New York State Medical Treatment Guidelines for Tenosynovitis (Including Stenosing Tenosynovitis) in workers compensation patients

The guidelines developed by the New York State Workers Compensation Board aim to assist physicians, podiatrists, and other healthcare professionals in offering suitable treatment for Tenosynovitis. These guidelines are designed to aid healthcare practitioners in deciding on the most appropriate level of care for patients dealing with elbow injuries.

It’s important to note that these guidelines should not replace clinical judgment or professional experience. The ultimate decision regarding the care of patients with Tenosynovitis should be made through collaboration between the patient and their healthcare provider.


Tenosynovitis (Including Stenosing Tenosynovitis)

Patients experiencing localized ankle discomfort that intensifies with movement may be exhibiting symptoms of tendinopathy. The pain might sometimes coincide with the affected tendon sheath.

Typically, the initial approach involves restricting activities presumed to contribute to the condition. In cases of moderate to severe tendinosis, walking casts, boots, splints, or braces might be advantageous. NSAIDs are often recommended for early


Diagnostic Studies for Tenosynovitis (Including Stenosing Tenosynovitis)

Diagnosing tenosynovitis is not usually accomplished through tests, and X-rays are typically unhelpful. Bony abnormalities may exacerbate tenosynovitis, and concealed fractures may arise.


Medications for Tenosynovitis (Including Stenosing Tenosynovitis)

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients dealing with acute, subacute, or chronic ankle tenosynovitis. If NSAIDs are not suitable for a patient, acetaminophen (or the analogue paracetamol) may be a potential alternative, although research suggests it is slightly less effective than NSAIDs. Evidence supports that NSAIDs are both less risky and as effective as opioids, such as tramadol, in treating pain.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Acute, Subacute, or Chronic Ankle Tenosynovitis: NSAIDs are recommended for treating acute, subacute, chronic, or postoperative ankle tenosynovitis. Initial use may involve over-the-counter (OTC) medications, with the frequency and duration based on individual needs.

NSAIDs for Patients at High Risk of Gastrointestinal Bleeding: For patients at high risk of gastrointestinal bleeding, NSAIDs are recommended along with cytoprotective drugs like misoprostol, sucralfate, histamine type 2 receptor blockers, and proton pump inhibitors. This is especially important for those with a history of gastrointestinal bleeding, the elderly, diabetics, and smokers.

NSAIDs for Patients at Risk for Cardiovascular Adverse Effects: Patients at risk for cardiovascular adverse effects are recommended to use acetaminophen or aspirin as the first-line treatment, and if necessary, non-selective NSAIDs. To minimize the risk of NSAIDs negating the protective effects of low-dose aspirin, NSAIDs should be taken at least 30 minutes after or eight hours before daily aspirin consumption.

Acetaminophen is recommended for treating acute, subacute, or chronic Achilles tenosynovitis pain, particularly in individuals for whom NSAIDs are contraindicated due to medical conditions.

Indications: It is suitable for all patients experiencing foot/ankle pain, covering acute, subacute, chronic, and postoperative cases.

Dose/Frequency: The usage should adhere to the manufacturer’s recommendations and can be employed on an as-needed basis. Caution is advised not to exceed four grams per day to prevent potential hepatic toxicity.

Indications for Discontinuation: Discontinuation is recommended when the pain is alleviated, side effects emerge, or intolerance becomes apparent.


Treatments Tenosynovitis (Including Stenosing Tenosynovitis)

Walking Boots, Casts, Splints, and Braces for Acute and Subacute Ankle Tenosynovitis

This recommendation advises the use of walking boots, casts, splints, and braces for the treatment of acute and subacute ankle tendinosis.

Indications: These devices are suitable for patients experiencing tendinosis in the acute and subacute stages.

Frequency/Duration: They are to be worn while ambulating, or moving around.

Indications for Discontinuation: Discontinuation is suggested in case of a lack of response to the treatment or upon resolution of the symptoms.

Rehabilitation for Tenosynovitis (Including Stenosing Tenosynovitis)

Rehabilitation, specifically supervised formal therapy, is crucial for addressing work-related injuries and should focus on restoring the injured worker to their pre-injury condition.

Active and Passive Therapy: Active therapy involves the patient’s effort in completing specific activities, while passive therapy relies on modalities administered by a therapist. Active interventions take precedence over passive ones. It is recommended that patients continue both active and passive therapies at home to sustain improvements.

Use of Assistive Technology: The incorporation of assistive technology into the treatment plan is encouraged to enhance functional improvements.

Therapy for Residual Deficits: Continuation of active and passive therapies at home is emphasized postoperatively to maintain improvements. The overall number of therapy visits may vary based on the severity of functional impairments, ranging from two to three for modest deficiencies to 12 to 15 for more severe cases.

Indications for Discontinuation: Discontinuation is recommended when there is relief from pain, improved tolerance, effectiveness, or compliance.

Other Non-Operative Interventions Including Manipulation and Mobilization, Massage, Deep Friction Massage, or Acupuncture for Acute, Subacute, or Chronic Ankle Tenosynovitis

These non-operative interventions, including manipulation and mobilization, massage, deep friction massage, or acupuncture, are not recommended for the treatment of acute, subacute, or chronic ankle tenosynovitis.

Iontophoresis for Acute and Subacute Ankle Tenosynovitis

This recommendation supports the use of iontophoresis, specifically with glucocorticoids and occasionally NSAIDs, for ankle tenosynovitis.

Indications: Iontophoresis is suitable for individuals with ankle tendonitis, particularly those who either refuse injection or do not respond well enough to NSAIDs, splints, and activity adjustments.

Dose: Glucocorticoids are commonly utilized in iontophoresis.

Frequency/Duration: Typically, two to three treatments are necessary to assess effectiveness. If deemed effective, an additional four to six sessions may be planned. Additional treatments are reasonable if positive results persist after six visits.

Indications for Discontinuation: Discontinuation is recommended in the case of treatment failure, the emergence of negative outcomes, or symptom resolution. Iontophoresis with either a glucocorticoid or NSAID is advised for a restricted group of patients who have not responded to prior treatments or have declined injection.


Injection Therapy for Tenosynovitis (Including Stenosing Tenosynovitis)

Glucocorticosteroid Injections for Acute, Subacute, or Chronic Ankle Tendinosis

This recommendation supports the use of glucocorticosteroid injections to treat ankle tendinosis in cases that are either acute, subacute, or chronic.

Indications: The use of glucocorticosteroid injections is indicated for ankle symptoms characterized by pain over a compartment. Typically, non-invasive treatments are attempted for at least a week before considering injections. If there’s no improvement, initiating treatment with an injection, often accompanied by an adjuvant injectable anesthetic, is recommended.

Frequency/Duration: It is advisable to administer a single injection and assess the outcomes to document improvement. If there’s no improvement after one to two weeks, a second injection might be considered, especially in cases where symptoms return months later. Repeat injections may be warranted if the last injection resulted in less pain and improved function. However, it’s not recommended to have more than three injections in a year due to the risk of tendon weakening and rupture. Additionally, yearly repetitive injections should be avoided.

Indications for Discontinuation: If there is only a partial response, consideration should be given to repeating the injection, typically at a slightly higher dose.

Surgical Release for Subacute or Chronic Ankle Tenosynovitis

This recommendation advises against surgical release for individuals who have not responded to non-operative treatments, including injections, and are dealing with subacute or chronic ankle tenosynovitis.


What our office can do if you have Tenosynovitis (Including Stenosing Tenosynovitis)

We possess the expertise to assist you with your workers’ compensation injuries. We empathize with the challenges you’re facing and are committed to addressing your medical needs in accordance with the guidelines established by the New York State Workers Compensation Board.

Recognizing the significance of your workers’ compensation cases, we are here to guide you through the complexities of interacting with both the workers’ compensation insurance company and your employer.

We acknowledge that this period can be stressful for you and your family. If you wish to arrange an appointment, please reach out to us. We are dedicated to making the process as smooth and convenient for you as possible.

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