Issue link: https://www.massageandbodyworkdigital.com/i/1315831
84 m a s s a g e & b o d y wo r k j a n u a r y/ fe b r u a r y 2 0 2 1 eccentric movements of the wrist in ulnar deviation. This can be tested by holding a long object like a broom and slowly lowering the heavy end of the broom to the ground from a horizontal position as the wrist moves in ulnar deviation. A modification of this movement called the Finkelstein test (Image 4) is often used to identify de Quervain's tenosynovitis. For this procedure, the client holds the thumb across the palm and wraps the fingers over the top of the thumb. With the thumb grasped, the client or practitioner moves the affected hand into ulnar deviation as far as possible. If this reproduces the characteristic pain near the radial styloid, this is a good indication of overuse pathology in the first dorsal compartment tendons (APL and EPB). The same movements can be used to identify potential pain problems with intersection syndrome. However, with intersection syndrome, the region of most sensitivity is more proximal to the radial styloid process and is located where the tendons cross over each other on the dorsal surface of the forearm, as noted earlier. All the motions that emphasize ulnar deviation for de Quervain's tenosynovitis should also be tested using wrist flexion since the ECRL and ECRB tendons are wrist extensors and we want to assess what happens as they are stretched or eccentrically loaded. TREATMENT STRATEGIES Traditional medical treatments for de Quervain's tenosynovitis and intersection syndrome focus on conservative approaches, such as wrist splinting, rest from offending activities, or the use of nonsteroidal anti-inflammatory drugs (NSAIDS). If these treatment approaches are not effective, traditional treatment for both conditions may also include corticosteroid injections to address the primary inflammatory component. A comprehensive treatment strategy should also address the chronic overuse factors that led to the problem to begin with. In many cases, if there is a repetitive activity that is going to continue, the condition will simply recur if there isn't some type of activity modification or decrease in intensity. Along with activity modifications, soft-tissue treatments addressing the muscles of both the first and second dorsal compartment can help reduce symptoms. When you have a chronic overuse tendon disorder, it is important to address the associated muscles that are pulling excessively on the affected tendon(s). Keep in mind that, in both conditions, these are long, thin tendons where the symptoms are being felt, but the involved muscles are farther up in the forearm and are moderately small. The affected muscle bellies may be short and thin, so a more targeted approach with a small contact surface is more effective in addressing hypertonicity in the muscle belly. Treatment can begin with more broad-based techniques, such as effleurage, with the palm or back side of the hand. In addition, sweeping cross- fiber applications applied with the thumb or fingers that give a more diagonal- oriented stroke across the involved muscles can help enhance tissue pliability and decrease initial hypertonicity as well. After enhancing tissue pliability and reducing initial muscle tightness, a more specific and small contact surface stripping technique applied to the muscle bellies is particularly effective. There are different ways to apply these stripping techniques, and here I will describe both a passive application as well as one using active engagement techniques, which are highly effective. Passive Technique In a passive technique for the wrist extensors, the practitioner puts the client's wrist in extension, so the affected muscles are somewhat shortened. This takes the load off these muscles at the outset of treatment. Then, the practitioner applies a longitudinal stripping technique to the wrist extensors as the client's wrist is slowly moved into flexion. By lengthening the tissue while we apply the stripping technique, there is more effective tissue mobilization and an increase in elasticity. If you are applying this treatment to the APL and EPB tendons, the approach is the same, but should focus on wrist ulnar deviation instead of wrist flexion as the passive movement. Ulnar deviation is more effective than flexion for stretching the first dorsal compartment muscles. 3 Tendon intersection in the forearm. Image from 3D4Medical's Complete Anatomy application.