Wrist and distal forearm pain complaints from overuse are increasingly common. As massage therapists, we grapple with these problems ourselves, and sometimes they can be career-ending injuries. Certain soft-tissue disorders, like carpal tunnel syndrome, are well known. Yet, there are other conditions—especially those affecting the tendons of the wrist and forearm region—that can produce chronic long-term pain as well. In this issue, we’ll take a look at two key chronic overuse tendon disorders of the wrist and distal forearm—de Quervain’s tenosynovitis and intersection syndrome.

The Pathology

The most common terms we hear related to overuse tendon pathology are tendinitis or tendinosis, which result from collagen degeneration in the tendon. Both de Quervain’s and intersection syndrome involve tenosynovitis, which is different in that it involves the synovial sheath surrounding certain tendons (the distal upper extremity in this case) (Image 1).

The Synovial Sheath

The purpose of the synovial sheath is to reduce friction between the tendon and a close adjacent structure, such as a binding retinaculum. Most tendons do not have a synovial sheath, however. The most common locations to find these sheathed tendons are in the distal upper and lower extremities where the tendons cross multiple joints.

The tendons of the distal upper extremity muscles must be able to freely slide within the synovial sheath. Repetitive overuse or other factors may lead to an inflammatory irritation between the tendon and surrounding synovial sheath. Adhesions can also develop as a result. The inflammatory reaction along with potential connective tissue adhesion is tenosynovitis.

De Quervain’s Tenosynovitis

De Quervain’s tenosynovitis is more common, and thus more well known, than intersection syndrome. There are two tendons involved in this condition: abductor pollicis longus (APL) and extensor pollicis brevis (EPB). Both tendons course under a retinaculum near the styloid process of the radius in an area sometimes referred to as the anatomical snuff box (Image 2).

Repetitive overuse of the APL and EPB tendons is common in many occupations and recreational activities. During repetitive use, the tendons may rub against the retinaculum and cause the inflammatory reaction. In some cases, there can be a septum (a small connective tissue wall or divider) between the two tendons as they pass under the retinaculum. Friction against the wall of the septum can also lead to the tenosynovitis.

Intersection Syndrome

Intersection syndrome involves the two tendons also associated with de Quervain’s tenosynovitis—the APL and EPB. Tendons in the distal upper extremity are divided into compartments that have connective tissue walls between them. The APL and EPB tendons are enclosed in the first dorsal compartment.

Intersection syndrome also involves two other tendons of the forearm that control the wrist: the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB). These two tendons are in the second dorsal compartment. Interestingly, the ECRB is also the forearm tendon most frequently affected in chronic lateral epicondylitis (tennis elbow). Epicondylitis affects the proximal end of ECRB near the elbow instead of the distal end in the forearm, which is affected in intersection syndrome.

Intersection syndrome is also a friction problem but occurs farther up the forearm (proximal) than where de Quervain’s tenosynovitis occurs in the wrist. The latter presents as the two tendons of the first dorsal compartment cross over those in the second (Image 3). Where these tendons cross is the intersection. Repetitive actions of the hand or fingers may cause these tendons to rub against each other and produce tenosynovitis as a result of the friction. Intersection syndrome is common in various sporting activities that involve repetitive wrist motions, such as rowing, canoeing, horseback riding, skiing, and racket sports. As a result of the shear forces and friction in the area, there may be resultant tendon thickening and inflammation between the tendon and surrounding synovial sheath. This can lead to further irritation and the resultant pain.

Assessment

Both de Quervain’s tenosynovitis and intersection syndrome involve an inflammatory reaction between the tendon and the surrounding synovial sheath. Tendon friction is the primary cause for this reaction. As with any good assessment of soft-tissue pathology, a thorough evaluation begins with a detailed client history. In both conditions, there will likely be some repetitive overuse activities involving the distal upper extremity. As noted earlier, this might be sporting activities such as rowing or racket sports. Certain occupations, such as massage therapy, are also likely to produce the chronic overuse tendon pathology in both conditions.

The name tenosynovitis would indicate that there is active inflammation associated with these conditions. However, characteristic signs of inflammation may not always be evident. For example, visible or palpable swelling may be present, but not always. There are no other clearly visible indicators of either condition.

Detailed palpatory examination is one of the most effective ways to identify both of these problems. Clients presenting with de Quervain’s tenosynovitis will usually report localized pain very close to the radial styloid process when those tendons are palpated. If the tendon is palpated during movements of the thumb, the characteristic pain is usually aggravated. Crepitus (a grinding or grating sensation) may be also be evident if these tendons are lightly palpated during movements of the wrist or thumb. Tendon thickening resulting from the inflammatory reaction may also increase crepitus during movement.

Pain near the radial styloid is likely with both active and passive ulnar deviation of the wrist (Image 4). The practitioner may be able to move the client’s hand farther into ulnar deviation during passive movements, and that may increase discomfort further. The pain is also likely to be more pronounced during 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.

Active Engagement Technique

An even more effective application of this technique might involve active eccentric engagement of these muscles as they are worked. An example of the active engagement technique applied to the APL and EPB tendons is shown in the associated video (link below).

To apply the active engagement technique, grasp the client’s hand in the handshake position. Passively move the client’s hand into full radial deviation first to shorten the affected tissues. Once the hand is in full radial deviation, ask the client to hold that position and don’t let you move it. This will establish an isometric contraction in the affected muscles. Use a moderate amount of force, since the contraction does not have to be strong.

Once the contraction is established, ask the client to slowly let go of that contraction and you will gradually pull their wrist into ulnar deviation. As you slowly pull the wrist into ulnar deviation, perform a stripping technique moving from distal to proximal on the affected muscle bellies (Image 5). Keep in mind that this technique can feel somewhat intense and uncomfortable for the client, so adjust your pressure accordingly. A minor degree of discomfort is acceptable, but if the discomfort is too much, it may further aggravate the nervous system to the point of increasing overall pain in the region and would be counterproductive.

Friction Technique

Another treatment approach that is frequently advocated for overuse tendon disorders is friction to the affected tendons. The initial rationale for friction applications was that they help break up fibrous adhesions between the tendon and surrounding synovial sheath. Recently, some clinicians and researchers have suggested that this mechanical effect may not be occurring the way we once described. However, we do know that this technique tends to get very beneficial results in many cases. Another potential explanation for this process could be that the pressure and movement of the friction technique helps stimulate fibroblast activity and positively contributes to repairing the damaged tendon.

The most effective treatment approaches are likely to include a variety of these different methods that address both the contractile components of the muscle belly farther up in the forearm as well as direct applications to the affected tendons themselves. Kinesiology taping has also shown some benefit in recent cases and is particularly helpful in reducing pain and increasing proprioceptive awareness about movement in the area after treatment has completed.

As with other chronic overuse muscle conditions, strength training should come along with activity modification once the initial symptoms have been reduced. Beginning strength training too soon can further aggravate the affected tendons. A good guideline is to protect and nurture the area more than you might think at the outset, and gradually work activity and strength training back in slowly and easily.

Conclusion

Overuse disorders of the upper extremity are a rampant problem in our society with both active individuals and occupational athletes (those with repetitive motion jobs), and massage therapy and other soft-tissue manipulation approaches are particularly helpful in addressing these types of problems. These conditions should be of particular interest to us as professionals because they can significantly impact us and produce career-ending injuries if we don’t manage them appropriately.