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96 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 1 4 Finklestein test. Image courtesy Whitney Lowe. 4 Many references to de Quervain's tenosynovitis refer to it as stenosing tenosynovitis. Stenosis means narrowing, and stenosing tenosynovitis refers to a narrowing of the channel through which the tendon passes. Sometimes fibrous nodules develop along a tendon right where the tendon passes beneath a retinaculum. The fibrous nodule causes the tendon to get stuck as it attempts to slide under the retinaculum. This pathology occurs most often in the flexor tendons of the fingers and is commonly referred to as trigger finger. ASSESSMENT AND EVALUATION Carpal tunnel syndrome and de Quervain's tenosynovitis can produce pain in a similar location. Yet, there are some key differences that help discriminate these conditions. The pain in carpal tunnel syndrome is more common in the palm of the hand, not the base of the thumb as Alan reports. Pain at the base of the thumb is more consistent with tenosynovitis. Palpating the tendons in the anatomical snuff box region reproduces Alan's primary complaint. Pain is significantly increased if the tendons are palpated while their associated muscles are being contracted. Many tendon complaints are more pronounced when there is a contraction force on the muscle-tendon unit. If median nerve compression was the culprit, pain reproduction in this region would be unlikely because pressure is not applied over the nerve. It is also unlikely that pain in that region would increase with the muscle contraction if it were median nerve compression. Alan's pain is also reproduced with resisted extension and resisted abduction of the thumb. These are the two key motions of the involved tendons. In addition to investigating motions of the thumb, other wrist motions are assessed. There was no pain associated with active or passive flexion of the wrist. In carpal tunnel syndrome, these motions generally reproduce symptoms because they compress the median nerve in the carpal tunnel. Another key factor that points to the likelihood of tenosynovitis is pain reproduced with a special orthopedic test called the Finklestein test. It is a simple procedure where the client pulls his thumb across his palm and then wraps his fingers over the thumb. With the thumb and fingers in that position, the wrist and hand are moved in ulnar deviation (Image 4). If this position reproduces the primary pain complaint, it is likely there is some involvement with the key thumb tendons and/or their synovial sheaths. This testing procedure does not stress the median nerve at all, so we can rule out carpal tunnel involvement in favor of a tendon overuse disorder (unless other symptoms indicate both conditions). TREATMENT CONSIDERATIONS The first step in our clinical management of any soft-tissue disorder is to normalize the soft-tissue dysfunction; in this case inflammatory irritation and fibrous adhesions between the tendon and surrounding synovial sheath. In any chronic overuse tendon disorder, it is crucial to reduce the cumulative tensile load on the tendon by working on the affected muscles to decrease their tightness as much as possible. The muscle bellies of the associated muscles extend quite a distance into the forearm, and should be worked throughout their entire length (Image 5). After initial tissue warming and superficial strokes are applied, deep specific stripping applications are applied to the bellies of the abductor pollicis longus and extensor pollicis brevis (Image 6). Pressure can increase in successive strokes as the client is able to tolerate it. The extensor pollicis longus should be treated with the same stripping techniques at this time as well. Abductor pollicis longus Extensor pollicis brevis 5 Abductor pollicis longus and extensor pollicis brevis muscle bellies in the forearm. Image is from 3D4Medical's Essential Anatomy 3 application.