De Quervain’s Tenosynovitis aka “Mummy Thumb” (Part 1)

De Quervain’s tenosynovitis or “mummy thumb” is a common hand condition that arises frequently with overuse of the thumb and wrist. It is a painful condition that involves the inflammation of two thumb tendons (the abductor pollicis longus and extensor pollicis brevis) at the side of the wrist and base of the thumb. Over time, this can also cause thickening of the tendon sheaths (soft tissue coverings encasing the tendons), which then traps the tendons. This makes it difficult for the tendons to glide through the sheaths during functional use and movements of the thumb.

How common is de Quervain’s tenosynovitis?

The prevalence of de Quervain’s tenosynovitis among adults of working age in the general population is about 0.5% in men and 1.3% in women, with it being diagnosed most frequently between the ages of 40 to 60 years old. Indeed, de Quervain’s have been found to be 4.5 times more likely to occur in women than men. It is also thought to occur more frequently in women during pregnancy and postpartum periods, hence its alternative name “mummy thumb”.

What causes de Quervain’s tenosynovitis?

It is often difficult to pinpoint the exact cause of de Quervain’s tenosynovitis, with some cases occurring after acute traumatic injuries (such as sustaining a blunt force impact over the wrist, forceful sideway movements of the thumb and wrist). Anatomical variations and abnormalities in the area where the two thumb tendons are located may also increase an individual’s risk of developing de Quervain’s tenosynovitis. Most cases, however, often occur from the accumulative effects of chronic overuse (i.e. repetitive movements/usage of the wrist and thumb), leading to increased frictional forces or microtrauma to the affected tendons and their sheaths. Some examples of activities which may lead to or aggravate de Quervain’s tenosynovitis symptoms include:

  • Activities that require repetitive wrist and thumb motion, such as mobile phone usage, golfing, playing the piano, fly fishing, carpentry, office workers (e.g. frequent usage of the thumb in writing, typing and using of stapler/hole punchers) and musicians (e.g. prolonged playing of musical instruments which may require the wrist and thumb to be in awkward positions).
  • Mothers of newborns who are repeatedly lifting a newborn or who are assuming breastfeeding postures that place the wrist and thumb in awkward positions.
  • Repetitive gripping, grasping, clenching, pinching, or wringing of objects (e.g. handwashing laundry, frequent wringing dry of rag cloths when cleaning furniture, prolonged scissor use when cutting objects).

What are the symptoms of de Quervain’s tenosynovitis?

The main symptom of de Quervain’s tenosynovitis is pain over the wrist, below the base of the thumb, which may radiate up along the forearm. This pain is usually aggravated with use of the affected hand and thumb in activities that require repetitive or forceful pinching and grasping, twisting of the wrist, and lifting of objects with the wrist/thumb positioned in awkward angles. Some examples include cutting objects with scissors, holding your mobile phone or tablet with your thumb and fingers for long periods of time, frequent texting on your mobile phone, pulling up pants, prolonged/frequent usage of tongs when serving food, and opening tight jar or bottle lids.

Swelling over the side of the wrist at the base of the thumb is also a common symptom, with some people reporting a “snapping” sensation over the wrist when moving/using the thumb. Muscles over the wrist and thumb can also become tighter with the ongoing inflammation, pain and swelling, leading to some restrictions in wrist and thumb movements.

Stay tuned for Part 2 of our discussion on de Quervain’s tenosynovitis, which will focus on assessment and treatment options for this condition.


Sources:

Allbrook, V. (November 2019). ‘The side of my wrist hurts’: De Quervain’s tenosynovitis. Australian Journal of General Practice, 48(11). Retrieved August 27, 2021, from https://www1.racgp.org.au/ajgp/2019/november/side-of-my-wrist-hurts

American Academy of Orthopaedic Surgeons. (2013). De Quervain’s Tendinosis. Retrieved August 27, 2021, from https://orthoinfo.aaos.org/en/diseases–conditions/de-quervains-tendinosis/

Physiopedia. (2021). De Quervain’s tenosynovitis. Retrieved August 27, 2021, from https://www.physio-pedia.com/De_Quervain%27s_Tenosynovitis

Wolf, J.M., Sturdivant, R.X., & Owens, B.D. (January, 2009). Incidence of de Quervain’s tenosynovitis in a young, active population. The Journal of Hand Surgery, 34(1), 112-115. Retrieved August 27, 2021, from https://sci-hub.do/https://doi.org/10.1016/j.jhsa.2008.08.020

Carpal Tunnel Syndrome

Carpal tunnel syndrome accounts for up to 90% of all nerve compression disorders and is one of the most common repetitive strain injuries that can affect people from all walks of life – from office workers and homemakers to manual laborers. Learn about carpal tunnel syndrome, how it can be treated and what can be done to prevent it in the article I have written for Prime Magazine below.

Trigger Finger


What is a trigger finger?

The bending movements of our fingers are controlled by muscle tendons called flexor tendons. These tendons travel down our forearms, wrists and palms to reach our fingers. At the fingers, the flexor tendons go through a series of ligament-like structures called pulleys, which help to position the tendons flat against the bones of the fingers. The A1 pulley is the one affected in most cases of trigger finger, although the A3 pulley has been known to be occasionally affected as well.

With frequent, repetitive and/or forceful use of our hands in daily activities (e.g. housework that requires frequent wringing dry of cleaning cloths/mops, cooking/baking activities, assembly line work, technical work that requires frequent use of hand tools, life events such as moving house), finger tendons may become strained over time, resulting in inflammation of the tendon and/or pulley. This can cause either swelling of the tendon (also called a nodule) and/or thickening of the A1 pulley, making it difficult for the tendon to glide though the pulley smoothly. A catch of the finger thus occurs when trying to straighten it from a bent position, which is often accompanied by pain over the base of the finger where the A1 pulley is located.

How common is trigger finger?

Trigger finger is the fourth most common reason for a referral to an orthopaedic or hand surgery clinic, with a lifetime risk of 2.6% among the general population. The average age on onset of the disorder is 58 years, with women being diagnosed with it 2 – 6 times more frequently than men. The thumb and ring finger of the right hand have been found to be the digits most commonly affected. Individuals with a medical history of diabetes, rheumatoid arthritis, gout, carpal tunnel syndrome, De Quervain’s disease and hypothyroidism also appear to be at higher risk of developing trigger finger. Forceful and repetitive overuse of the hand and fingers have also been thought to contribute to the development and subsequent aggravation of trigger finger symptoms.

What are the signs and symptoms of trigger finger?

Individuals affected by trigger finger are often unable to pinpoint a specific incident or injury that caused the onset of symptoms. Rather, symptoms tend to occur and worsen gradually after a period of heavy or extensive hand use in activities that require forceful and often repetitive gripping or pinching of the fingers or thumb.

Symptoms of trigger finger include:

  • A lump or swelling at the base of the finger/thumb on the palm side of the hand which may be painful or tender when pressure is applied over it.
  • During finger/thumb movements, the finger/thumb becomes stuck in a bent position and a greater amount of force is required to straighten it out. This may result in a “clicking” or “popping” sensation when opening up your finger/thumb, and may also be accompanied by pain.
  • Feelings of stiffness over the affected finger/thumb (especially upon waking up in the mornings), which may result in an inability to form a full fist.
  • In severe cases, the affected finger/thumb may become permanently locked in a bent position and surgery is often required to help straighten it out again.

How can trigger finger be treated?

Treatment for trigger finger includes both non-surgical and surgical options. Non-surgical treatment options are usually effective for trigger finger cases that are mild to moderate in severity, while severe cases of trigger finger will likely require surgical interventions. It is important to seek early treatment for trigger finger as non-surgical treatment success rates tend to decrease as more time passes before the start of treatment (severity of trigger finger may worsen with time).

Non-surgical Treatment Options

Trigger finger cases that are mild to moderate in severity often respond well to non-surgical treatment, which largely involves resting of the affected finger/thumb to allow the inflammation to subside naturally and specific exercises to prevent or alleviate finger/thumb stiffness. Your doctor may refer you to an occupational therapist, who will be able to provide the following services:

  • Advice on lifestyle and activity modifications so as to eliminate or minimize daily activities or finger/thumb movements which may further aggravate the condition (e.g. heavy housework, lifting of heavy loads, active/repetitive/forceful gripping or pinching activities).
  • Provide a customised splint to be worn over the affected finger/thumb when you are using your hands to perform daily activities so as to provide support and encourage further rest of the finger/thumb. Resting will help reduce inflammation and its associated symptoms (i.e. pain and triggering over the finger/thumb).
  • Teach appropriate range of motion and stretching exercises that can help reduce finger stiffness while avoiding aggravation of trigger finger symptoms.
  • Use of therapeutic modalities such as heat treatment and ultrasound therapy, which may provide temporary relief of trigger finger symptoms.

Other non-surgical interventions your doctor may prescribe include:

  • Short-term oral medications (e.g. non-steroidal anti-inflammatory drugs) to help reduce inflammation and pain.
  • Corticosteroid injections over the site of inflammation which can also help reduce inflammation, pain and triggering over the involved finger/thumb. These injections are usually done a maximum of two times over the same finger/thumb. If trigger finger symptoms still persist after two injections, surgery may be considered.

Surgical Treatment Options

Surgical interventions to help relieve trigger finger symptoms may be recommended in the following situations:

  • The symptoms of trigger finger do not improve over time with non-surgical interventions.
  • Trigger finger symptoms have been present for prolonged periods of time (i.e. more than six months) and has been diagnosed to be severe in nature (e.g. the finger or thumb has become stuck in a bent position and you are no longer able to straighten it on your own).

The surgical procedure for trigger finger is called a “trigger finger release or tenolysis”. During this procedure, a small incision is made over the palm at the base of the finger/thumb. The A1 pulley of the affected finger/thumb is then cut, “releasing” the tendon and opening up more space for the tendon to glide through during finger/thumb movements. As there are multiple pulleys present along the finger, releasing a single pulley (the A1) should not affect finger/thumb function in the future.


Recovery from trigger finger release surgery can take anywhere from several weeks to several months. Occupational therapy is often required after surgery to help regain the movement, strength and function of the affected finger/thumb.

Precautions

Even after your trigger finger/thumb has recovered from non-surgical interventions (i.e. therapy and/or steroid injections), there is still a risk of it recurring if you continue using your hands to perform strenuous activities frequently. As such, precautionary measures should be considered when performing daily activities (e.g. household chores, cooking/baking activities, work tasks) to avoid the recurrence of previous trigger fingers and prevent the development of new trigger fingers. These measures include:

  • Lifestyle modifications to avoid or minimize activities that require repetitive and/or forceful gripping and pinching (e.g. wringing dry a wet washcloth, wringing dry a wet mop, kneading of dough during baking, carrying of heavy loads or bags, squeezing of brake levers while cycling, gripping of the steering wheel while driving, serving food with tongs).
  • Use larger upper limb joints to carry loads instead of using your fingers (e.g. hanging a bag of groceries over your elbow instead of carrying it with your fingers).
  • Take frequent short rest breaks (every 20 to 30 minutes) when performing strenuous activities, household chores or work tasks to allow adequate rest of your hands.
  • Practice activity pacing to prevent overstrain of your hands and wrists (e.g. plan to perform strenuous activities, such as household chores and grocery shopping trips, over a few days instead of completing everything on a single day).
  • Once you start feeling any pain or strain over your thumb or fingers, rest them well over the next few days. Early detection of strain and adequate rest of your hands are often the only things you need to keep trigger fingers away!

Sources:

American Academy of Orthopaedic Surgeons. (2018). Trigger finger. Retrieved May 31, 2021, from https://orthoinfo.aaos.org/en/diseases–conditions/trigger-finger

Brozovich, N., Agrawal, D., & Reddy, G. (August, 2019). A critical appraisal of adult trigger finger: pathophysiology, treatment, and future outlook. Plastic and Reconstructive Surgery. Retrieved May 31, 2021, from https://journals.lww.com/prsgo/fulltext/2019/08000/a_critical_appraisal_of_adult_trigger_finger_.18.aspx

Langer, D., Maeir, A., Michailevich, M., & Luria, S. (January 10, 2017). Evaluating hand function in clients with trigger finger. Occupational Therapy International. Retrieved May 31, 2021, from https://doi.org/10.1155/2017/9539206

Mallet Finger

You are playing a friendly game of basketball with your friends on the weekend and you reach overhead to catch a ball thrown to you. However, instead of getting a firm grip on the ball, it hits you on the finger and bounces off. You feel a “pop” in your finger as this happens and when you look at the finger, something does not look right. The last joint of the finger seems to be jammed in a bent position and try as you might, you are not able to straighten it on your own. There is also some pain and swelling over the last joint of your finger, but not too much to cause immediate concern. “Maybe it’s just a mild sprain and it’ll get better on its own in a few days”, you think. After a few days, the pain and swelling seems better, but you are still unable to straighten the last joint of your finger. What is happening here? Will you be able to straighten your finger ever again? If this sounds like a familiar scenario, it is likely that you have sustained a mallet finger injury.

What is a mallet finger?

Mallet finger is a common tendon injury that occurs in everyday life, so termed due to the classic presentation of a finger deformity that resembles a “hammer” or ” mallet”. Also known as a “baseball finger”, this finger deformity results from the disruption of a muscle tendon, called the extensor tendon, which helps to straighten the last joint of your finger or thumb. The extensor tendon travels along the back of the finger or thumb and attaches to the last bone of the digit. Its main function is to assist in the straightening of the thumb or finger.

During injury, this tendon is torn from its attachment site on the bone (called a tendinous mallet finger). But, there are also cases whereby the force of impact causes a small fracture at the base of bone where the tendon is attached to (called a bony mallet finger). In both cases, the tendon is no longer attached to the last bone of the digit and is thus unable to pull the end joint into a straightened position, resulting in a fingertip that droops.

How common is a mallet finger injury?

The prevalence of mallet finger is relatively high, accounting for 9.3% of all tendon and ligament lesions in the body. Injury trends indicate that it is more common among young to middle-aged men and occasionally in older women. 74% of mallet injuries occur in the dominant hand, and >90% of the injuries involve the middle, ring and/or little fingers.

How does a mallet finger occur?

Common injury mechanisms include (clockwise from right to left): (a) stubbing the finger against a hard surface while cleaning, (b) injuring the finger while removing a sock forcefully, (c) injuring the finger while tucking in bedsheets, and (d) the hand/finger is hit by a ball during sports activities.

A tendinous mallet injury (only the tendon is ruptured) usually occurs from a traumatic blow, which results in the sudden forceful bending of the end joint of the finger (e.g. the hand is hit by a ball during sports activities, the finger is injured after a fall, stubbing of the finger against a hard surface while cleaning furniture). This force tears the tendon at the back of the finger from its attachment site on the bone. Occasionally, the force of the impact may be strong enough to break off a piece of bone (fracture) together with the tendon, resulting in the aforementioned bony mallet finger. Finally, a crush injury over the fingertips (e.g. having a finger caught in a door) or a deep cut over the back of the fingertip can also result in detachment of the tendon.

What are the signs and symptoms of mallet finger?

In the initial stages following the injury, you may experience pain, swelling and bruising over the end joint of your finger or thumb. The end joint of your finger stays in a bent position and there is an inability to straighten the joint on your own, unless helped by your other hand.

How can mallet finger be treated?

It is important to seek early treatment for mallet finger as treatment success rates tend to decrease as more time passes by before the start of treatment.

Non-surgical Treatment Options

Most mallet finger cases can be treated successfully without surgery. Generally, the doctor will refer you to an occupational therapist, who will fabricate a customised splint for your finger. This splint will help to support your fingertip in a straight position so that the ends of the ruptured tendon are positioned close to each other, allowing for healing to take place. It is therefore of utmost importance that this splint is worn at all times for a period of at least 6 to 8 weeks. There should be no movement of the end joint of the finger during this period as bending of the joint during can lead to a re-rupture of the tendon.

After this period of immobilisation, if your finger has regained the ability to straighten on its own, your therapist will advise you on gentle exercises that will help you gradually regain the movement and strength of the finger. The amount of time required for splint wear will also be gradually reduced according to your progress. It usually takes around 4 to 6 weeks of therapy after immobilisation to regain maximal movement and strength of the injured finger.

Surgical Treatment Options

Surgery may be needed for mallet injuries under the following circumstances:
– Bony mallet injuries where the bone fragment that broke off is of a larger size
– The presence of joint misalignment
– The tendon has been injured via a cut by a sharp object
– Previous non-surgical management by splinting has been unsuccessful

Surgical procedures may include the use of wires or small screws/metal plates to help realign the joint or re-attach the fracture fragment onto the original bone, as well as the repair or reconstruction of the cut tendon. Regular therapy sessions are usually required after surgery to help in regaining movement and strength of the injured finger/thumb.

Why is it important seek early treatment for mallet finger?

Without early treatment of a mallet finger, the extensor tendon will not be able to re-attach itself onto the bone and heal, leading to a permanent deformity of the finger. Over time, this may continue to worsen due to the imbalance in muscle tendon forces, resulting in a swan-neck deformity of the finger, where the middle joint becomes hyperextended in addition to the end joint being in a permanently bent position. Swan-neck deformities can cause difficulties in finger bending, as well as a snapping sensation during finger movements.


Sources:
American Society for Surgery of the Hand. (2020). Mallet finger: Symptoms & Treatment: The hand society. Retrieved April 13, 2021, from https://www.assh.org/handcare/condition/mallet-finger

Physiopedia. (2021). Mallet finger. Retrieved April 13, 2021, from https://www.physio-pedia.com/Mallet_Finger

Salazar Botero, S., Hidalgo Diaz, J., Benaïda, A., Collon, S., Facca, S., & Liverneaux, P. (2016, March 18). Review of acute traumatic closed mallet finger injuries in adults. Retrieved April 13, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807168/

Sheth, U. (2019). Mallet finger. Retrieved April 13, 2021, from https://www.orthobullets.com/hand/6014/mallet-finger


Have burning questions on hand conditions? In need of hand therapy or ergonomics consultancy services? Click here!


The hand is the tool of tools ~Aristotle

As Aristotle so aptly puts it, the hand is the tool of tools. Try living your life without the use of your hands and you will find that you not only lose the ability to perform simple self-care tasks such as eating, wearing your clothes, showering and brushing your teeth. Work activities are largely done by our hands as well, be it the mechanic who uses hand tools to repair machinery, or the office worker who has to write and operate the computer. Even leisure activities (such as playing racquet sports, baking, craftwork) and housework are often unachievable without the use of your hands. With such extensive use of the upper limbs, it is not surprising that they are also subject to frequent injury.

Injury can occur to different anatomical structures present in the upper limbs, and can be either traumatic or cumulative in nature. Wrist fractures are one of the most common upper limb fractures, accounting for approximately 25% of these fractures, and often occur as a result of trauma, such as falling onto an outstretched hand. Upper limb function is usually affected after a fracture, with reduced range of movements and decreased strength being some of its potential long-term effects. Cumulative injuries to the upper limb on the other hand, tend to take the form of repetitive strain injuries and often affect soft tissues such as tendons, muscles and ligaments. Examples of repetitive strain injuries include carpal tunnel syndrome, trigger finger, tennis elbow and De Quervain’s tenosynovitis. Pain, inflammation and loss of strength are the main symptoms of these injuries, and individuals often experience difficulty in performing their daily activities as a result (e.g. a cook/chef finding it hard to grip and carry a frying pan while cooking due to pain arising from a trigger finger, a laboratory worker finding it hard to do pipetting work due to pain over the wrist/thumb arising from De Quervain’s tenosynovitis).

The debilitating nature of upper limb injuries and its huge impact on an individual’s productivity and finances means that early diagnosis and treatment are of the utmost priority so that the recovery process can be as fast as possible. Medical and surgical treatment approaches aside, therapeutic and rehabilitative interventions, such as exercises, splinting, therapeutic modalities and appropriate patient education, are important contributors to a timely recovery following any upper limb injury. In the upcoming posts, we will discuss in more detail the common injuries that tend to afflict the upper limb.


Have burning questions on hand conditions? In need of hand therapy or ergonomics consultancy services? Click here!

Welcome!

Hi there! I’m Joanna, an occupational therapist by training. I have always been in interested and passionate in hand therapy and upper limb rehabilitation, since most of the activities we perform daily rely so much on our hands. Often times, we do not realise how important our hands are to us until an injury is sustained and we lose function of the hand. Can you imagine performing your daily self-care, work and leisure activities using only one hand? Having to do simple tasks such as pulling up your pants without the use of your thumb, having difficulty controlling the mouse when using the computer due to pain in your wrist, or being unable to play tennis or basketball due to an injury to your wrist or fingers? These are very true scenarios which may happen to each and every one of us at some point in our lives.

Even without an acute injury or trauma, poor ergonomics and postures, as well as prolonged overuse of the upper limbs also contribute to the development of musculoskeletal and repetitive strain injuries – i.e. persistent aches and pain in the neck, shoulders, arms, elbows, wrists and fingers. These aches and pain tend to persist over long periods of time – days, weeks, months and for some, even years! Proper ergonomic advice and therapeutic interventions are often necessary to ensure full recovery and prevent these musculoskeletal injuries from recurring in future.

It is my strong belief that education and knowledge on the nature of the injury or condition, injury prevention strategies and lifestyle modifications are essential not just for recovery, but in the achievement of a healthy and pain-free life. As such, I embark on my journey with you to understand the common injuries and conditions that tend to afflict the hand and upper limb, as well as good ergonomics principles that can be applied to daily activities. Always remember, prevention is better than cure!