De Quervains

Tenosynovitis
Louis PATRY, Occupational Medecine Physician, Ergonomist
Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist
Marie-Jeanne COSTA, Nurse, Ergonomist
Martine BAILLARGEON, Plastic Surgeon
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GUIDE TO THE DIAGNOSIS OF

WORK-RELATED MUSCULOSKELETAL
DISORDERS

Excerpt of the full publication

GUIDE TO THE DIAGNOSIS OF

WORK-RELATED MUSCULOSKELETAL
DISORDERS

Carpal
Tunnel
De Quervains
Syndrome
Tenosynovitis
Louis PATRY, Occupational Medecine Physician, Ergonomist
Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist
Marie-Jeanne COSTA, Nurse, Ergonomist
Martine BAILLARGEON, Plastic Surgeon

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Canadian Cataloguing in Publication Data

Main entry under title:
Guide to the diagnosis of work-related musculoskeletal injuries
Translation of: Guide pour le diagnostic des lsions musculo-squelettiques
attribuables au travail rptitif.
Includes bibliographical references.
Contents: 1. Carpal tunnel syndrome 2. De Quervains tenosynovitis 3. Shoulder
tendinitis.
Co-published by: Institut de recherche en sant et en scurit du travail du Qubec.
ISBN 2-921146-70-3 (v. 1) ISBN 2-921146-71-1 (v. 2) ISBN 2-921146-72-X (v. 3)
1. Musculoskeletal system Wounds and injuries Diagnosis. 2. Overuse injuries Diagnosis.
3. Carpal tunnel syndrome Diagnosis. 4. Tenosynovitis Diagnosis.
5. Tendinitis Diagnosis. 6. Occupational diseases Diagnosis. I. Patry, Louis. II. IRSST (Quebec).
III. Workplace Safety & Insurance Board.
RC925.7.G8413 1998
616.7075
C98-940950-3

Translation:

Les Services Organon, Steven Sacks

Graphic design:

Grard Beaudry

Illustrations:

Marjolaine Rondeau, Medical Illustration Department

of the Laval University Hospital Centre (CHUL)
Max Stiebel, Instructional Communications Centre (ICC),
McGill University

Rear-cover photographs:

Gil Jacques

Legal deposit Bibliothque nationale du Qubec, 1998

Legal deposit National Library of Canada, 1998
ISBN 2-921146-71-1 ditions MultiMondes (Original edition: ISBN 2-921146-38-X)
ditions MultiMondes, 1998
ditions MultiMondes
930, rue Pouliot
Sainte-Foy (Qubec)
Canada G1V 3N9
Tel.: (418) 651-3885
Fax: (418) 651-6822

Institut de recherche en sant

et en scurit du travail
505, boul. de Maisonneuve Ouest
Montral (Qubec)
Canada H3A 3C2
Tel: (514) 288-1551
Fax: (514) 288-7636

Rgie rgionale de la sant

et des services sociaux Montral-Centre
Direction de la sant publique
1301, rue Sherbrooke Est
Montral (Qubec)
Canada H2L 1M3
Tel.: (514) 528-2400
Fax: (514) 528-2459

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preface

The diagnosis of cumulative trauma disorders (CTDs) presents many unique problems, especially
for physicians. The absence of precise criteria upon which to establish a clinical diagnosis of
CTD or decide whether a musculoskeletal injury is related to occupational factors was noted by
several members of the advisory committee supporting an international expert group mandated
by the IRSST to review the literature on CTDs*. To remedy this situation, in 1992 the IRSST
asked a group of researchers to develop diagnostic guides for carpal tunnel syndrome, De
Quervains tenosynovitis, and tendinitis of the shoulder.
The project team was initially composed of Louis Patry, occupational medecine physician
and ergonomist, and Michel Rossignol, occupational medecine physician and epidemiologist, but
quickly grew and increased the scope of its expertise through the addition of Marie-Jeanne Costa,
a nurse with ergonomics training, and Martine Baillargeon, a plastic surgeon. All four team
members participated in the drafting of the guides.
These guides were designed to help physicians arrive at a clinical diagnosis and identify the
most probable etiological agents. It should be noted that these guides were not designed for
administrative or legal purposes and that their reliability has not been evaluated by the researchers.
The publication of these guides designed specifically for physicians is one more advance in
the IRSSTs efforts to shed light on the phenomenon of cumulative trauma disorders and provide
specialists with appropriate tools with which to prevent these injuries and reduce related risk
factors.

Jean Yves Savoie

Director general
Institut de recherche en sant et en scurit du travail du Qubec

* Hagberg, M., Silverstein, B., Wells, R., Smith, M.J., Hendrick, H.W., Carayon, P., Prusse, M. (1995), Work related musculoskeletal disorders (WMSDs): a reference book for prevention, scientific editors: Kuorinka, I., Forcier, L., publishers Taylor
and Francis, London, 421pages.

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introduction

This guide is the second in a series of practical summaries of current medical knowledge on
musculoskeletal injuries with well-documented occupational etiology, namely:
carpal tunnel syndrome (CTS)
De Quervains tenosynovitis
tendinitis of the shoulder
When occupational in origin, these injuries are often referred to as CTDs, a term applicable to problems and diseases of the musculoskeletal system that include, among their causes,
some factor related to work (Hagberg et al., 1995). Whatever term is used to designate them
occupational overuse syndrome (OOS), repetitive strain injuries (RSI) or cumulative trauma disorders (CTDs) in English, troubles musculo-squelettiques (TMS), lsions musculo-squelettiques
(LMS), lsions musculo-tendineuses (LMS), lsions musculo-tendineuses lies aux tches rptitives, or pathologies dhyper-sollicitation in Frenchtheir defining characteristic is the presence
of an injury caused by biomechanical strain due to tension, pressure, or friction which is exces
sively forceful, repetitive, or prolonged.
This guide is designed for physicians who are called upon in the course of their practice to
diagnose musculoskeletal injuries and establish the extent to which these injuries are caused by
their patients work. Its goal is to help physicians arrive at clinical and etiological diagnoses. To
this end, the guide first reviews the anatomical, physiopathological, and etiological knowledge
upon which diagnosis depends. This is followed by guidelines for the evaluation of symptoms,
the conduct of the clinical examination, and the control of potential risk factors related to the
development of the injury.
Musculoskeletal injuries may have many causes. For carpal tunnel syndrome (CTS), De
Quervains tenosynovitis, and tendinitis of the shoulder, these include not only occupational,
sports-related, recreational, and household activities, but also specific health problems and conditions. This guide was prepared in response to requests from physicians, increasingly preoccupied
by CTDs, for information and support on this subject. Although the approach taken emphasizes
the documentation of potential occupational risk factorsa subject little discussed in formal
medical trainingit does not neglect the evaluation of other potential causes of De Quervains
tenosynovitis.
This guide is meant to be used in a clinical setting. To help physicians collect the information
they need to diagnosis the injury and establish its causes, it therefore includes a series of questions,
presented in readily identifiable text boxes, for them to ask their patients. These questions were
derived from psycho-physical scales used by ergonomists to subjectively evaluate workload
(Sinclair, 1992) and medical questionnaires developed for the diagnosis of CTS and the evaluation
of functional capacity (Katz et al., 1994; Levine et al., 1993; Rossignol et al., 1995).

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vii

Should however a physician remain unable to come to a definitive conclusion about the workrelatedness of an injury after consulting this guide, she or he should continue to seek information
which will enable her or him to better evaluate the occupational musculoskeletal load to which
her or his patient is subjected.
Finally, it should be noted that this guide does not address the issues of multiple injuries and
the psychosocial aspects of musculoskeletal injuries, important as they may be for the global
evaluation of the patient.

viii

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TABLE of contents

Chapter 1 General Considerations

Introduction and Terminology........................................................................................................... 1

Epidemiology......................................................................................................................................... 1

Anatomical Review............................................................................................................................... 1

Pathophysiology.................................................................................................................................... 1

Chapter 2 Etiology

General Considerations........................................................................................................................ 3

Work-relatedness of Musculoskeletal Strain..................................................................................... 3

Chapter 3 Differential Diagnosis

Thumb carpometacarpal osteoarthrosis............................................................................................ 5

Intersection Syndrome......................................................................................................................... 6

Wartenbergs Syndrome........................................................................................................................ 6

Brachioradialis Insertion Tendinitis (Insertion of the Brachioradialis)........................................ 7

Tendinitis of the Extensor Digitorum Communis.......................................................................... 7

Chapter 4 Clinical Considerations

Symptoms............................................................................................................................................... 9

Location of Symptoms (Where?)............................................................................................... 9

Onset of Symptoms (When?)..................................................................................................... 9

Characteristics of Onset (How?)................................................................................................ 9

Impact on Activities of Daily Living............................................................................................... 10

Chapter 5 Recording of Information on Exposure Factors

Occupational History......................................................................................................................... 11

Previous Work............................................................................................................................. 11

Current Work............................................................................................................................... 12

Current Work and Organisational Factors.............................................................................. 14

Sports-related, Recreational, And Household Activities.............................................................. 15

Chapter 6 Clinical Examination

Physical Examination......................................................................................................................... 17

Observation.................................................................................................................................. 17

Palpation....................................................................................................................................... 17

Assessment of Range of Movement....................................................................................... 17

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ix

Dynamic Movements against Resistance................................................................................. 17

Diagnostic Tests.......................................................................................................................... 18

Chapter 7 Summary of the Evaluation.......................................................................................... 19

Chapter 8 Guidelines for Therapeutic and Preventive Interventions

Therapeutic Guidelines...................................................................................................................... 21

Prevention Guidelines........................................................................................................................ 22

Conclusion.................................................................................................................................................. 23
Bibliography.............................................................................................................................................. 25
List of Figures
Figure 1.1 Insertion and Action of the Tendons of the Extensor Pollicis Brevis

and Abductor Pollicis Longus............................................................................................. 2
Figure 3.1 Test for Carpometacarpal Osteoarthrosis of the Thumb.............................................. 5
Figure 3.2 Test for the Intersection Syndrome................................................................................... 6
Figure 3.3 Test for Wartenbergs Syndrome......................................................................................... 6
Figure 3.4 Test of the Brachioradialis................................................................................................... 7
Figure 3.5 Test of the Extensor Digitorum Communis.................................................................... 7
Figure 6.1 Groove of the Radial Styloid Process, First Dorsal Compartment

of the Wrist.......................................................................................................................... 17
Figure 6.2 Test of the Abductor Pollicis Longus.............................................................................. 18
Figure 6.3 Test of the Extensor Pollicis Brevis................................................................................. 18
Figure 6.4 Finkelsteins Test.................................................................................................................. 18
Figure 8.1 Therapeutic Intervention Flow-chart............................................................................... 21
List of Table
Table 8.1

Preventive Approach.......................................................................................................... 22

List of Boxes

Box 2.1

Most Common Stressful Movements of the Abductor Pollicis Longus

and Extensor Pollicis Brevis................................................................................................ 4

Box 4.1

Symptoms Reported by the Patient.................................................................................... 9

Box 4.2

Presentation and Clinical Severity of Symptoms........................................................... 10

Box 4.3

Questions about Activities of Daily Living.................................................................... 10

Box 5.1

Questions about Previous Work....................................................................................... 11

Box 5.2

General Questions on Occupational Activity and Associated Symptoms.................. 12

Box 5.3

Questions about Activities that Cause Pain in the Hands or Wrist............................ 13

Box 5.4

Questions about Organisational Factors at Work.......................................................... 14

Box 5.5

Questions about Sports, Recreational, and Household

Activities Involving the Hands or Wrist.......................................................................... 15

Box 7.1

Clinical Aspects.................................................................................................................... 19

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General Considerations

Introduction And Terminology

Anatomical Review

De Quervains tenosynovitis or tendinitis was first

described in 1895 by Fritz De Quervain, a Swiss surgeon.
Prior to this, the first use of the terms tenosynovitis
and crepitating peritendinitis to describe injuries to the
tendons and surrounding tissues was by Velpeau in 1825.
This condition is a wrist tendinitis with inflammation of
the tendon sheaths of the abductor pollicis longus and
extensor pollicis brevis.

The tendons of the forearm are relatively long, extending

beyond the wrist to cover the dorsal aspect of the hand
and thumb. The tendons of the abductor pollicis longus
and extensor pollicis brevis both run through the groove
of the radial styloid process in the first of the six dorsal
compartments of the wrist and have their insertion at
the base of the first metacarpal and the proximal phalanx
of the thumb (Figure 1.1).

Epidemiology
De Quervains tenosynovitis is the most common
tenosynovitis affecting the dorsal tendons of the wrist.
It is usually diagnosed in individuals between 30 and 50
years of age and is ten times more prevalent among
women than men (Dupuis, 1986). American and
Scandinavian studies examining the relation between
work activities and De Quervains tenosynovitis have
rarely distinguished between this condition and other
type of tendinitis of the wrist and hands. Epidemiological
studies have demonstrated that workers in the meat
processing and manufacturing industries run a higher risk
of developing tendinitis of the hand and wrist: perform
ing highly repetitive work increases the relative risk of
developing De Quervains tenosynovitis to 3.3, while
performing work requiring the exertion of great force
increases it to 6.1. Among individuals performing work
that is both highly repetitive and forceful, the relative risk
is 29 (Hagberg et al., 1995).

These muscles, individually and jointly, extend and

abduct the trapezometacarpal joint and extend the
metacarpophalangeal joint. They are also active during
radial deviation and, to a lesser extent, flexion of the
wrist (Kendall et al., 1988). Both are innervated by the
posterior interosseous branch of the radial nerve, which
originates mostly in the C6, C7, and C8 roots.
pathoPhysiology
De Quervains tenosynovitis is a stenosing tenosynovitis
involving inflammation of the tendon sheath of the
extensor pollicis brevis and abductor pollicis longus
(Dupuis, 1986; Hagberg et al., 1995). The rigidity of the
structures and limited space within the wrist compartment
favour the development of tenosynovitis.

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Guide to the Diagnosis of Work-Related

Muskuloskeletal Disorders

Figure 1.1

Insertion and Action of the Tendons of the Extensor Pollicis Brevis

and Abductor Pollicis Longus

Abductor pollicis longus

Extensor pollicis brevis

Tenosynovitis may result from trauma or from

excessive friction between the tendon and surrounding
tissues during movements of the thumb and wrist. The
thickness of the synovial membranes is an indication of
the stage of the tendinitis. As the inflammation progresses,
the tendon tends to thin out and become more friable,

and stenosis increases. In the final stages, the sheath of

the first dorsal compartment thickens, becomes fibrous,
and impinges on the space of the fibro-osseous groove.
This may result in trigger finger, a chronic form of De
Quervains tenosynovitis.

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Work-related musculoskeletal injuries are one of the most common occupational

health problems for which physicians are consulted. There is solid scientific evidence that
these injuries may be occupational in origin.
This guide was designed to help physicians interpret the results of a medical
examination. By combining the standard clinical assessment procedure with guidelines
concerning the identification of etiological factors, it helps physicians identify the cause
of injury.

AUTHORS
Louis Patry holds a degree in medicine from Laval University and
a diploma in ergonomics from the Conservatoire National des Arts
et Metiers de Paris (CNAM). He is a specialist in occupational medicine, an associate member of the Royal College of Physicians and
Surgeons of Canada, a professor in McGill Universitys Department
of Epidemiology and Biostatistics and Occupational Health, and consulting physician to the Direction de la sant publique (Public Health
Department), first in Qubec City and currently at the MontralCentre board.

from the University of Sherbrooke, in epidemiology and community

health from McGill University, and in occupational medicine from
John Hopkins University. He is a professor in McGill Universitys
Department of Epidemiology and Biostatistics and Occupational
Health, co-director of the Centre for Clinical Epidemiology of the
Jewish General Hospital of Montral, and physician-epidemiologist
at the Montral-Centre board of the Direction de la sant publique
(Public Health Department).

Marie-Jeanne Costa holds a nursing degree from the Institut

dtudes paramdicales de Lige and a degree in ergonomics from
the cole Pratique des Hautes tudes de Paris. She is an ergonomics
consultant and has collaborated on several studies of CTDs. She is
particularly interested in the development of participatory ergonomics, specifically in the problem-resolution and diagnostic processes.

Martine Baillargeon holds a degree in medicine from the

Universit de Montral. She is a plastic surgeon and associate member of the Royal College of Physicians and Surgeons of Canada.
After years of practising surgery she is now consulting physician,
mainly in the field of musculoskeletal injuries affecting the upper
limb, at the Montral-Centre board of the Direction de la sant
publique (Public Health Board).

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Michel Rossignol holds degrees in biochemistry and medicine