Ultrasound Takes Center Stage in Treating De Quervain’s Tenosynovitis

De Quervain’s tenosynovitis, a stenosing inflammatory condition affecting the first extensor compartment of the wrist, causes pain at the radial styloid during thumb and wrist activities. A new narrative review published in Egyptian Rheumatology and Rehabilitation argues that ultrasound should be central to both diagnosis support and treatment, from guiding corticosteroid injections into the correct tendon sheath to enabling minimally invasive percutaneous release of the constricting retinaculum.

The condition involves the tendon sheaths of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL), the two tendons that make up the first extensor compartment. Diagnosis is primarily clinical, and conservative management traditionally includes rest, orthotics, nonsteroidal anti-inflammatory drugs and corticosteroid injections into the tendon sheath. Corticosteroid injection has been shown to be a safe and effective treatment, particularly when supported by ultrasound, with symptomatic relief rates reported up to 93.8 percent.

Treatment failure, however, is a recognized problem. The review attributes failed injections largely to the imprecision of non-ultrasound-guided techniques and to anatomical variations in the first extensor compartment. A cadaveric study cited in the review found a striking difference in accuracy: ultrasound-guided injection reached the target in 93.3 percent of attempts, compared with just 40 percent for manual injection guided by anatomical landmarks alone. Injection by anatomical references, the authors note, carries a high probability of missing the target.

Ultrasound findings in the condition include thickening of the APL and EPB tendons at the level of the radial styloid, edema within the first extensor compartment, thickening of the overlying retinaculum and synovial sheath, and occasionally nodular fluid collections. Doppler imaging may reveal a hypoechoic ‘halo sign’ and peritendinous subcutaneous hyperemia. These features allow clinicians to characterize the disease directly rather than relying on external landmarks.

Anatomical variation is where ultrasound proves especially valuable. Variations of the first extensor compartment are common and occur more frequently in people with the disease than in healthy cadavers. In normal cadavers, the prevalence of a septum dividing the compartment was 43.7 percent, while a single APL tendon without accessory slips was observed in 18.3 percent. Among patients with de Quervain’s tenosynovitis, those figures rise to 62.2 percent for a dividing septum and 27.2 percent for a single APL tendon. The review’s authors hypothesize that these variations create a restricted, high-friction environment that is highly susceptible to stenosing tenosynovitis.

The septum can be complete or incomplete and located proximally or distally to the radial styloid. Some authors suggest that patients with a proximally located septum face greater risk and recommend injecting five millimeters proximal to the radial styloid. High-resolution ultrasound allows identification of three anatomical patterns: complete subcompartmentalization, distal incomplete subcompartmentalization, and no subcompartmentalization. A protocol described by Bing and colleagues in 2018 tailored the injection accordingly, treating each affected subcompartment separately when a complete septum was present, injecting proximally where both tendons shared a compartment, and injecting the single compartment when no septum existed. That approach achieved symptomatic relief rates of 95.7 percent.

A more recent randomized controlled trial adds a simplification. Because the primary pathology in de Quervain’s tenosynovitis typically resides within the EPB tendon, Jung and colleagues in 2022 investigated whether, in cases of complete subcompartmentalization, a single injection into the EPB subcompartment was as effective as two separate injections into each subcompartment, regardless of signs suggesting APL tenosynovitis. The trial found no difference in pain relief at six weeks between the groups, and the single-injection group had fewer side effects. This suggests that targeted injection into the EPB sheath alone may suffice even when both tendons appear involved.

Ultrasound guidance may also rival surgery. One study compared patients undergoing ultrasound-guided corticosteroid infiltration with those undergoing surgical release, and reported similar results in pain, function and complications up to six months of follow-up, with no recurrence in either group. The review concludes that ultrasound-guided injection can deliver outcomes comparable to surgical release without the potential complications of the operative approach.

Emerging therapies are also covered. Platelet-rich plasma (PRP) injection, supported by a meta-analysis, significantly reduced pain on the Visual Analogue Scale, improved wrist and hand function measured by Mayo wrist, DASH and Jebsen-Taylor scores, and improved ultrasound findings including tendon thickness, combined tendon and sheath thickness, and extensor retinaculum thickness. Compared with corticosteroids, PRP has a slower onset of analgesic effect, with corticosteroids producing greater pain reduction during the first month, but PRP showed superior long-term outcomes after six months, according to Giroti and colleagues. PRP avoids the risk of cutaneous adverse effects, and recurrence rates of 32 to 48 percent have been reported after a single corticosteroid injection. Reported PRP dosages range from 1.5 to 4 milliliters, with some studies using three injections at four-week intervals, but no high-quality studies have directly compared single versus multiple injections or different doses, limiting protocol standardization.

Ultrasound-guided percutaneous release offers another minimally invasive option. In the technique described by Croutzet and colleagues, pre-procedural ultrasound identifies the tendons, detects subcompartmentalization and localizes the superficial branch of the radial nerve to avoid injury. Under continuous guidance, a percutaneous blade releases the extensor retinaculum with a retrograde cutting motion, decompressing separate subcompartments individually; the median procedure duration was eight minutes, and it proved feasible in an outpatient setting with a manageable learning curve. A retrospective study of 34 patients by Villanova and colleagues reported significant improvements in VAS pain and QuickDASH scores with no major complications and faster recovery than open surgery. A cadaveric study of 59 wrists by Shen and colleagues found an 87 percent success rate for the ultrasound-guided acupotomy technique versus 75 percent for the blind technique, though a small clinical trial of 30 patients found both approaches improved pain and hand function without significant difference. The review’s authors caution that the current evidence base remains limited by small, heterogeneous studies with short follow-up, dependence on operator expertise, and preliminary data for newer therapies that require larger, long-term randomized trials.

Subject of Research: The role of ultrasound in the diagnosis and treatment of de Quervain's tenosynovitis

Article Title: De Quervain's tenosynovitis: the role of ultrasound in management

Article References: Da Costa Neves, F., & Ramos Gonçalves, M. (2026). De Quervain's tenosynovitis: the role of ultrasound in management. Egyptian Rheumatology and Rehabilitation, 53(1), Article 76. https://doi.org/10.1186/s43166-026-00435-8

Image Credits: AI Generated

DOI: 10.1186/s43166-026-00435-8

Keywords: de Quervain's tenosynovitis, ultrasound, corticosteroid injection, platelet-rich plasma, percutaneous release, first extensor compartment, extensor pollicis brevis, abductor pollicis longus, tendon sheath, wrist pain, anatomical variation, tenosynovitis