The guidelines outlined by the New York State Workers Compensation Board offer fundamental principles for addressing Extensor Compartment Tenosynovitis. These directives are designed to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in managing Extensor Compartment Tenosynovitis can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.
It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The final decision regarding the management of Extensor Compartment Tenosynovitis should entail collaboration between the patient and their healthcare provider.
Extensor Compartment Tenosynovitis
Diagnostic Studies
There may be occupational instances of De Quervain’s stenosing tenosynovitis when jobs involve repetitive forceful gripping or sustained wrist extension. However, it is mostly not considered occupational. This condition is the most common among extensor compartment tendinoses.
X-Rays
Not recommended, as they are usually unhelpful. Testing for confounding conditions like diabetes mellitus and hypothyroidism should have a low threshold.
MRI
Not recommended for diagnosing extensor compartment tenosynovitis. However, it may be considered in select circumstances with an unclear diagnosis or a lack of appropriate response to clinical treatments, especially injection.
Medications
Ibuprofen, Naproxen, or Other NSAIDs
Recommended as first-line medications for most patients. Acetaminophen can be an alternative for those not suitable for NSAIDs, but evidence suggests it is modestly less effective.
NSAIDs for Treatment
Recommended for acute, subacute, or chronic extensor compartment tenosynovitis. Over-the-counter agents should be tried first, and the use may be as needed.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for concomitant use with cytoprotective drugs for patients at high risk. Proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are recommended.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with cardiovascular disease or risk factors should discuss the risks and benefits of NSAID therapy. Acetaminophen or aspirin is recommended as the first-line therapy.
Acetaminophen for Treatment
Recommended for wrist compartment tendinoses pain, especially for patients with contraindications for NSAIDs. It can be used on an as-needed basis.
Not recommended for acute, subacute, or chronic extensor compartment tenosynovitis. Recommended for limited use (not more than seven days) for postoperative pain management as adjunctive therapy to more effective treatments.
Prescribed as needed throughout the day, then later only at night, before weaning off completely. The rationale is for patients with insufficient pain relief with NSAIDs, and opioids are recommended for brief, select use in postoperative patients, especially for nocturnal use.
Treatment for Extensor Compartment Tenosynovitis
Initial Care
In the early stages, limiting physical factors considered contributors is usually the initial approach. Thumb spica splints for De Quervain’s and wrist braces for other compartment tendinoses are generally considered beneficial. Non-spica wrist splints may be used for other compartment tendinoses. Initial treatment often includes NSAIDs.
Mobilization / Immobilization
Thumb Spica and Wrist Splints
Recommended for acute and subacute thumb extensor compartment tendinoses and non-spica wrist splints for other extensor compartment tendinoses. Generally recommended to be worn while awake, and discontinuation is advised in case of failure to respond or symptom resolution.
Rehabilitation
Rehabilitation for work-related injuries should focus on restoring functional ability for daily and work activities. Active therapy, requiring internal effort, should be emphasized over passive interventions. The patient is instructed to continue both active and passive therapies at home to maintain improvement levels. Assistive devices can be included for additional support.
Active Therapy
Therapeutic Exercise – Acutely
Not recommended as most patients with extensor tendon entrapment do not require an exercise program.
Therapeutic Exercise – Residual Defects
Recommended, particularly post-operatively. The frequency and duration depend on the severity of deficits and ongoing objective functional improvement.
Passive Therapy
Iontophoresis for Acute and Subacute Extensor Compartment Tenosynovitis
Recommended for select patients with wrist compartment tendinoses using glucocorticosteroids and sometimes NSAIDs. Generally, two or three treatments are conducted initially, with additional sessions based on efficacy. Discontinuation may occur due to a lack of response, adverse effects, or symptom resolution.
Other Passive Interventions
Not recommended – Other non-operative interventions including manipulation and mobilization, massage, deep friction massage, or acupuncture for acute, subacute, or chronic extensor compartment tenosynovitis.
Injection Therapy
Glucocorticosteroid Injections
Recommended for acute De Quervain’s or other wrist compartment tendinoses. Generally, at least one week of non-invasive treatment is attempted before considering injection. The response should be evaluated, and a second injection may be considered if necessary.
Surgery
Surgery – Surgical Release
Recommended for patients with subacute or chronic extensor compartment tenosynovitis who do not respond to injections. Indications include failure to respond to nonoperative interventions, usually involving two glucocorticosteroid injections. Surgery is considered after evaluating the condition’s recurrence and the need for further intervention.
