How Do I Distinguish Between Carpal Tunnel Syndrome and

De Quervain’s Disease?

Krista Paulson, BSc, BMR-PT, MSc

Acupuncture Provider

Physiotherapist

Certified Hand Therapist

Co-owner of EastCity Physiotherapy: A Hand to Shoulder Clinic

May indirectly benefit from increased referrals to our clinic, although no specific referrals will be solicited.

Relationships with Commercial Interests:

Objectives

✦ Review anatomy, patient history, exam,

diagnostic imaging findings

✦ Review evidence-based conservative and surgical

management

✦ Review when / where to refer (Winnipeg)

Carpal Tunnel Syndrome (CTS)Carpal Tunnel

Syndrome (CTS)

CTS - Anatomy

(Source: http://noelhenley.com/noelhenley-new2/wp-content/uploads/2012/01/carpal-tunnel-cross-section.jpg)

(Source: Author)

APB

T

S

H

P

CTS - Anatomy

(Source: http://ars.els.cdn.com/content/image/1-s2.0-S0025712508001326-gr1.jpg)

(Source: http://upload.wikimedia.org/wikipedia/commons/

7/77/Musculusabductorpollicusbrevis.png)

CTS - History

✦Most common focal neuropathy

✦Women > Men (especially ages 40-60)

✦Diabetes, RA, Obesity, Smoking

✦Pregnancy, menopause, estrogen use

✦Vibrating tools, repeated forceful gripping

(Calandruccio & Thompson, 2018; D’Arcy & McGee, 2000; Leblanc & Cestia, 2011)

CTS - Examination

✦ Variety of clinical tests with varying sensitivity

and specificity

✦ Multiple positives = more compelling

CTS - Examination (Motor)

(Source:

http://www.onmedica.comgetresourceid=658c7oce-b169-

42a4-8087-665497f9affd)

*

(D’Arcy & McGee, 2000)

“The Abductor Pollicus Brevis (APB) Test” Abductor Pollicus Brevis Wasting

CTS Examination - Durkan’s

✦Apply pressure over

carpal tunnel for 30

seconds

✦Positive:

Numbness/tingling

in median

distribution

✦Sensitivity 87%

✦Specificity 90%

(Calandruccio & Thompson, 2018)

(Source: Author)

CTS Examination - Tinel’s

(Source: Skirven, T. Clinical Examination of the Wrist. J Hand Ther. 1996 Apr-Jun;9(2);96-107)

✦Percuss median

nerve just distal to

wrist crease

✦Positive:

Numbness/tingling

in median

distribution

✦Sensitivity 62%

✦Specificity 93%(Skirven, 1996)

CTS Examination - Phalen’s✦Passive wrist flexion

30-60 seconds

✦Positive:

Numbness/tingling

in median

distribution

✦Sensitivity 68-70%

✦Specificity 73-83%

(Source: Skirven, T. Clinical Examination of the Wrist. J Hand Ther. 1996 Apr-Jun;9(2);96-107)

(Calandruccio & Thompson, 2018; D’Arcy &

McGee, 2000)

X

(Source: Author)

CTS - Electrodiagnostic Testing

✦ Often required by third party payers

✦ Nerve Conduction*: impaired conduction of median

nerve across carpal tunnel

✦ Electromyography (EMG): usually assesses

pathologic changes in Abductor Pollicus Brevis,

more used if other neuropathy/radiculopathy

suspected

✦ Sensitivity 49-84%, specificity 95-99%(Calandruccio & Thompson, 2018)

CTS - Management

✦ Mild to Moderate: consider 3-6 months of

conservative management (splinting, injection)

✦ Severe: consider surgical evaluation

(Leblanc & Cestia, 2011; Wiperman & Goerl, 2016)

(Source: Author)

CTS Management - Splinting

(Hall et al., 2013; So, Chung, Cheung & Yip, 2018)

✦ Mild to moderate CTS

✦ 8-12 weeks of nightly splint use

✦ Unclear if custom more effective

than off-the-shelf

✦ Sweating

✦ Comfort

✦ Insurance coverage

(Source: Author)

~$60

~$95

✦ Only one RCT comparing splinting vs

methylprednisolone acetate premixed with

lidnocaine (mild to moderate CTS)

✦ Equally effective on Boston Carpal Tunnel

Questionnaire

✦ But injection yielded better hand function scores

CTS - Injection

(So, Chung, Cheung & Yip, 2018)

CTS - Injection

(Source: specialistphysio.com)

✦As effective as

splinting

✦Repeat injection

after 6 months

✦Delay surgery up to

1 year

Wiperman & Goerl, 2016)

CTS - Surgical Intervention

✦Results favorable up to 9 years post-op even in severe

cases

✦Two portal endoscopic vs open release:

✦ Endoscopic: less post op pain

✦ Both equivalent for scar pain, patient satisfaction

and recurrence rate at 5-yrs post op

(Atroshi et al, 2009; So, Chung, Cheung & Yip, 2018; Tang, Lai & Tay, 2017)

De Quervain’s DiseaseDe Quervain’s Disease

“New Mom Thumb”

“Baby Wrist”

“Washerwoman’s Syndrome”?

First Dorsal Compartment Tendinopathy

De Quervain’s DiseaseDe Quervain’s Disease

(Source: Author)

(Source: http://3.bp.blogspot.com/-Y76uWzfJ2uQ/T2tAkZmZgPI/AAAAAAAAA4A/o0dmhmZdDhA/s1600/asb2.jpg)

De Quervain’s History

Three Groups of Patients:

✦ Anatomical

✦ Pregnancy/lactation

✦ Mechanical

✦Anatomical variations:

✦ Septum between APL and EPB (30%-60%)

✦ Multiple tendon slips of APL

✦? More prone to De Quervain’s

(Mirzanli et. al., 2012; Orlandi et. al., 2014 Scheller, 2009; Vuillemin et. al., 2012)

(Source:

http://www.sciencedirect.com/science/articla/pii/S197134951

2000069)

De Quervain’s History

✦Pregnancy / Lactation

✦? d/t fluid retention, hormones

✦Mechanical stress of infant care

✦Self limiting with cessation of lactation (Avci et.

al., 2002; Orlandi et. al., 2014; Peters-Veluthamaningal et al., 2009; Scheller, 2009)

De Quervain’s History

✦Degenerative:

✦ Intrinsic, degenerative mechanism rather than

extrinsic inflammatory

✦Thickened sheath

✦ Increased ground substance (Scheller, 2009)

De Quervain’s - Examination

✦Finkelstein’s Test

✦Eichoff’s Test

✦WHAT Test

(Avci et. al., 2002; Peters-Veluthamaningal et al., 2009; Scheller, 2009)

Finkelstein’s Test

✦Often described

incorrectly!

✦Ulnar deviation with

longitudinal traction

✦Sensitivity: ?

✦Specificity: ?

(Goubau et al., 2014)

(Source: Goubau et al., 2014)

Eichoff’s Test

✦Often mislabeled as

Finkelstein’s Test

✦Passive Thumb

Opposition with Ulnar

Deviation

✦Sensitivity: 89%

✦Specificity: 14%(Source: Goubau et al., 2014)

(Goubau et al., 2014)

WHAT Test

✦Wrist in flexion

✦Resist thumb palmar

abduction

✦Sensitivity: 99%

✦Specificity: 29%

(Source: Goubau et al., 2014)

(Goubau et al., 2014)

(Source: Jbara, Patnana, Kazmi & Beltran; 2014)

De Quervain’s - MRI

✦De Quervain’s is primarily a clinical

diagnosis

✦Fluid in tendon sheath

✦+/- tendon sheath thickening

✦Low-signal intensity within tendon

sheath = fibrosis = poorer prognosis

(Source: Jbara, Patnana, Kazmi & Beltran; 2014)

De Quervain’s - Splinting

✦Best for more mild cases

✦ Short to midterm benefit demonstrated (moderate evidence)

✦ Contradictory evidence re: combining with steroid injection

✦ No studies comparing custom vs off-the-shelf splints

(Huisstede, Gladdines, Randsdorp & Koes, 2017; Richie & Briner, 2003Weiss et. al.; 1994)

De Quervain’s Management - Splinting

(Source: Author) (Source: Author)

(Source: dme-direct.com)

~$60

~$95

~$95

De Quervain’s Management - Injection

✦ Short to midterm benefit demonstrated (moderate evidence)

✦Superior to splinting alone

✦ Contradictory evidence re: combining with splinting injection

✦ Not as beneficial in females, obesity

✦ Suggestion that US guided is superior, particularly if septum is present

(Huisstede, Gladdines, Randsdorp & Koes, 2017; Oh, Messing, Hyrien & Hammert, 2017; Orlandi et. al., 2014; Richie & Briner, 2003; Weiss et. al.; 1994)

✦Before considering Sx:

✦4-6 months of conservative tx

✦1-3 cortisone injections (in both APL, EPB*)

✦Last resort treatment (Scheller et al., 2009)

De Quervain’s Management - Surgery

De Quervain’s Surgical Release

✦ If septum present, both APL EPB released

✦ Favorable outcomes in the long-term (16 years)

✦ High patient satisfaction

✦ Dorsal radial sensory nerve lesion more common

in open procedure vs. endoscopic

(Kang, Hahn, Kim & Choi, 2011; Scheller, 2009)

Hand TherapyHand Therapy

Hand Therapy

✦ Public (*Splinting = OT): HSC

✦ Private: EastCity Physiotherapy, Green Hand to

Shoulder Physiotherapy, Foundation

Rehabilitation Services, Centric Health

✦ “Splinting as required” on referral, please

Injections/Surgery

✦ Sports Medicine:

✦ Pan Am (* US guided - Dr. H. Peters)

✦ Legacy

✦ Plastic Sx (Hands)

✦ Ortho Sx (Hands)

Electrodiagnostic Testing

✦ Riverview Health Centre

✦ Health Sciences Centre

✦ St. Boniface Hospital

✦ Deer Lodge

✦ Private Neurologist

✦ Private Physiatrist

ReferencesAtroshi, I., Hofer, M., Larsson, G. U., Ornstein, E., Johnsson, R., & Ranstam, J. (2009). Open compared with 2-portal endoscopiccarpal tunnel release: a 5-year follow-up of a randomized controlled trial. J Hand Surg Am, 34(2), 266-272. doi:10.1016/j.jhsa.2008.10.026

Brunelli, G. (2003). [Finkelstein's versus Brunelli's test in De Quervain tenosynovitis]. Chir Main, 22(1), 43-45.

Calandruccio, J. H., & Thompson, N. B. (2018). Carpal Tunnel Syndrome: Making Evidence-Based Treatment Decisions. Orthop Clin

North Am, 49(2), 223-229. doi:10.1016/j.ocl.2017.11.009

D'Arcy, C. A., & McGee, S. (2000). The rational clinical examination. Does this patient have carpal tunnel syndrome? Jama, 283(23), 3110-3117.

Goubau, J. F., Goubau, L., Van Tongel, A., Van Hoonacker, P., Kerckhove, D., & Berghs, B. (2014). The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff'sTest. J Hand Surg Eur Vol, 39(3), 286-292. doi:10.1177/1753193412475043

Hall, B., Lee, H. C., Fitzgerald, H., Byrne, B., Barton, A., & Lee, A. H. (2013). Investigating the effectiveness of full-time wrist splinting and education in the treatment of carpal tunnel syndrome: a randomized controlled trial. Am J Occup Ther, 67(4), 448-459. doi:10.5014/ajot. 2013.006031

Huisstede, B. M., Gladdines, S., Randsdorp, M. S., & Koes, B. W. (2017). Effectiveness of Conservative, Surgical, and Postsurgical Interventions for Trigger Finger, Dupuytren Disease, and De Quervain Disease: A Systematic Review. Arch Phys Med Rehabil. doi:10.1016/j.apmr. 2017.07.014

Jbara, M., Patnana, M., Kazmi, F., & Beltran, J. (2006). MR imaging: Arthropathies and infectious conditions of the elbow, wrist, and hand. Radiol Clin North Am, 44(4), 625-642, ix. doi:10.1016/ j.rcl.2006.04.009

Kang, H. J., Hahn, S. B., Kim, S. H., & Choi, Y. R. (2011). Does endoscopic release of the first extensor compartment have benefits over open release in de Quervain's disease? J Plast Reconstr Aesthet Surg, 64(10), 1306-1311. doi:10.1016/j.bjps.2011.05.015

LeBlanc, K. E., & Cestia, W. (2011). Carpal tunnel syndrome. Am Fam Physician, 83(8), 952-958.

ReferencesOh, J. K., Messing, S., Hyrien, O., & Hammert, W. C. (2017). Effectiveness of Corticosteroid Injections for Treatment of de Quervain's Tenosynovitis. Hand (N Y), 12(4), 357-361. doi: 10.1177/1558944716681976

Orlandi, D., Corazza, A., Silvestri, E., Serafini, G., Savarino, E. V., Garlaschi, G., . . . Sconfienza, L. M. (2014). Ultrasound-guided procedures around the wrist and hand: how to do. Eur J Radiol, 83(7), 1231-1238. doi:10.1016/j.ejrad.2014.03.029

Richie, C. A., 3rd, & Briner, W. W., Jr. (2003). Corticosteroid injection for treatment of de Quervain's tenosynovitis: a pooledquantitative literature evaluation. J Am Board Fam Pract, 16(2), 102-106.

Scheller, A., Schuh, R., Honle, W., & Schuh, A. (2009). Long-term results of surgical release of de Quervain's stenosing tenosynovitis. Int Orthop, 33(5), 1301-1303. doi:10.1007/ s00264-008-0667-z

Skirven, T. (1996). Clinical examination of the wrist. J Hand Ther, 9(2), 96-107.

So, H., Chung, V. C. H., Cheng, J. C. K., & Yip, R. M. L. (2018). Local steroid injection versus wrist splinting for carpal tunnel syndrome: A randomized clinical trial. Int J Rheum Dis, 21(1), 102-107. doi:10.1111/1756-185x.13162.

Tang, C. Q. Y., Lai, S. W. H., & Tay, S. C. (2017). Long-term outcome of carpal tunnel release surgery in patients with severe carpal tunnel syndrome. Bone Joint J, 99-b(10), 1348-1353. doi: 10.1302/0301-620x.99b10.Bjj-2016-0587.R2

Weiss, A. P., Akelman, E., & Tabatabai, M. (1994). Treatment of de Quervain's disease. J Hand Surg Am, 19(4), 595-598. doi:10.1016/0363-5023(94)90262-3

Wipperman, J., & Goerl, K. (2016). Carpal Tunnel Syndrome: Diagnosis and Management. Am Fam Physician, 94(12), 993-999.