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ice, iontophoresis, and transverse friction massage directed to the first dorsal tunnel. Conventional reach their insertions on the first
joint mobilization techniques addressed the motion limitations of the first carpometacarpal, metacarpal and proximal pha-
radiocarpal, and midcarpal joints. In addition, MWM techniques were utilized to promote lanx.3 The greater incidence of de
pain-free wrist and thumb mobility. The specific MWM techniques used with this patient involved Quervains tenosynovitis in women
active movements of the thumb and wrist superimposed on a passive radial glide of the proximal is thought to be related to the fact
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
continued research. J Orthop Sports Phys Ther 2002;32:8697. a gripping motion of the thumb.16
Key Words: joint alignment, manual therapy, tendinitis People who use their thumbs in
repetitive pinching, wringing, lift-
ing, grasping, or extension activi-
ties of the wrist and hand are sus-
ceptible to inflammation and
D
e Quervains tenosynovitis is a form of stenosing
progressive stenosis in the first
tenosynovitis affecting hand function in a wide range of
dorsal tunnel of the
patients, including mothers of young children, computer
wrist.3,7,10,12,14,16,23,25
keyboard operators, machinists, golfers, and mountain bik- Surgical evidence implicates in-
ers.10,12,26 De Quervains tenosynovitis involves inflamma- flammation of the retinaculum,
tion of the abductor pollicis longus (APL), the extensor pollicis brevis
the synovial sheath, and the ten-
(EPB), and each of their synovial sheaths (Figure 1). At the level of the dons in de Quervains
radial styloid process, the APL and EPB tendons enter the first dorsal
tenosynovitis.3,7,14,16
CASE
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STUDY
ics.
force went through the web space of her right, domi-
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Academy of Orthopaedic Surgeons guidelines.8 provided a manual force to achieve a radial glide of
These goniometric measurements are listed in Table the proximal row of carpals, then asked the patient
1. to move her thumb into radial abduction-adduction.
Isometric Resistive Testing Pain was elicited with The patient reported a significant decrease in pain
contraction of the right EPB and APL. Weakness was with active thumb movement while the wrist joint was
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
noted, but could not be assessed accurately due to held in this position.
pain.
Manual Muscle Testing Manual muscle testing was
deferred initially due to pain. Physical Therapy Evaluation and Intervention
Accessory Motion and Positional Testing Accessory Planning
motion was assessed according to the techniques of
Edmond.6 Accessory motions in the right radiocarpal The patient presented with signs and symptoms
and midcarpal joints were limited when compared to consistent with de Quervains tenosynovitis. These
those of the left. Motions tested included distraction, included pain, swelling and tenderness in the area of
Journal of Orthopaedic & Sports Physical Therapy
radial-ulnar glides, and volar-dorsal glides. The acces- the first dorsal tunnel, pain with isometric activation
sory motions (distraction, radial-ulnar glides, and of the EPL and APB (hitchhikers sign),13 and a
volar-dorsal glides) of the right first CMC joint were positive Finklestein test.7 Additionally, the patient
also limited. presented with stiffness of the wrist and first CMC
Upon palpation, it was noted that the right joint, as indicated by range-of-motion limitations and
capitate was positioned volarly when compared to the decreased accessory motion.
CASE
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STUDY
radial abduction was painful even with the main-
strain on the involved tendons, thus augment resolu-
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
reported pain level, functional status, impairment sion, she was asked to indicate her pain range in the
status, and intervention is given in Table 2. time since her last session and her current pain level
The patient came to the first session with an elas- with movement attempts. MWM was the first inter-
tic wrist support that firmly encircled the wrist alone vention used, and the chosen techniques resulted in
and fastened with Velcro. The patient reported that immediate relief of the painful motion (0/10), as
this nonrestrictive support relieved her symptoms verbally reported by the patient. This pain-relief phe-
somewhat, and so was used by the patient through- nomenon dictated the technique chosen.
out the 2 months of treatment. The MWM intervention was supplemented by the
A manipulation as described by Cyriax5 was used addition of an elastomere horseshoe added to the
during the initial visit to correct the volar position of elastic splint on the sixth visit. The purpose of the
the right capitate. To stabilize the capitate in a neu- elastomere horseshoe was to provide constant pres-
tral position, a small, oval button was fashioned from sure toward radial deviation (Figure 2).
elastomere putty, and the patient was instructed to The MWM and elastomere inserts served as ad-
place it between her elastic support and the capitate juncts to more conventional interventions for
on the volar surface of her wrist (Figure 2). This ma- tenosynovitis and joint limitations. Limitations in
nipulation was used only during the initial interven- joint accessory motions were addressed through joint
tion session, as the capitate appeared to remain in a mobilization techniques as described by Edmond.6
neutral position upon subsequent examinations. These conventional mobilization techniques differ
Following the manipulation, MWM was performed. from the MWM techniques in that they are com-
All active motions of the wrist and thumb were lim- pletely passive, determined by examination of acces-
Ice
Continuation of the elastic support
3 0/104/10 Able to brush teeth All impairments remain but are As on session 2
Able to bear weight diminished
Increased ease of
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
motion
4 0/103/10 Able to lift Pain with wrist flexion, extension As on session 2
Pain with forearm pronation,
supination
Tenderness over first dorsal tunnel
Slight swelling at wrist
Positive Finklestein test (at end range
only)
Decreased accessory motion in all
joints of wrist and first CMC
Range-of-motion limitations for all
Journal of Orthopaedic & Sports Physical Therapy
CASE
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STUDY
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
11 0/101.5/10 Gardening without Occasional pain with wrist and thumb MWM
pain motions Continuation of exercise program
Slight increased girth at wrist Iontophoresis
12 0/101/10 Infrequent episodes of Slight increased girth at wrist Review of HEP
wrist pain Discharge
Journal of Orthopaedic & Sports Physical Therapy
CASE
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STUDY
Restoration of the patients previous functional
Quervains tenosynovitis. The prospect of positively
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Invited Commentary
This is the perfect case study! Perfect in that a rated into the management of musculoskeletal im-
clinical treatment technique, which in this case pairments.
worked brilliantly, is documented. It also serves as a It is apparentand I believe Ms. Backstrom and I
perfect exemplar, in that potential pitfalls inherent agree on thisthat the first dorsal compartment ten-
Journal of Orthopaedic & Sports Physical Therapy
in case studies are evident: mechanistic insights into dons, abductor pollicis longus (APL), and the exten-
treatments are lacking, and one can neither predict- sor pollicis brevis (EPB) were irritated. We would
ably identify who might benefit from the treatment also agree that what makes this case of de Quervains
nor determine the validity of the treatment. There- unusual is that the EPB and APL were irritated sec-
fore, my commentary echoes the authors cautious ondary to a carpal abnormality, and that MWM
enthusiasm for the clinical technique Mobilization eliminated the irritation. Where we might disagree,
With Movement (MWM). My comments will also try however, is that I see this case as a wrist joint prob-
to identify the pitfalls, amplify the caveats, and refine lem primarily and a thumb tendon problem second-
the biomechanical rationale for MWM in an appar- arily. We also may differ on what the nature of this
ent case of de Quervains tenosynovitis. carpal abnormality was, and how the radial glide of
In this case, the MWM technique, a radial glide of the proximal carpal row (MWM technique) provided
the proximal row of carpals, provided immediate re- relief. From my arm-chair therapist perspective, it
lief in this atypical patient with de Quervains appears unlikely that any subtle capitate-specific
tenosynovitis. This is an amazing feat as the conserva- abnormality was the source of the irritation. Rather,
tive management for de Quervains is anything but my suspicion is that a very specific carpal instability
predictably effective,4 and rarely is such pain relief (ie, a midcarpal instability) was present.
provided instantaneously. Ms. Backstrom should be The MWM maneuver, as described, manually stabi-
lizes the ulnar carpus (specifically, the triquetrum)
applauded for sharing how MWM can be incorpo-
and tightens the radially based extrinsic ligaments
CASE
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The author hypothesizes that the positional ir- Quervains? Absolutely not. Is the MWM radial
regularity of the capitate found on the involved wrist glide a simple maneuver to use for diagnostic and
reflects a specific carpal sprain. However, to my therapeutic reasons in suspected midcarpal instabil-
knowledge, no carpal instability pattern (besides a ity? Absolutely yes. In this case, it is apparent that
STUDY
frank volar dislocation) results in an isolated capitate the MWM was effective in stabilizing the wrist, which
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
malalignment. To Ms. Backstroms credit, she ac- may have allowed pain-free thumb tendon excursion.
knowledges the possibility of an intercalated segment I do question, however, the biomechanical rationale
instability, carpal instability dissociative (CID) of the put forth by the author that the radial glide ad-
lunate, but no clinical or specialized imaging inquiry dressed the negatively affected line of pull or func-
was made. Again however, the case suggests a tion of the tendons (APL and EPB). In fact, it
midcarpal instability of the nondissociative (CIND) seems that a radial glide of the carpus would ad-
type (because no instability pattern was noted on the versely create tension on the irritated APL and EPB,
initial radiograph) may have been present. Coupled hence, increase pain and impairment (which is an-
with the positive response to the MWM, the patients other reason why this case appears to be primarily a
Journal of Orthopaedic & Sports Physical Therapy
recalcitrant (even 4 months after injury), yet infre- wrist instability problem, and secondarily a thumb
quent, wrist pain is a classic complaint of those with tendon problem). The probable midcarpal instability
a CIND wrist.2,3,9 It also suggests the presence of an may have been complicated further by a strain injury
unresolved (yet minimally symptomatic) wrist instabil- to the extrinsic wrist ligaments coursing from the
ity, despite the noted resolution of the positional radial styloid to the distal carpal row. In this sce-
malalignment of the capitate. nario, a CIND-type instability, the radial glide would
The likelihood that a tendon irritation was second- have transiently tensioned, and therefore stabilized
ary to a midcarpal wrist instability is high. The fact the midcarpal joint. Therefore, a refined, alternative
that the pain and impairment on the radial wrist was hypothesis is that the MWM provided a stable and
treated successfully with a radial glide of the proxi- pain-free midcarpal joint, resolved the joint dysfunc-
mal row is not surprising. As well, the limited acces- tion, and allowed the thumb and wrist to move pain-
sory wrist and thumb motion, due to a joint dysfunc- lessly.
tion, responded predictably well to a manual gliding The take-home message of this case is not that
technique. The description of intermittent wrist MWM should be used for de Quervains
symptoms at the 4-month follow-up is consistent with tensoynovitis, but rather that a thorough assessment
a CIND wrist. The capitate malalignment noted in for a carpal instability is necessary when trauma to
the evaluation, however, still remains problematic as the wrist is followed by joint and tendon pain and
it is unclear how, or if, this was in any way causally impairment. As well, MWM appears to be a reason-
related to the symptoms. My intuition is that the able clinical technique for acute relief from pain and
presence or absence of this subtle malalignment of impairment due to a carpal instability. Therefore, in
Author Response
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First, I need to thank my patient, who was enthusi- Intercalculated Segmental Instability (DISI),3 where
astic and willing to try something new. Her wrist in- the lunate assumes a dorsally directed position and
jury has challenged me and raised many questions the capitate is relatively volar. I did not consider a
and ideas. Second, I need to thank Dr. Paul LaStayo midcarpal instability nondissociative (CIND) type of
for bringing up additional concepts, questions, and instability, as suggested by Dr. LaStayo, and I am
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
pathways of thought. I appreciate his expert and grateful for his thoughts and education regarding
thought-provoking commentary. My hope is that this logical possibility. The concept of moving the
through this response, I can clarify the points on triquetrum into a stable position to facilitate normal,
which we disagree, and further explain my own pain-free motion is a very feasible explanation for
thought processes. the success of the MWM technique in this patient. In
While Dr. LaStayo and I have developed differing any case, I believe that de Quervains tenosynovitis as
rationales for what may be the causal factors for the a result of carpal instability may be a possibility and
symptoms described in this case, and for the mecha- warrants consideration during examination, prefer-
nism by which Mobilization with Movement (MWM) ably through specific examination techniques and
Journal of Orthopaedic & Sports Physical Therapy
provided relief, we actually agree that the radiographs, as Dr. LaStayo suggested. The best an-
tenosynovitis is secondary to a wrist joint problem. I swer to this question, of course, lies in a research
believe that this point is one of the most intriguing study that examines the correlation of wrist instability
aspects of the case report. It encourages the clinician with de Quervains tenosynovitis. Case studies merely
executing an examination, and subsequent interven- serve as a jumping-off point for continued research
tion, to move beyond the inflamed tendons alone to with larger numbers of patients.
the joints these tendons cross. It appears that the mechanism by which the use of
The finding of the capitate malalignment (reliable MWM, along with other conventional interventions,
or unreliable as it is) and its treatment through ma- was successful in this case of de Quervains
nipulation during the patients first visit did not hold tenosynovitis may be attributed to several, yet un-
a tremendous amount of significance for my assess- proven, theories. Dr. LaStayos viable suggestion is
ment of this patients condition at the time. It was that the mechanism is one of stabilization of a
during the write-up of this manuscript that I began midcarpal laxity. Because of a CIND instability, the
to consider the possibility of a carpal instability. hamate and triquetrum are not positioned correctly
Therefore, further diagnostics in terms of special and are therefore unable to move in a physiologically
tests and radiographs were not done. I did not in- normal manner. The result is pain and limited mo-
tend to imply that the capitate itself was the defini- tion. This hypothesis of midcarpal instability is not in
tive source of instability, only that it might represent conflict with the basic MWM premise that a malalign-
an underlying instability, such as a Dorsal ment exists (in this case, possibly due to an instabil-
CASE
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STUDY
Copyright 2002 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy