Tenosynovitis: Causes, Symptoms, and Treatment

The disease known in medical terminology as tenosynovitis is an inflammation of the tendon sheaths. In most of the affected patients, it manifests itself by the appearance of severe, stabbing pain, which is intensified by movement and decreases by immobilization.

In principle, tenosynovitis can affect any tendon of the body. In everyday clinical life, however, it becomes clear that especially tendons at heavily strained body regions are affected. Typical localisations of tenosynovitis are the ankle joints and wrists.

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Causes of tenosynovitis

The causes of tenosynovitis can be very different. In the majority of cases, the occurrence of tenosynovitis can be attributed to overloading or incorrect loading of the joints. The reasons for the development of tenosynovitis can be divided into two main groups. In medicine, a rough distinction is made between non-infectious and infectious causes.

Infectious causes

To understand the causes of tenosynovitis, one must be aware of the structure and function of a tendon sheath. As a double-walled sheath filled with synovial fluid, the tendon sheath lies outside the tendons.

Roughly speaking, it consists of a tight layer of connective tissue (stratum fibrosum) and a synovial part (stratum synovial). In healthy people, the tendon sheath is a closed system that primarily performs a protective function.

Besides, the tendon sheath is intended to absorb the forces and friction that occur during movement processes. Due to the structure of the tendon sheath, it is generally not possible in a healthy organism for the tissue to be damaged by pathogens (for example, bacteria).

However, in the case of traumatic injuries, such as a stab wound, the barrier of the tendon sheath is penetrated, and bacterial colonization is possible. Staphylococci and streptococci are among the most common bacterial pathogens that are considered to be the trigger of tenosynovitis. Furthermore, damage to the tendon sheath can also be caused by chlamydia, mycoplasma, and gonococci. In this case, too, tenosynovitis can develop with severe, stabbing pain and limited joint function.

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Non-infectious causes

Infectious or purulent tenosynovitis is generally less common than non-infectious forms of tenosynovitis.

The leading causes include long-term mechanical misuse or overloading, which leads to irritation of the tendon tissue. According to this, it is precisely long-lasting monotonous movement sequences and severe postural defects that cause the tendon sheaths to rub particularly hard against the bone and thus become damaged. Over time, the abrasion is followed by the roughening of the collagen fibers, which can lead to the development of inflammatory processes.

For this reason, non-infectious tenosynovitis mainly affects office workers and athletes. In most cases, tenosynovitis occurs at the tendon sheaths of the wrists and ankles, i.e., at those places that have to withstand a high degree of stress. Risk factors are especially unergonomic working devices (e.g., keyboards) at the desk.

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Symptoms of tenosynovitis

Patients suffering from tenosynovitis generally complain of severe stabbing pain in the area of the affected tendon sheath. Also, many concerned persons report a pressure pain along the course of the tendon, which can also extend into the muscle. In many cases, overheating of the joint and reddening of the areas of skin above the tendon sheath can also be observed.

The occurrence of pain at rest occurs only in obvious cases. Pain at rest is rather untypical for tenosynovitis. In the case of long-lasting (chronic) forms of tenosynovitis, nodular thickening, palpable crunching, and rubbing of the tendon may also occur. Besides, the pain phenomenon can be triggered by passive stretching of the tendon in the presence of a tendosynovitis.

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Diagnosis of tenosynovitis

Since the causes for the development of tenosynovitis can be both infectious and non-infectious, a comprehensive diagnosis must precede the choice of the appropriate therapy.

One of the most critical points in the diagnosis of tenosynovitis is the detailed doctor-patient consultation (anamnesis).

The treating physician receives an initial suspected diagnosis from the patient’s description. In addition to the description of the type, intensity, and localization of pain, information about the patient’s professional activity is also of great importance.

Besides, the doctor can draw further conclusions about the underlying disease by palpating the affected area. If the findings are unclear, it is then possible to initiate further examinations. Inflammation markers in the blood (especially elevated white blood cells and the so-called CRP value) indicate an inflammatory event. The blood should be examined for a specific rheumatoid factor. The preparation of an X-ray or an MRI (magnetic resonance imaging) can also be useful in the diagnosis of tenosynovitis.

In medical terminology, an inflammation of the tendon sheaths is called tenosynovitis (synonyms: tenosynovitis, peritendinitis, paratendinitis). In most cases, tenosynovitis manifests itself by a severe stabbing pain in the area of the affected tendons. In severe cases, even redness and overheating may occur.

In principle, tenosynovitis can occur in all tendons of the body, but in everyday clinical practice, it has been shown that mainly the ankle joints and wrists are affected. Among the most frequent causes of tenosynovitis are mechanical overloading or incorrect strain. However, inflammation of the tendon sheaths can also be triggered by bacterial pathogens. In the event of repeated occurrence or long-lasting complaints, other possible causes of pain (so-called differential diagnoses) should be urgently clarified.

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Differential diagnosis

Among the differential diagnoses of tenosynovitis are various arthritic diseases and inflammations of the penis processes.

The disease known as thyroiditis is an inflammatory pain phenomenon, which particularly often affects the bones of the ulna, radius, or metacarpus. Similar to tenosynovitis, thyroiditis also manifests itself through the appearance of stabbing pain in the wrist area.

Besides, many patients describe a painful pressure over the affected penis process. Especially the ulnar thyroiditis, which affects the bony ulna, is regarded as a differential diagnosis to the tenosynovitis. Also, patients who frequently complain of complaints in the wrist area should be considered for differential diagnosis of degenerative joint disease.

The joint disease known under the technical term rhizarthrosis mainly affects the wrist and thumb saddle joint and can, therefore, easily be mistaken for tenosynovitis. In contrast to tendosynovitis, however, rhizarthrosis patients suffer not only from the typical stabbing pain but also from sometimes severe swelling in the area of the affected joint. Furthermore, the joint function of affected patients is severely restricted. The differential diagnosis of rhizarthrosis can be made with the help of an x-ray, in which clear signs of osteoarthritis can be seen. Wrist arthrosis is also considered a frequent differential diagnosis of tenosynovitis. In wrist arthrosis, there are signs of wear and tear of cartilage tissue on joint forming bone surfaces. Cartilage wear and tear can have many causes, but in the majority of patients affected, no reason can be found for the occurrence of wrist arthrosis. The main symptoms include pain and swelling in the area of the affected joint. Besides, many patients complain of severe limitations in joint function and also show visible deformities.

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Diagnosis for treatment approach

Especially about the different possible causes of tenosynovitis, the diagnosis plays a decisive role in the choice of the best viable therapy strategy.

While infectious forms can usually be treated with the help of an antibiotic, the non-infectious tenosynovitis types require a more extensive treatment. The most crucial point in the diagnosis of tenosynovitis is a comprehensive doctor-patient consultation (anamnesis).

By questioning the patient regarding pain quality, intensity, and localization, the attending physician can already gain first indications for the presence of a tenosynovitis. Furthermore, the radiation of the pain via the muscle adjacent to the inflamed tendon is a characteristic feature of tenosynovitis.

Furthermore, special tests are usually carried out for diagnosis, which indicates the presence of a tenosynovitis with a high probability.

Finkelstein test

In the so-called Finkelstein test, the doctor grasps the patient’s thumb and tries to move the hand quickly in the direction of the ulna. If a tenosynovitis is present, intense pain in the area of the radius will occur.

Eichhoff test

The preparation of x-rays can be helpful in the diagnosis of tenosynovitis.

During the Eichhoff test, the patient is asked to place the thumb of the aching hand on the palm and wrap it with the other fingers. Then the doctor will move the hand in the direction of the little finger. Patients with tenosynovitis report intense pain radiating into the arm during this test.

Apart from the description of the symptoms, information about professional activities, and possible leisure time activities is of great importance. Office workers, musicians, and athletes tend to suffer from tenosynovitis much more frequently.

The second step in the diagnosis of tenosynovitis is the physical examination of the patient. By palpation of the affected body region, the pain usually increases in intensity.

Also, so-called “crunching noises” can often be detected when moving the affected joint, which are caused by rubbing the inflamed tendon sheath over the bone.

If the findings are unclear, it may also be necessary to initiate further examinations. In addition to the physical results and symptoms, a blood test can be used to detect unique inflammation markers. In the presence of tenosynovitis, the blood contains mainly elevated white blood cells and CRP values. In addition to the classic signs of inflammation, blood analysis with the detection of a particular rheumatoid factor also provides information about the diagnosis.

Also, the preparation of an X-ray or an MRT (magnetic resonance imaging) can be useful in the diagnosis of tenosynovitis.

Therapy of tenosynovitis

The choice of a suitable therapy for tenosynovitis depends primarily on its causes.

Infectious forms usually require antibiotic treatment, whereas non-infectious types require relief, pain relief, and physiotherapy. Furthermore, the therapy of tenosynovitis depends on the extent as well as on the frequency with which the symptoms occur.

For the majority of the affected patients, drug therapy is entirely sufficient to eliminate the symptoms.

Especially such painkillers (analgesics), which belong to the class of non-steroidal anti-inflammatory drugs, can help to effectively relieve the stabbing pain in the area of the affected joint. When choosing an analgesic, anti-inflammatory drugs should be the means of choice.

In addition to relieving pain, these can contain the course of the disease and bring about a rapid recovery of the tendon sheaths.

In addition to pain relief, immobilization of the affected joint also plays a vital role in tenosynovitis therapy.

The application of supporting bandages and the use of anti-inflammatory ointments or creams are considered helpful by most patients.

In the case of chronic forms of tenosynovitis or such patients who frequently suffer from tenosynovitis, the adjustment of a so-called chain splint may become necessary. A warp splint is a splint adapted to mechanical stress symptoms, which alleviates the complaints of external compression of the affected area.

A further point not to be neglected in the treatment of tenosynovitis is the adjustment of the working conditions.

Patients who work a lot with computers should change over to ergonomic keyboards and mice. Ultimately, the non-infectious forms of tenosynovitis can only be counteracted by a reduction of incorrect and excessive strain. For chronic forms of tenosynovitis, the use of local anesthetics or cortisone-containing preparations can also be considered.

Surgical corrections of the tendon sheath apparatus are necessary in rare cases. This treatment option mainly concerns those patients in whom, despite adequate pain therapy and a change in life circumstances, no or only slight improvement of the pain problem is achieved.

By splitting the affected tendon sheath, a permanent relief of tenosynovitis symptoms can be guaranteed in most cases.

Prognosis

The prognosis for tenosynovitis (tenosynovitis) is generally excellent. Although the course of this disease and thus the painful intervals can be very long, tenosynovitis can be treated well and effectively with comparatively simple means.

In this sense, however, it is essential to get to the bottom of the exact cause of the development of the tenosynovitis. Only a therapy that is precisely adapted to the causal problem can fight the inflammatory processes in the area of the tendon sheath in the long run and thus lead to a good prognosis.

An essential factor for successful healing is the avoidance of activities that are particularly stressful for the joints and can trigger renewed inflammatory attacks. Tenosynovitis that is not treated promptly can lead to the chronicity of the symptoms. In medical terminology, the clinical picture resulting from this phenomenon is called “Repetitive Strain Injury” (short: RSI). Furthermore, a tenosynovitis persisting over a more extended period can lead to inflammatory processes, thickening, and loss of function in the area of the finger flexors. In patients suffering from tenosynovitis and additionally showing rheumatic side effects, the prognosis turns out to be somewhat worse.

Prophylaxis

The development of tenosynovitis can be prevented by following a few simple rules of conduct. One of the most critical factors of prophylaxis is to avoid long-lasting, uniform movements that put excessive strain on the joints. Furthermore, a wrong posture during sports, music-making, and office work should be avoided.

For this reason, typists or office workers should consider the purchase of ergonomic work equipment. Simple cushions, which are placed in front of the keyboard at the workplace, can already achieve significant effects. It has also been proven that a keyboard lying as flat as possible on the table is particularly easy on the joints and tendons. Furthermore, taking regular breaks between typing intervals can be considered a suitable prophylaxis against tenosynovitis.

During these pauses, various muscle relaxing exercises should be carried out, thus preventing the development of inflammatory processes. Also, the regular stretching and warming of the stressed tendon sheaths effectively contributes to a tenosynovitis prophylaxis.

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