288 OCCUPATIONAL THERAPY - SEPTEMBER.

1986

Tenosynovitis of Hand and Wrist:

A Literature Review
by
Ashok Chandani, BSe, BA, BScOT, PGCR
Postgraduate Student. Department of Occupational Therapy, University of Queensland,
St Lucia, Queensland, Australia

This literature review of tenosynovitis of hand and wrist concentrates on the definition of
tenosynovitis, aetiology and causative factors, site of occurrence, general methods of treatment
and specific occupational therapy procedures. Despite extensive research into tenosynovitis, very
little is yet known about causative factors. There also continues to be much controversy
surrounding how to use splinting and the usefulness of rest in the treatment of tenosynovitis. On
the basis of descriptive studies it can be said that tenosynovitis mostly affects the wrist and hand
and more commonly the extensor tendon of the right/dominant hand. It is suggested that
tenosynovitis occurs more commonly in females and the peak incidence is in the 35-40 years age
group. Common opinions regarding causative factors are work related, infections and manifesta-
tions of diseases, Treatment of tenosynovitis mostly lies in rest and splinting and some suggest
that electrotherapy and diathermy may help, If conservative treatment fails, many advocate
surgery.
INTRODucnON Various types of tenosynovitis are reported and named accord-
The term tenosynovitis was first used by Velpeau in 1818and ing to their causative factors or signs and symptoms. Nodular
was later described by him in Anatomie Chirurgicale, published tenosynovitis is a relatively rare, proliferative synovial condition
in 1825(cited in Hunter'). The definition and description were of joint, bursae and tendon sheath." Gray" described the term
based on the assumption of involvement of the synovial sheath. suppurative tenosynovitis which causes tenderness over the
However, although tenosynovitis was described so long ago, entirety of the tendon sheath. Coccidioidal tenosynovitis of the
confusion still remains regarding its definition and related flexor surface of the hand has also been reported." Weckesser'[
terminology. reported tenosynovitis caused by blood-borne infections.
Gouty tenosynovitis is an entity which rarely causes symptoms,
According to Dorland's Illustrated Medical Dictionary (25th although it has been recognized as a cause of carpal tunnel
edition) the terms tenosynovitis, tendovaginitis, tenovaginitis syndrome." In 1885, the surgeon Fritz de Ouervain described
and peritendinitis are synonymous. At present, professionals de Ouervain's disease as a tenosynovitis involving the abductor
prefer using the term tenosynovitis as a name for the inflamma- pollicis brevis tendon in an osseofibrous tunnel. It is also
tion of the muscle tendon unit and tendon sheath (Fig. 1). The known as 'washerman's sprain.l? Nasca" described stenosing
term tenosynovitis was specified and defined by Miller and tenosynovitis of the flexor finger as 'trigger finger'.
Keane? and endorsed by Forns'' as an inflammation of a tendon
and its sheath, the lubricated layer of tissue in which the tendon
is housed and through which it moves. Tenosynovitis was also AETIOLOGY AND CAUSATIVE FACTORS
defined as a general term applied to conditions in which the There are various opinions regarding the common aetiological
tendon or its sheath is SWOllen with subsequent restricted and causative factors of tenosynovitis. These are work related,
movement and pain." infections, manifestation of disease, genetic factors, anomaly
and various other causes. These factors will be examined in
Region of tenosynovitis
decreasing order of frequency as causal in tenosynovitis as
Tendon sheath suggested by the literature.
Work-related tenosynovitis
A local blunt trauma in conjunction with repetitive work is a
Synovial membrane~' ,,~--s::;.
major causative factor of tenosynovitis.P''" A study reported
Synovial membrane.~ that movement carried out with poorly designed equipment in
outer sheath ~ a work environment which was not designed ergonomically
I resulted in the development of teno~novitis. 15 This study
I Fibrotic tendon sheath supported an earlier study by McPhee l who found that, with
Cross-section of tendon I
increasing movement and postural deviation from the neutral
Tendon sheath position of function, there existed an increasing occurrence of
tenosynovitis. In an ergonomic analysis of tool design, Tichauer

~
llllllt::FibrotiC
Synovialtendon sheath
membrane,
and Gage'? suggested that a tool whose design calIs for ulnar
deviation coupled with supination of the wrist may increase the
inner sheath
occurrence of tenosynovitis. A study by Hunting et al 18 found
Synovial membrane, that common motions which predispose to tenosynovitis are
outer sheath clothes wringing, insertion of screws, looping of wires, using
,/- Mesotenon L. Vincula pliers and manipulation of rotating switches with long rods.
Two studies noted that a long, continued and excessive static
Fig. 1. The muscle tendon unit. (Adapted from: Kurppa K, workload leads to increased inflamation of tendon sheaths. 19.20
Waris P, Rokkanen P. Peritendinitis and tenosynovitis. Tenosynovitis occurs in a wide range of occupations,
'Scandinavian J ournal of Work, Environment and Health' 1979; particularly in the process industry which demands very fast
5(suppI3): 19-24). and repetitive finger, wrist and forearm movements."

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 OCCUPATIONAL THERAPY -
Infectionas a causeoftenosynovitis
Infections introduced through lacerated wounds caused by
direct penetration andlor by blood-borne infections such as in
gonorrhoeal tenosynovitis have also been reported. 8.21.22
Various case studies have been reported which show bacterial
and protozoal infections to be a cause of tenosynovitis. 7.23.24
Manifestationofdisease
Rheumatoid arthritis commonly causes flexor tenosyno-
vitis. 25 •26 Maudsley" and Primm and Allen" reported gouty
tenosynovitis as a well recognized entity. Two cases of
tuberculous tenosynovitis were also reported by Piganiol et
at. 28 An increased frequency of flexor tenosynovitis has also
been found in patients with diabetes mellitus. 29
Geneticfactors
Some case studies suggest the role of genetic factors in
tenosynovitisJO· 31 but there is little documented evidence for
this. Van Genechterrf concluded that the cause of trigger
thumb remains controversial despite finding six members of the
same family suffering from trigger thumb.
Tendonanomaly
Four cases were reported in which an anomaly (the tendon
slips from the flexor pollicis longus to the flexor digitorum
profundus) was probably the cause of chronic tenosynovitis."
In another case, reported by Murakami and Edashige,34 it was
also concluded that an anomaly was probably responsible for
chronic tenosynovitis.
Other causes
Merrell et al35 reported that tenosynovitis can be the result
of migration of foreign objects within the body. Georgitis'"
found that extensor tenosynovitis can occur as a result of
exposure to cold. Similarly, some cases are reported of patients
with tenosynovitis secondary to inadvertent injections of
heroin into the synovial sheath." The small, repetitive static
movements required to play video games have been established
as a causative factor for tenosynovitis.P Weeks 39 presented
four cases in which the cause of tenosynovitis could not be
found. Upton et al40 reported that the most common forms of
idiopathic tenosynovitis are trigger finger and de Quervain's
disease.
SITE OF OCCURRENCE
Kurppa et al4 1 found that tenosynovitis is located more
commonly in the wrist where tendons cross tight ligaments and
each other (Fig.2). Other sites are the radial wrist extensors,
extensor ~ollicis lonfus and brevis and abductor pollicis
longus. 14 ,4 -43 Hunter reported that the ulnar extensors are
occasionally involved.
Some studies report that assembly-line packers suffer teno-
synovitis of the extensors significantly (p <.(01) more often
than the flexors." Several studies report involvement of the
flexor tendons in individuals with rheumatoid arthritis 26 ,45
While other studies report that the flexor tendons are involved
even in the absence of rheumatoid arthritis. 1,15,45 Adams23
found that in chronic infective tenosynovitis the flexor tendon
sheath of the lower forearm and hand was the most common
site of occurrence. The site of tenosynovitis seems to vary
depending on aetiological factors, although there are no
systematic studies on this.
TENOSYNOVITIS IN RELATION TO HAND
DOMINANCE
Few studies have recorded the symptoms of tenosynovitis in
relation to hand dominance. In studies that do record domi-
nance, the right or dominant hand is more commonly affected
than the left hand. 1 .41,46 Other studies which record the side
affected but not dominance also report that the right hand
and/or wrist is most commonly affected. 15 ,44 ,46 Bilateral
involvement is seldom found. 15 ,41,44,47 A study by Luopajarvi
et al44 reported that shop assistants had significantly (p <.(01)
more symptoms in their left hand.
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SEPTEMBER, 1986 289
Extensor pollicis
longus
Tendon ..k----='F"i'.\ Extensor pollicis
sheaths brevis
Extensor carpi
radialis longus
Extensor Extensor retinaculum
carpi Extensor carpi
ulnaris radialis brevis
Extensor pollicisbrevis
Extensor carpi
radialis longus
L.lJ-4Itt---- Extensor carpi
radialis brevis
Abductor pollicis
longus
Fig. 2. Arrangement of extensor tendons on the back of the left
hand. (Adapted from: Stevenson MG, Baidya KN. Repetitive
work design to reduce the danger of tenosynovitis. 'Australian
Safety News' 1983; Mar/Apr: 35·42,)
AGE AND SEX DISTRIBUTION
Although studies report sex distribution of their samples,
these studies have not been designed to establish a relationship
between sex, age and occurrence of tenosynovitis.
It has been claimed, however, that in general there is a
predominance of females suffering from tenosynovitis.f
Investigators report varying ratios of female to male sufferers:
2:1, 49 2:3,5 and 2:5. 46 Ninety-three per cent of cases in a study
by An so were females.
Singh et al51 found that, in India, females are more
commonly affected because of their engagement in household
activities and because of the greater angulation of the tendon at
the radial side of the styloid process in women compared with
men. 52 A single case study by Howardf reported that
crepitating peritendinitis is found more commonly in males
than females. Another study of triggering of the flexor tendon
showed males and females to be equally affected,"?
This general predominance of females has been questioned
in a critical statement by Ferguson.P who stated that although
the great majority of women with injuries were genuine about
their symptoms some may have psychosocial reasons to
prolong absence from work. Many males suffering from
tenosynovitis performed other duties which relieved the mono-
tony of constant repetitive work which could have contributed
to the difference in ratio between males and females. 46
Age distribution of cases is also poorly addressed in past
studies. Nasca'? found a majority of sufferers from triggerinji
of the flexor tendons to be above 50 years of age. Singh et al
reported that a majority of people having de Quervain's
disease belonged to the above 40 years age group. Nodular
tenosynovitis was found by Baes and Tanghe" to affect mainly
the young and middle aged. Only Lanfear and Clarke 43 found
an excessive incidence of tenosynovitis in the 25-34 years age
group.
290 OCCUPATIONAL THERAPY -
SIGNS AND SYMPTOMS
Different types of tenosynovitis show varying signs and
symptoms but, in general, diagnosis is made on the basis of the
presence of two or more symptoms of the following four: pain,
localized swelling, crepitus and loss of hand function. 41
Symptoms are discussed in order of decreasing frequency of
occurrence.
Pain
Pain on movement and tenderness along the involved tendon
are the most common and earliest symptoms to develop.22,54 In
fact, pain is the only common symptom which brings patients
for treatment." Onset of this pain is usually gradual. 39,51,55
Initially it is experienced only towards the end of the working
day and the most marked pain occurs proximally and dis-
appears after work is stopped. 56
Some studies report that pain is produced by movements of
the affected tendons and becomes progressively worse until it is
almost continuous. 15,27,43 Pain can be exacerbated by activities,23
particularly against resistance. 57 The persistent nature of the
pain and its increasing severity following movement results in
considerable functional disability.13,54,S8 Lanfear and Clarke 43
described this as weakness in gripping power and inability to
lift and pull, in which even the use of scissors or a pen becomes
a painful task. Miller and Keane/ reported that pain in the
hand has a marked effect in reducing grip and functional
ability, although this depends upon the subject's threshold for
pain. Tenosynovitis is, therefore, a temporarily disabling
condition.
Swelling
Usually, swelling is localized and fusiform in shape if the
tendon sheath is involved, but if the paratendon ~ig,1) is the
site of inflammation, swelling is more diffused. 14,4 A study by
Kanavel,59 however, found a symmetrical enlargement of the
whole finger. The presence of swelling is variable. Some studies
reported that all cases oftenosynovitis showed swelling," while
in another study only one third of cases had swelling.15
Crepitus
A common symptom of tenosynovitis is crepitus 43 but it may
not be present simultaneously with pain and swelling. In a
study by Georgitis,36 crepitus was not noted by any subject and
in another study crepitus was present in only 12% of cases. 15
Crepitation is not r~larly present because it occurs only on
tendon movement.27, ,57,~ Fine crepitus results from teno-
synovitis caused by overuse and coarse crepitus is due to
rheumatoid disease or tuberculous tenosynovitis.P Feather-
stone" believed that crepitation may be due to friction
between the roughened inside wall of the sheath and the
moving tendon.
TREATMENT
The treatment of tenosynovitis has been influenced by
ergonomical, technical and pharmacological advances but
certain fundamental principles have been retained, namely
rest, immobilization of the inflamed tendon and anti-inflam-
matory and analgesic medication. 1,8,27,40,45 Hunter! reported
that partial immobilization gives better results than rigid
immobilization in plaster of Paris. While most traditional
orthopaedic texts prescribe such treatment,~,62,63 Adams 23
considers immobilization and splintage to be so cumbersome,
slow to take effect and uncertain in its results that it should be
forgotten. He advocates injections of corticosteroids and
surgery instead,
Most authors suggest that only if conservative treatment fails
and pain is continuous should surgical procedures be used. 8,25,40
Singh et al51 reported an 85% success rate in treating cases of
de Quervain's disease with operative methods and McConnell
and Neale 64 reported a 41% success rate when only conservative
treatment was used. Synovectomy and anastomosis were
successfully used to treat five patients with tenosynovitis
secondary to injection of heroin into the synovial sheath."
Apoil 65 reported consistently good results when he analysed
early surgical treatment of 45 subjects.
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SEPTEMBER, 1986
Other surgical methods, used if conservative treatment fails,
include decompression,54,63 reduction flexor tenoplasty to treat
stenosing flexor tenosynovitis'" and dorsal tenosynovectomy. 67
Postoperative measures following a reduction flexor tenoplasty
include active exercise and the patient is advised to avoid heavy
labour and activities requiring power grip for 3-4 weeks.
Following a dorsal tenosynovectomy, bulky dressings and a
volar splint applied with the digits held initially in extension are
employed. Ranf.e-of-motion exercises are begun 2-4 days
postoperatively. 4 Singh et al51 suggest that movement of the
thumb begins just after the operation. It can be difficult to get
patients to participate in exercises due to pain, but this is
essential in order to avoid extension lag. 54
In cases of infective and pyogenic tenosynovitis, studies
support early operative treatment and continuous draining,
antibiotics and antibacterial drugs. 22,24,68 Steroid in!ections
also playa valuable role in treatment of tenosynovitis. ,39,51,~
Some clinical reports sUMest, as additional treatments, local
massage and ultrasound, ,69 electrotherapy, diathermy and
baking,I,8,43 and passive stretching. 32 These reports are based
solely on clinical observation and no attempt has been made to
evaluate their usefulness empirically. Indeed, the role of
physiotherapy continues to be uncertain/"
As prevention is better than cure, some authors have done
studies on preventive measures for tenosynovitis. Effective
prevention could be achieved by industrial designers, engineers
and ergonomists through careful consideration of man-machine-
tool relations and the work and rest cycle." This should help to
reduce the possibility of tenosynovitis developing and will also
increase productivity on the job.
OCCUPATIONAL THERAPY PROCEDURES
While most occupational therapy authors recommend various
types of resting and functional splints, there are very few
evaluative reports on the effectiveness of such treatment. The
earliest clinical study of 34 cases treated by complete immobili-
zation with plaster splinting was strikin~ly effective in reducing
total disability and hastening recovery. 2 This study, however,
was criticised because such immobilization keeps the patient
away from work and there is no guarantee that the pain will not
recur once the plaster is removed. 70
A number of clinical studies have been carried out to
examine the use and effectiveness of a variety of types of splints
and treatment regimens. These have been outlined in a
comparative way in Table 1. Published work by occupational
therapists has dealt primarily with questions of rest and
splinting. A notable exception is a descriptive paper by
Cornally75 of a comprehensive treatment programme for
repetitive strain injuries including counselling and support,
work evaluation and resettlement, activity limitations, leisure
and an active treatment programme in addition to rest and
splinting.
DISCUSSION AND SUMMARY
Most writers on tenosynovitis agree that it is an inflammation
of the sheath which surrounds and provides lubrication for the
tendon, and that a diagnosis can be made from the presenting
symptoms which are pain, especially on movement, localized
swelling, crepitus and partial functional loss of the affected
part. The reports concerning aetiology generally agree that
some common factors, such as the force, speed and direction of
movement, awkward posture, poorly designed jobs and equip-
ment, overexertion and blunt trauma, contribute to the
development of tenosynovitis. Some other aetiological factors
which may be involved, but are not adequately demonstrated
to contribute to tenosynovitis, are genetic factors, intrinsic
predisposition and the particular occupations that most com-
monly initiate or exacerbate tenosynovitis.
There are no studies on aetiology with an adequate control
group. Thus, the general opinion regarding the relationship of
the workload to tenosynovitis of wrist and hand requires
further scientific study.
 OCCUPATIONAL THERAPY - SEPTEMBER, 1986 291

Table 1. Comparative studies of various spOnt5 used In the b'atment of tellOll)'llOvitis of band and wrist

Type or splint DescrIption Leqtb or Combined with or Ou~COIIIIIIeDts

use other b'atment

plaster splint Total immobilization with Not Complete Effective in reducing total disability;4
plaster splint mentioned immobilization study criticised by Ellis 70 because
there is no guarantee that pain will
not recur once splint is removed
Perspex splint Detachable 12 days At times with Relapse of 6% 14
short wave therapy
Plaster splint Padded plaster splint incorporating 10-14 days Rest Effective71
the thumb and extending up
the forearm
Annular splint Made up of orthoplast; PIP joints 21-28 days One or two injections of Splint was used regularly; 80% of
were partially immobilized by a loose steroids into the tendon patients were able to discard the
fitting splint sheath splint without return of symptoms72
Removable splint Made of plaster, fibreglass or metal 7 days or Anti-inflammatory Symptoms usually diminished after 7
3-6 weeks medication days of use of splint; if symptoms
recurred, medication and splinting
were used for a longer period4.5
Hexcelite splint 1-3 weeks, Not discussed'?
average -
15 days
Palmar splint Supportive splint 14 days Very effective in reducing pain, but
found no significant improvement in
hand function74
Dorsal splint This splint permits a much larger 21 days Combine with palmar First the palmar splint was worn
range of movement of wrist and a (resting) splint continuously for 15 days after which
stronger grip it was replaced by a dorsal splint;
mean recovery period was 24 days3

It has been claimed that there is a predominance of female
sufferers and the opinion of most studies is that the peak
incidence occurs in the 35-40 years age group. These opinions
and claims are the result of a number of uncontrolled studies,
most of which are based on clinical observations. There is,
however, little evidence contrary to these opinions and claims.
Currently, the generally agreed approach to treatment
consists of early identification and treatment of the condition
through partial immobilization of the affected part accomplish-
ed by splinting and anti-inflammatory drugs, except in cases of
infective or pyogenic tenosynovitis. Further research needs to
be carried out into aetiological factors and treatment including
the use of splints, counselling and the work-rest cycle. Research
should be prospective, controlled and longitudinal.
Acknowledgements
I wish to thank Dr Frikkie Maas (Senior Lecturer) and Mrs Patricia
Agnew (Lecturer) of the Department of Occupational Therapy,
University of Queensland, St Lucia, Australia, for their valuable
suggestions and assistance in the preparation of this paper. I also wish
to express appreciation for help given by Ms Cathy Hill.
Fig.l is republished by kind permission of the Scandinavian Journal
of Work, Environment and Health, and Fig.2 is republished by kind
permission of Australian Safety News.
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Ballot for a Study Tour in the United States
For the 17th time, the International Committee of the
American Occupational Therapy Association will be sponsor-
ing a study tour project in 1987 for occupational therapists from
WFOT member and associate member countries. Similarly to
previous tours, the 1987 tour offers up to 2 months of transport-
ation with limited stops to visit occupational therapy centres in
the USA and attend the American Annual Conference.
The deadline for nominations to be in America is at the end of
October. Anybody interested in applying should contact Mrs T
Alexander at the College of Occupational Therapists, 20 Rede
Place, London W2 4TU, for the appropriate application form.
The AOTA Conference will be held in Indianapolis,
Indiana, from 5-8 April 1987. In order to allow the visitor the
opportunity to become thoroughly acquainted with the people
and programmes in each of the selected stopovers and to allow
for a more leisurely pace, the tour will be limited to stops
within a l,OOO-mile radius of Indianapolis.
Travel to and from the United States will continue to be the
responsibility of the visitor, but local hospitality may help to
reduce the cost of meals and lodging. A number of hospitals
and individual therapists in America have expressed interest
in providing meals and a place to stay while the therapist is at
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SEPTEMBER, 1986
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53. Ferguson D. Repetition injuries in process work. Med J Aust 1971;
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54. Williams IG. Surgical management of traumatic non-infective
tenosynovitis of the wrist extensors. J Bone Joint Surg 1977;59-B:
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55. Barrick EF. Acute gonococcal flexor tenosynovitis in a woman
with asymptomatic gonorrhoea [letter]. J Hand Surg 1983; 8(2):
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56. Stevenson MG. Tenosynovitis: The nemesis of the factory worker.
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57. Dickson DD, Luckey CA. Tenosynovitis of the extensor carpi
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58. Waris P, Kuorinka I, Kurppa K. Epidemiologic screening of
occupational neck and upper limb disorders. Scand J Work
Environ Health 1979; S(suppl.3): 25-28.
59. Kanavel AB. Infections of the hand. Philadelphia: Lea and
Febiger, 1943: 337-51.
60. Ivesen P, Dawson DK. Manual of acute orthopaedic therapeutics.
2nd ed. Boston: Little, Brown and Co, 1982.
61. Featherstone DF. Industrial injuries, their prevention and treatment.
Bristol: Iohn Wright, 1964.
62. Wynn Parry CB. Rehabilitation of the hand. 3rd ed. London:
Butterworth, 1973.
63. Calliet R. Hand pain and impairment. 3rd ed. Philadelphia: FA
Davis, 1975.
64. McConnell CM, Neale HW. Two year review of hand infections at
a municipal hospital. Am Surg 1979; 45(10): 643-46.
65. Apoil KA. Traitement des philegmons des gaines digitales des
tendon flechisseurs a la phase aigue. Ann Chir 1981;35(6): 415-18.
66. Seradge H, Kleinert HE. Reduction flexor tenoplasty. J Hand
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67. Millender L, Nalebuff E. Preventive surgery - tenosynovectomy
and synovectomy. Orthop Clin North Am 1975; 6(3): 765-92.
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report and literature review. J Hand Surg 1981; 6(5): 470-72.
69. Quinnell RC. Conservative management of trigger finger. Practi-
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71. Field IH. Dc Quervain's disease. Am Fam Physician 1979; 20(1):
103-4.
72. Weiser HI. A splint for stenosing tenovaginitis of the finger.
Harefuan 1981; 100(1): 29.
73. Parks BI, Barrett PK, Voss K. The use of hexcelite in splinting the
thumb. Am J Occup Ther 1983; 37(4): 266-67.
74. Webb L. Splinting and muscle tendon syndrome. Thesis. St Lucia:
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their clinics. Although the cost of living varies in different parts
of the country, the visitor should be prepared for an average
daily rate of $15.00 to $20.00 for restaurant meals.
The period of travel sponsored is a maximum of 2 months
during April and Mayor March and April.
All preliminary selections of persons to be nominated will be
made by the College of Occupational Therapists on the basis of
such aspects as:
1. At least 2 years' experience as an occupational therapist
2. Demonstrated professional interest and participation
3. Specific purpose in wishing to visit the USA.
Arrangements for the therapist to see the programme of his
or her choice in America will be made as follows:
1. The therapist's personal preference can be indicated in the
first application letter
2. A resource person in the USA, experienced in the visitor's
area of interest, will be appointed to plan the tour.
The final selection in America will be made by drawing one
of the names, and a second name as an alternate.
The College of Occupational Therapists will be responsible
for submitting the name of a successful UK applicant to
America.