Thumb/Wrist Pain? It could be De Quervain’s Tenosynovitis.

de quervain's treatment

De Quervain’s Tenosynovitis is a painful condition which affects the thumb muscles (Abductor Pollicis Longus and extensor Pollicis Brevis).

Commonly seen in females who are in the post-natal phase, it is caused by a rapid increase in load on the thumb muscles and tendons. This over-load is usually caused from repetitive feeding positions, lifting and holding of an new infant. It can also commonly occur in golfers.

Symptoms will include swelling and local tenderness over the tendons. It can also be a sudden sharp feeling, which is not ideal when holding a young child!

Diagnosis

It is diagnosed by conducting a simple test called the Finkelstein test. The tests involve bending your thumb across the palm of your hand and then bending your fingers over the thumb. The wrist is then bent toward your little finger. If this reproduces the same pain you experience, it is likely De Quervains syndrome.

A physiotherapist will also conduct some tests on the joints around the thumb and wrist to exclude them as a source of the pain symptoms.

De Quervain’s Treatment

Successful De Quervain’s treatment techniques include splinting/bracing of the wrist to off-load the thumb tendons, and then progressive weaning from the brace to reintroduce load in a monitored way.

Gradual strengthening of the tendon is highly important as increasing the tendons tolerance to load is the fundamental component of rehab. As with any tendon strength program, load needs to be slowly introduced as a sudden increase in strength exercises can easily overload and aggravate the tendon! If bracing is left on for too long the tendon will become weaker and hence when you remove the brace the pain will come back.

If you start treatment early, your symptoms should improve over the next 4-6 weeks. If your symptoms start during or after pregnancy your symptoms are likely to resolve once breast feeding has stopped.

Despite common belief, a corticosteroid injection is not the first line treatment. An injection should only be considered if bracing and physiotherapy has failed over a 4-6 week period.

TOP TIPS:

  • ICE for pain relief

  • BRACE to off-load the tendon

  • STRENGTH to increase the tendons tolerance to load (likely the reason the thumb was sore in the first place).

  • CORTISONE injection only after 6 weeks if the above fails.

If you have any questions or if you think you may have De Quervain’s then please do not hesitate to get in touch with us here.

 

How to exercise safely during and post pregnancy

As a women’s health physiotherapist I frequently get asked about what type of exercise to do, how much to do, what is safe and how to return to exercise in pregnancy and postnatal period.

Below you can find all the evidence-based answers to the commonly asked questions that I get!

What is a safe amount of exercise to do during pregnancy?

The current 2016 RANZC exercise during pregnancy guidelines recommend that pregnant women should aim to be physically active, preferably all days of the week and should accumulate between 150-300 minutes of moderate intensity exercise per week. Exercise should be at least 30 mins at a time but it is advised to limit duration to 60 mins, unless the exercise is at a light intensity.

We encourage women to begin some type of exercise during pregnancy, even if you have not exercised prior to pregnancy. We would recommend if you are just starting out, to have guidance from a women’s health physiotherapist and to gradually build up over time. If you have already been exercising it can be a good idea to check that your current program is appropriate.

What is a safe intensity to exercise at?

Exercise intensity will depend on your baseline level of fitness and previous exercise routine. For those who have been previously inactive and are starting a new exercise program, maintaining a moderate level of intensity is recommended.

There is currently no evidence to suggest that women who previously participated in regular high intensity exercise and who continue to participate in vigorous exercise, are doing harm during pregnancy. Provided that they adjust the routine based on changes in comfort and tolerance.

Athletes should be wary of excessive exertion as fetal well-being may be compromised above a certain threshold of activity.

The talk test is quick and easy way to gauge exercise intensity. Intensity is considered moderate if you can comfortably hold a conversation, or is considered vigorous intensity if you have a need to pause for breath during conversation.

What type of exercise should I be doing?

There isn’t a one type fits all approach to exercise, find an exercise that incorporates strength, flexibility and aerobic components, and most of all you should enjoy doing it!

Provided that there are no contraindications to exercise, pregnant women should participate in both aerobic and resistance based activity. Women should aim for two sessions of strengthening per week, on non-consecutive days. Resistance can be light weights, rubber bands or body weight and should be performed at a moderate intensity, slowly with appropriate breathing.

Some great forms of exercise when pregnant are:

  • Clinical Pilates: it is a great way to perform resistance exercise, and is tailored to the individual.

  • Walking is a good aerobic exercise but should be performed at a brisk pace.

  • Hydrotherapy is great in the later stages of pregnancy, especially for its weight supported nature. It also reduces lower limb swelling and oedema due to the redistribution of fluid. Prolonged immersion in waters above 34 should be avoided, and immersion at above this temperature during the first trimester is not advised.

  • Stationary bike/ Cycling

  • Swimming

  • Pregnancy yoga

  • Strength based gym classes.

Why we haven’t mentioned running and high impact exercises? You can participate in these activities if you were doing it regularly prior to pregnancy, however pregnancy is such a short time of a woman’s life, that avoiding high impact activity during this time when your body is experiencing ligament laxity and softening is a good idea. This can help to prevent incontinence and prolapse issues!

Activities to avoid whilst pregnant:

  • Heavy lifting

  • Hot yoga

  • Skydiving/ bungee jumping

  • Scuba diving

  • Activities with a high risk of falling or getting hit in the stomach

  • Activities that involve straining, holding the breath or

  • Working at a high and unaccustomed intensity

I would highly recommend at your next GP, midwife or Obstetrician review to ask if there are any medical issues that would affect your participation in exercise. As there are some conditions where exercise is not advised.

So what happens to the body during pregnancy? and why does this affect exercise?

Weight Gain:

A number of changes will take place during pregnancy. Women will generally experience 10-15kg of weight gain to account for the baby, the placenta, amniotic fluid and increase in blood volume.

Vascular:

Vascular changes will occur especially in the second and third trimesters, where the cardiac volume will increase by 70-80mls, the cardiac output will increase by 40%,the resting heart rate will increase and blood pressure will decrease. These vascular changes reach maximum around the 20-24 weeks.

With this in mind, rapid postural changes should be avoided, heat and hydration levels should be closely monitored and women should be aware of how to track their level of exertion. It is advised to perform a cool down after exercise and not to stop suddenly.

Relaxin:

Relaxin is a hormone that is commonly blamed for SIJ pain (also known as pelvic girdle pain) and ligament laxity during pregnancy. It is a hormone that prepares the lining of the uterus for the implantation of the embryo. Relaxin peaks at the 12th week and will stabilise to 50% of this level at 17 weeks. The Relaxin level will return to normal within hours to days of birth. However what we know is that joint laxity increases during pregnancy and is most marked in the last three months of pregnancy and 3 weeks postpartum (i.e Joint laxity increases even though relaxin levels stabilise at 17weeks).

Peripheral joint laxity does not return to normal ranges within the first 6 weeks post birth, therefore is advised to not participate in heavy joint loading exercises during these periods, such as jumping and changing direction.Women who have abnormally high levels of relaxin have been correlated to experience more pelvic girdle pain.

Venous Return:

As the uterus grows with pregnancy, the weight of the enlarged uterus may abstract venous/ blood return. Therefore pregnant women in the second and third trimester should avoid exercise lying on the back for prolonged periods of time. Try sitting or standing instead.

Those who experience light-headaches, nausea or feel unwell when they exercise flat on their back should modify their exercise.

Pelvic floor laxity:

Activities that involve jumping or bouncing may add extra load to the pelvic floor muscles and connective tissue and are best avoided. Pelvic floor Strengthening exercises are generally recommended.

What effect does exercise have on gestational diabetes?

Exercise is now acknowledged as an effective way to decrease insulin resistance and thus help control blood glucose levels. It can prevent gestational diabetes if performed throughout the entire pregnancy at least three times per week.

Women should eat about 1 hour prior to exercise, to help balance blood glucose levels.

Who should perform the pre-exercise screen for a pregnant woman?

A general practitioner and/ or obstetrician will advise you if you have any contraindications to exercise. Examples of these may include cardiovascular disease, poorly controlled asthma, poorly controlled diabetes and bone or joint problems. They will also advise you if you have a pregnancy related complications.

Expectant mothers must be conscious of pregnancy-related complications, such as bleeding, sudden swelling, abdominal and back pains or decreased fetal movements. At the onset of any of these, activity should be ceased and seek medical assistance.

Back pain in pregnancy

Back pain affects between 48-90 % of pregnant women. The most common locations are the sacroiliac joint at the back, and the pubic symphysis joint at the front. The lumbar spine and thoracic spine can also become painful however are generally less affected. Pregnancy-related Pelvic girdle pain is mostly likely to present between 18-22 weeks.

Will back pain get worse as pregnancy progresses?

Generally low back pain that is present before pregnancy will start to feel better as pregnancy progresses, but new onset back pain during pregnancy may progressively increase if not managed appropriately. In pelvic girdle pain, resistance exercises are generally prescribed to increase the strength and endurance of pelvic stabilising muscles, such as the gluteal muscles.

What is the pelvic floor and what does it do?

The pelvic floor is a sling like structure of muscles, ligaments and connective tissue (fascia) that supports and contracts to hold the internal and reproductive organs up high and enables voluntary control of the bowel’s and urine.

Should everyone be doing pelvic floor exercises during pregnancy?

Most women will benefit from doing pelvic floor exercises, not only for strength purposes but also to prepare you to relax the muscles during labour. The research shows that if you do pelvic floor exercises throughout pregnancy you will be less likely to be incontinent in the postnatal period.

The internal pelvic floor muscles will therefore be less likely to tear and have trauma if you can relax them.

Some women have the opposite of a weak pelvic floor, they can be too tight and over active! These women should not aim to increase pelvic floor tone and strength but rather have a strong focus on relaxing and letting go.

What are safe exercises to do in the post-natal period?

Remember that during a vaginal delivery some pelvic floor muscles and connective tissue’s have to stretch up to 600x their normal length. This is a significant amount of trauma and quite a shock to the system. Therefore in the early days postpartum, slow gentle walking is advisable.

Hormones that are present due to breastfeeding, can continue to cause ligament laxity, therefore it may take up to a year before your ligament laxity is back to normal. I would advise to limit unnecessary bouncing, running and heavy joint loading activities if you are still breastfeeding.

For pelvic floor strengthening before seeing pelvic physio, you could start your rehab by doing one pelvic floor contraction per week postpartum

For example:

  1. Week one postnatal, hold 1 x contraction for one second, Repeat x three sets.
  2. Week two, do 2 x contractions holding 2 seconds each contraction. Repeat x three sets.
  3. Week three, do 3 x contractions holding 3 seconds each contractions, Repeat x three sets.
  4. Progress as the weeks progress until you see your women’s health pelvic floor physiotherapist after week 6.

When should a post natal abdominal separation assessment be done?

I encourage women to be assessed in private practice, two weeks post delivery. This is to ensure appropriate management is commenced, and to make the most of healing time frames and hormone changes. An abdominal separation check may only take 40 mins and management can include abdominal bracing, taping, progressive strengthening and tips to avoid overload.

When should I get a postnatal Pelvic floor examination?

Generally at 6 weeks once medically cleared by GP or Obstetrician, a women’s health pelvic floor physiotherapist can assess the internal muscles. These assessments are very important for specific strength training depending on your pelvic floor presentation. From here measurements can be done to see whether you are ready to return to running, weight lifting, over head weights, standing weight, kicking, boxing, jumping etc.

If you need to book in to see Jessica for an assessment, please click here

This blog is based on the 2016 Royal Australian and New Zealand College of Obstetricians and Gynaecologists current recommendation guidelines for exercise in pregnancy.

For a more comprehensive guide see:

http://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Exercise-during-pregnancy-(C-Obs-62)-New-July-2016.pdf?ext=.pd