Article Text

other Versions

PDF

Acupuncture in De Quervain’s disease: a treatment proposal
  1. João Bosco Guerreiro da Silva1,
  2. Fernando Batigália2
  1. 1Department of Medicine II, Rio Preto Medical School (FAMERP), São José do Rio Preto, Sao Paulo, Brazil
  2. 2Department of Anatomy, Rio Preto Medical School (FAMERP), São José do Rio Preto, Sao Paulo, Brazil
  1. Correspondence to Professor João Bosco Guerreiro da Silva, Department of Medicine II, Rio Preto Medical School (FAMERP), Rua Pernambuco, 3147 Redentora, São José do Rio Preto, SP 15015-770, Brazil; jbgsilva{at}hotmail.com

Abstract

De Quervain's disease is a painful stenosing tenosynovitis of the first dorsal compartment of the hand affecting the tendons of the abductor pollicis longus and extensor pollicis brevis, caused mainly by overuse. Conventional treatments include rest, immobilisation, oral anti-inflammatory drugs, corticosteroid injection and even surgery, but none of these is established as clearly effective. Acupuncture is rarely mentioned and the points suggested are rather general—regional, tender and ah shi points. Tendinopathy is almost always associated with problems in the relevant muscles and this paper calls attention to the correct identification and needling of the affected muscles, in order to increase the specificity of acupuncture treatment.

View Full Text

Statistics from Altmetric.com

Introduction

De Quervain's disease is described as a painful stenosing tenosynovitis of the first dorsal compartment of the hand.1 It is characterised by pain on the radial side of the wrist, impairment of thumb function and thickening of the ligamentous structure covering the tendons of that compartment.2 In the words of De Quervain himself: “On moving the thumb, the patient experiences more or less severe pain that radiates from the area of the wrist towards the thumb and the forearm, so that they are often no longer able to hold an object that they have grasped. Palpation yields either a negative result, or some thickening of the tendovaginal chamber that rests against the distal radius end. The tendovaginal chamber is in all cases markedly sensitive to pressure, whilst the remaining tendon sheath is much less so, or not at all. The progression of the condition is chronic.”3

The disease is caused by overuse and/or an increase in repetitive activity, resulting in shear microtrauma from persistent gliding of the first dorsal compartment tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB).1

Diagnosis classically depends on a positive Finkelstein test (also called Eichhoff test), which consists of four stages: “first with the application of gravity assisted gentle active ulnar deviation at the wrist, then the patient actively deviates the wrist in an ulnar direction, then further passive ulnar deviation by the examiner, and in the final stage, the examiner passively flexes the thumb into the palm”.4 However, arthritis of the thumb joint may readily mimic the pain of de Quervain's disease and give a false-positive result. Another new test, the so-called WHAT (Wrist Hyperflexion Abduction of the Thumb) test, seems to be an improvement but more experience with the test is needed to confirm this.5 Radiculopathy, carpal tunnel syndrome and scaphoid fracture are some differential diagnoses that should be considered. Ultrasound can be helpful for diagnostic confirmation.6

The incidence of De Quervain's disease is three times greater in women than men, being more common in the fifth and sixth decades, and in pregnant and lactating women.7 Other susceptible groups are musicians, assembly workers, golfers, machinists1 and more recently, video game players and people who overuse smartphones.8

Conventional treatment

Until 40 years ago, surgery was the preferred treatment. Nowadays, most experienced hand surgeons are reluctant to use the expression ‘the patient wakes up cured’ preferring to warn the patient that the ‘operation may not be successful’.9 Many conservative treatments are recommended—namely, rest, early immobilisation, heat, cold, diathermy, strapping, transverse friction massage, medication (such as non-steroidal anti-inflammatory drugs) and corticosteroid injection,10 but it is difficult to determine which modality is the most effective. A Cochrane review found that corticosteroid injection showed positive results, although it has the potential for side effects, of which tendon rupture and infection are the most common.11 The high possibility of finding two compartments separating the tendons also decreases the efficacy of the injection and increases the chance of rupture.12

Role of acupuncture

Acupuncture is rarely cited as an option for treatment. Even acupuncture textbooks make little mention of it.13–15 Baldry14 cites the muscles involved but does not prioritise acupuncture, preferring to recommend immobilisation and corticosteroid injection. One recent textbook recommends local tender points and classic acupuncture points, and avoiding needling the ligament sheath. However, it seems that acupuncture can be an effective approach in tendon diseases such as Achilles tendinopathy,16 rotator cuff tendonitis17 and tennis elbow.18 Acupuncture may facilitate blood flow to the tendon locally19 and at a distance,20 through the release of several neuropeptides such as calcitonin gene-related peptide, substance P, 21 and the increase of collagen and amino acids such as hydroxyproline, and by inducing a better molecular organisation of the collagen fibres, which may improve the mechanical strength of the tendon after injury.22

Thickening of the tendon is the result of acute or chronic overload.21 Muscle shortening leads to tension in the tendons and their terminal insertions.23 Most treatment focuses on pain and inflammation of injured tendons, ignoring the main problem of tendinitis: the affected muscles. Tendinopathy is usually a secondary lesion caused by a primary lesion: muscle disease.

Even in the few cases where tendons are damaged primarily, muscles are also involved as painful areas or through muscle spasm. Therefore, tendinopathy is always associated with affected muscles regardless of whether these are a primary or secondary cause. Thus, to treat tendinopathy, muscles and tendons are often needled simultaneously because the tendon problem may be associated with a tense and fatigued muscle.

However, it is clear that we must avoid needling the sheath,11 ,14 ,15 so we suggest that in addition to the most useful acupuncture points such as LI4, LI10 and LI11,1 we must add needling of the APL and EPB (figures 1 and 2).

Figure 1

Anatomical dissection of the dorsal wrist. Red pin, radial nerve; blue pin, tributary of the cephalic vein; yellow pin, extensor pollicis brevis; green pin, abductor pollicis longus.

Figure 2

Left needle, extensor pollicis brevis; right needle, abductor pollicis longus.

Surface anatomy and location of muscles

After positioning the hand with dorsal side up and locating the anatomical snuffbox (AS) with the thumb in voluntary and sustained abduction, the lower limit of the AS is formed (and easily detected by palpation) in turn by the APL tendon inferiorly, and the EPB tendon superiorly. At the junction of the inferior and middle thirds of the forearm, both muscles can be identified by palpation after asking the patient to extend or abduct the thumb. In this sustained position, the two muscle centres can be separated under the skin by palpation, using index, middle and ring fingers, positioned obliquely to the longitudinal axis of the forearm and pointing towards the thumb; after relaxation of the muscles, the two muscles can still be identified. They are both innervated by the deep branch of the radial nerve that is deep within subcutaneous adipose tissue. Although the superficial branch of the radial nerve and the cephalic vein run up the radial side of the forearm within subcutaneous adipose tissue and over the centres of the APL and EPB, accidentally puncturing them would not cause significant harm because of the small size and multiple branches of the superficial branch of the radial nerve, and the highly variable tributaries of the cephalic vein.

Comment

Acupuncture has been used for a variety of diseases. Much of its traditional specificity, however, has been questioned. Apparently, even needling locations that are not classic points (or we should say, even non-points) may produce non-specific outcomes, mainly in the field of pain. The field of musculoskeletal pain is one area where we may increase the specificity of treatment through accurate diagnosis, knowledge of anatomy and the correct needling of affected structures.

This seems to be the case in De Quervain's disease. It is caused by an overuse of the thumb or an overuse of APL and EPB muscles.

In our short experience of treating patients with this approach, we have seen a better response with needles than seen previously with other treatments. Of course, this should be confirmed in a proper trial, but we would like to advise our colleagues of this possibility. The affected muscles should be identified precisely—for example, using a unipolar stimulator on the needle to contract the muscle, to ensure that the correct one is located. We believe that correct needling is difficult but well worth the effort.

References

View Abstract

Footnotes

  • Contributors JBGdS has clinical experience and has treated many patients with this method. FB is an anatomist professor and performed the anatomical dissections. Both authors wrote and revised the manuscript.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.