By De Quervain's tenosynovitis, the thumb-side wrist pain that new mothers know as 'mother's wrist', rarely settles on its own. Specialists agree on the anatomy, but not on whether it is really inflammation, whether physiotherapy helps, or how soon patients should lift again

For many new mothers, the first sign is a sharp ache on the thumb side of the wrist, felt each time the baby is picked up. The baby, meanwhile, keeps growing.

"Repeatedly lifting a baby, holding the child during feeding and keeping the wrist bent or the thumb stretched for prolonged periods can put considerable stress on these tendons. It is sometimes referred to as 'mother's wrist'," says Dr. Avinash Date, consultant orthopaedic surgeon at Kokilaben Dhirubhai Ambani Hospital, Mumbai. "And the weight of babies keep on increasing and so does the pain."

The condition has a formal name, De Quervain's tenosynovitis, and a wider constituency than the nickname suggests. "But it is not limited to new mothers," Dr. Date says. "People whose work or hobbies involve repetitive gripping, lifting or thumb movements can also develop it."

A rope through a pinched hose

The pain has a specific address. "In De Quervain's, pain is typically on the thumb side of the wrist and becomes worse when the patient grips, lifts something or moves the thumb," Dr. Date says.

What is happening underneath is a problem of space. "In the wrist, two of these tendons guide the thumb up and away from the hand. They pass through a narrow tunnel on the thumb side of the wrist… In De Quervain's, the sheath and the fibrous roof over it thicken, narrowing the space," says Trevor Petrie, a certified hand therapist based in Washington State in the United States. "It's a bit like trying to pull a rope through a hose that's slowly being pinched shut."

Dr. Glen Lee, a hand and wrist surgeon at VCU Health in Richmond, Virginia, names the structures involved. "It involves the abductor pollicis longus and extensor pollicis brevis tendons on the thumb side of the wrist. The covering of the tendons (tendon sheath/retinaculum) gets thickened and causes increased pressure and friction along the tendons," he says.

Inflammation, or something else?

The suffix suggests inflammation, and here the specialists begin to part ways.

"De Quervain's tenosynovitis is not a true inflammatory condition," Dr. Lee says. "Secondarily, inflammation (tenosynovitis) can occur around the tendons, but that is not the primary problem."

Mr. Petrie takes a similar view. "It's more of a thickening of the tissue and a wear-and-tear change than a hot, angry flare-up, although it can go through periods of acute inflammation after overuse or excessive strain," he says.

Dr. Vanessa G. Cuellar, a board-certified orthopaedic hand and wrist surgeon at DISC Palm Beach and Jupiter Medical Center in Florida, is less willing to set inflammation aside. "DeQuervain's is often a combination of both," she says. "The inflammation is largely what causes the pain and symptoms."

Not arthritis, but easily mistaken for it

Whatever its precise nature, De Quervain's is a condition of the soft tissue rather than of the joint. The distinction matters because a different problem sits close by.

"It's a soft tissue problem, not a joint problem. But it can be easily confused with CMC osteoarthritis… I often see patients mistake one condition for the other, especially in female patients over 50," Mr. Petrie says. CMC osteoarthritis affects the joint at the base of the thumb.

The diagnosis is made in the clinic, not the laboratory. "Blood tests such as ESR, CRP and rheumatoid factor are not routinely required for a straightforward case of De Quervain's. It is a clinical diagnosis," Dr. Date says.

The other De Quervain's

Patients who search the name online may run into a second, unrelated condition. "De Quervain's tenosynovitis (wrist condition) and De Quervain's thyroiditis (thyroid condition) share a name because they were both described by the same surgeon, but they aren't related conditions," Mr. Petrie says.

That does not mean the wrist exists in isolation from the rest of the body. "Some autoimmune conditions can lead to more inflammation and swelling of tendons, which can lead to DeQuervain's tenosynovitis. There is no significant connection to thyroid dysfunction," says Dr. Jason Somogyi, a board-certified orthopaedic surgeon specialising in hand and upper extremity surgery at Texas Orthopedics.

Dr. Lee is more guarded on the thyroid question. "Diabetes and thyroid disease can be risk factors," he says.

Waiting rarely works

Left untreated, the condition tends to entrench itself. "It doesn't tend to resolve on its own… Left alone, the tunnel tends to keep tightening, and patients often start avoiding thumb use altogether, which just creates new strain patterns elsewhere," Mr. Petrie says.

The first line of treatment

Early on, the emphasis is on changing how the hand is used and resting the thumb, typically in a splint. When that is not enough, the next step in many clinics is an injection.

"The mainstay of treatment in my practice is a steroid injection into the tendon sheath," Dr. Lee says. "The majority of the time, injections are curative. We can try up to two injections prior to considering surgery."

The physiotherapy divide

If the specialists differ mildly on inflammation, they differ sharply on physiotherapy.

"Typically, I do not recommend PT or exercises for this condition, as I find it usually makes the symptoms worse," Dr. Cuellar says.

Dr. Date sees a role for it at both ends of treatment. "Physiotherapy can be useful, particularly in patients with early or persistent symptoms… Physiotherapy can also be useful after an injection or surgery, particularly when there is stiffness, weakness or apprehension about using the hand normally again," he says.

On the machines that often accompany a course of physiotherapy, Dr. Somogyi is blunt. "Unfortunately, laser and ultrasound treatments have not been found to be consistently effective," he says.

When surgery enters the conversation

"The tipping point is usually one of two things: two proper steroid injections that didn't provide lasting relief, or pain that's genuinely interfering with daily life," Mr. Petrie says.

The second of those is not the same for everyone. "Someone who relies heavily on their hands for work may be affected much more by the same degree of pain than someone with fewer demands on the wrist," Dr. Date says.

The operation itself is a matter of making room. "The affected tendons are passing through a tight compartment, so the surgeon releases the roof of that compartment to give them more room to move. The tendon itself usually does not need to be repaired because there is generally no tear," Dr. Date says.

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