effective result, such as
static orthoses, which prevent movement of the hand
and thumb, and result in a reduction in inflammation of
the tendon sheath¹⁶ and the thumb stabilizer splint,
which reduces movement of the wrist and thumb and
can be of the thermoplastic type made to measure or
made of prefabricated neopre
ne ¹⁷.
Immobilization techniques can be indicated mainly in
patients with mild symptoms¹⁷. The use of orthoses has
been shown to be very effective in the acute phase, and
their main purpose in this phase is to inert the limb
involved and reduce inflammation, helping to cure De
Quervain's tenosynovitis¹⁶. Regarding the types of
thumb splint, it is important to note that the
thermoplastic splint has a greater advantage over the
neoprene splint, as it adjusts better to each patient and
does not present eczema or dermatitis, symptoms that
can be caused by the neoprene splint¹⁷.
CONCLUSION
It can be concluded that even though injections and
corticosteroids alone are considered a promising choice
of conservative treatment, current evidence points to a
multimodal approach, employing various non-surgical
modalities associated with better results. Thus, the
studies show that the combination of thumb
immobilization and corticosteroid injection is a first-line
treatment
for
patients
with
De
Quervain's
tenosynovitis.
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FIGURES
Figure 1 - Studies selected according to the PRISMA methodology.
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Table 1. Results obtained by the selected studies.
Table 2- DASH score after 6 months of corticosteroid injection versus corticosteroid injection
with thumb immobilization
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Figure 2 - shows the Forest graph with the analysis of the Disabilities of the Arm, Shoulder and
Hand (DASH) scale of the studies analyzed.
