General Guideline Principles for Extensor Compartment

Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis

and Intersection Syndrome) for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome).

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome) of Hand, Wrist and Forearm Injuries

When jobs require repeated forceful gripping or sustained wrist extension, De Quervain’s stenosing tenosynovitis may occur. However, the majority of cases are unlikely to be occupational. The most common extensor compartment tendinose is De Quervain’s.

  1. Diagnostic Studies of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

    Diagnostic Studies of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome) X-Rays is not recommended are usually ineffective and thus not recommended.

    The cutoff for testing for confounding conditions like diabetes and hypothyroidism should be low. Extensor Compartment Tenosynovitis: Evidence for the Use of Special Studies

     

  2. MRI

    MRI is not recommended to determine the presence of extensor compartment tenosynovitis.

    MRI are recommended when there is an ambiguous diagnosis and/or a failure to respond appropriately to clinical treatments, particularly injection.

Medications of Hand, Wrist and Forearm Injuries

For most patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications.
Acetaminophen (or the analog paracetamol) may be a reasonable alternative to NSAIDs for patients who are not candidates for NSAIDs, although most evidence suggests acetaminophen is modestly less effective. There is evidence that NSAIDs are as effective for relief of pain as opioids (including tramadol) and less impairing.

  1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Extensor Compartment Tenosynovitis

    Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Extensor Compartment Tenosynovitis are recommended extensor compartment tenosynovitis, whether acute, subacute, or chronic

    Indications – NSAIDs are prescribed for acute, subacute, and chronic pain. Over-the-counter (OTC) medications may be adequate and should be tried first.

    Frequency/Duration: For many patients, using it as needed may be appropriate. Discontinuation is indicated when symptoms have resolved, there is a lack of efficacy, or adverse effects have developed, necessitating discontinuation.

     

  2. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

    NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is recommended Misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors should be used concurrently in patients at high risk of gastrointestinal bleeding.

    Indications:Cytoprotective medications should be considered for patients with a high-risk factor profile who also have indications for NSAIDs, especially if long-term treatment is planned. Patients at risk include those who have a history of gastrointestinal bleeding, the elderly, diabetics, and cigarette smokers.

    Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are recommended. Dose and frequency should be determined by the manufacturer. There are no significant differences in efficacy for gastrointestinal bleeding prevention.

    Indications for Discontinuation: Intolerance, adverse effects, or discontinuation of an NSAID.

     

  3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    The risks and benefits of NSAID therapy for pain should be discussed with patients who have known cardiovascular disease or multiple risk factors for cardiovascular disease.

     

  4. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     

    • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

      NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended Acetaminophen or aspirin as first-line therapy appears to be the least risky in terms of cardiovascular side effects.

       

    • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

      NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended If necessary, non-selective NSAIDs are preferred over COX-2 specific drugs.

      To reduce the possibility of the NSAID counteracting the beneficial effects of aspirin in patients receiving low-dose aspirin for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.

       

  5. Acetaminophen for Treatment of Wrist compartment Tendinitis Pain

    Acetaminophen for Treatment of Wrist compartment Tendinitis Pain is recommended for the treatment of wrist compartment tendinitis pain, especially in patients who are contraindicated to NSAIDs.

    Indications: All patients suffering from wrist compartment tendinitis pain, whether acute, subacute, chronic, or post-operative.

    Dose/Frequency: According to the manufacturer’s recommendations; may be used as needed. When taken in excess of four grammes per day, there is evidence of hepatic toxicity.

    Indications for Discontinuation: Pain relief, adverse effects, or intolerance

     

  6. Opioids of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

    Opioids of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome) is not recommended for acute, subacute, or chronic extensor compartment tenosynovitis

    Opioids of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome) is recommended for brief (no longer than seven days) usage as an adjuvant therapy to more potent therapies for postoperative pain control.

    Indications: It is frequently necessary, especially at night, to provide short-term opioids as adjuncts to more effective treatments (notably NSAIDs, acetaminophen).

    Frequency/Duration: Prescribed as needed throughout the day, then later only at night, before weaning off completely.

    Rationale for Recommendation: A careful use of opioids, especially for nighttime use, may be beneficial for patients for whom NSAIDs do not provide adequate pain relief. It is advised that postoperative patients only use opioids sparingly and selectively, primarily at night to induce sleep.

Treatment of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

Initial care usually involves limitation of the physical factors thought to be contributing. Thumb spica splints for de Quervain’s and wrist braces for the other compartment tendinitis are generally believed to be helpful.

Thumb spica splints have been widely used for treatment of wrist compartment tendinoses while nonspica wrist splints have been used for treatment of other compartment tendinoses. NSAIDs are often prescribed for initial treatment.

Mobilization / Immobilization of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

Thumb Spica and Wrist Splints for Acute and Subacute Thumb Extensor Compartment Tenosynovitis

Thumb Spica and Wrist Splints for Acute and Subacute Thumb Extensor Compartment Tenosynovitis are recommended for the treatment of various extensor compartment tendinoses as well as non-spica wrist splints for the treatment of acute and subacute thumb extensor compartment tendinoses.

Frequency/Duration – It is typically advised to wear them while awake. warning signs of

Discontinuation – Resolution or non-response.

Rehabilitation of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

Rehab (supervised formal therapy) needed after a work-related injury should be concentrated on regaining the functional ability needed to meet the patient’s daily and work obligations and enable them to return to work, with the goal of returning the injured worker to their pre-injury status to the extent that is practical.

Active therapy calls for the patient to put forth an internal effort to finish a particular exercise or task. The interventions known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their part.

Passive interventions are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Over passive interventions, active interventions should be prioritised.

To maintain improvement levels, the patient should be advised to continue both active and passive therapies at home as an extension of the therapeutic process.

To facilitate functional gains, assistive devices may be used as an adjunctive measure in the rehabilitation plan.

Therapy: Active of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

  1. Therapeutic Exercise – Acutely

    Therapeutic Exercise – Acutely is not recommended because an exercise regimen is typically not necessary for patients with extensor tendon entrapment.

     

  2. Therapeutic Exercise – Residual Defects

    Therapeutic Exercise – Residual Defects is recommended especially after surgery.

    Frequency/Dose/Duration – With documentation of ongoing objective functional improvement, the total number of visits may be as low as two to three for patients with mild functional deficits or as high as 12 to 15 for those with more severe deficits.

    If there is evidence of functional improvement toward specific objective functional goals, more than 12 to 15 visits may be necessary when there are persistent functional deficits (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities).

    A home exercise programme should be created as part of the rehabilitation strategy and carried out alongside the therapy.

Therapy: Passive of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

Iontophoresis for Acute and Subacute Extensor Compartment Tenosynovitis

Iontophoresis for Acute and Subacute Extensor Compartment Tenosynovitis are recommended glucocorticoids and occasionally NSAIDs are used for specific patients with wrist compartment tendinoses. who either refuse injection or do not respond well to NSAIDs, splints, and activity modifications.

Frequency/Duration – Usually two or three treatments are necessary to determine effectiveness; if effective, another four to six treatments may be planned. Additional four to six treatments are reasonable if improvements persist after six sessions.

Indications for Discontinuation – Failure to act, the emergence of negative effects, and resolution.

Other Passive Interventions of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

Other Passive Interventions

Other Passive Interventions is not recommended Other Non-operative Interventions for Acute, Subacute, or Chronic Extensor Compartment Include Manipulation and Mobilization, Massage, Deep Friction Massage, or Acupuncture Tenosynovitis

Extensor Compartment Tenosynovitis: Acupuncture’s Benefits as a Treatment

Injection Therapy of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

Injection Therapy Glucocorticosteroid Injections
Injection Therapy Glucocorticosteroid Injections is recommended to treat wrist compartment tendinosis that is acute, de Quervain’s, or another type.

Indications – symptoms of pain over a compartment on the wrist. Usually, it takes at least a week of non-invasive treatment to see if the condition will go away on its own. It makes sense to start treating cases with an injection.

Frequency/Duration – It is advised to schedule a single injection and assess the outcomes to document improvement.

The diagnosis should be reevaluated and a second injection should be taken into consideration if there is no response or a subpar response within two to three weeks. The need for a surgical evaluation may be indicated by the return of symptoms.

Surgery of Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

Surgery – Surgical Release

Surgery – Surgical Release is recommended for patients who do not respond to injection and have subacute or chronic extensor compartment tenosynovitis.

Indications – wrist compartment tenosynovitis that is unresponsive to nonoperative treatments, which typically include two injections of glucocorticoids.

What our office can do if you have Extensor Compartment Tenosynovitis (Including de Quervain’s Stenosing Tenosynovitis and Intersection Syndrome)

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.

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