Tenosynovitis Clinical Presentation

Updated: Jan 06, 2021
  • Author: Christopher S Crowe, MD; Chief Editor: Harris Gellman, MD  more...
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Presentation

History

General considerations

The history and examination will guide the differential diagnosis of tenosynovitis. Acute pathologies (eg, pyogenic flexor tenosynovitis [PFT] and gout) will often be seen in the emergency department (ED). More indolent or progressive pathologies will often be seen in the clinic. Regardless of setting, a thorough history should be gathered as part of any hand evaluation.

Handedness, occupation, vocations, and functional status should all be ascertained during the patient interview. When infectious etiologies are under consideration, the past medical history should focus on the presence of diabetes mellitus, immunosuppression, peripheral vascular disease, renal disease, smoking status, and injection drug use. When inflammatory tenosynovitis is being considered, determine if the patient has a prior diagnosis, presence of arthritis, or other sites of tendinitis. The onset of symptoms should be estimated as accurately as possible.

Infectious tenosynovitis

Patients may describe antecedent trauma in the form of a puncture wound, laceration, or bite, though no obvious injury may be reported. Often, patients will describe progressive pain, swelling, stiffness, and erythema along the affected finger. Fever was infrequent (17%) in one large study, and no patients had signs of systemic infection. [11]  

Gonococcal flexor tenosynovitis most commonly affects sexually active teenagers and young adults. It is more common in women, especially during pregnancy or after menstruation, when systemic dissemination of gonorrhea is more likely to occur. Features of gonococcal tenosynovitis include the following:

  • The interval from sexual exposure to onset of symptoms of dissemination can range from 1 day to several weeks
  • Vaginal or penile discharges are usually absent
  • Fever, chills, malaise, and polyarthralgias are common
  • The most commonly affected sites are the dorsum of the wrist, hand, and ankle

Idiopathic or stenosing tenosynovitis

Patients with early development of trigger digits may describe a painless clicking with passive digit motion that generally improves throughout the day. With disease progression, patients may describe painful catching or locking of the digit into flexion. This may or may not require passive extension with the contralateral hand to "unlock" the affected digit. This phenomenon is related to the powerful flexor's ability to overcome a stenotic sheath (and the extensor's inability to generate the necessary force to unlock the digit). In severe delayed cases, prolonged locking of the digit can lead to secondary contractures. 

The primary symptom of de Quervain tenosynovitis is pain along the thumb radial wrist that often radiates proximally and is typically gradual in onset. Pain is usually worse with power grip and weightbearing with the wrist in the neutral position. Swelling may be noted adjacent to the radial styloid. Crepitus and frank triggering are rarely reported. Classically, de Quervain tendinitis may afflict new mothers who are repeatedly lifting newborns and infants.

Inflammatory tenosynovitis

The presentation of inflammatory tenosynovitis is typically more indolent and progressive fashion than that of infectious tenosynovitis. However, it may sometimes mimic that of an infection, which may be further complicated if the patient has no prior diagnosis (eg, gout or rheumatoid arthritis [RA]). Reported symptoms are similar to those of other types of tenosynovitis and include digital stiffness, swelling, and, in some instances, frank triggering. When an acute inflammatory response is present, the digit may be erythematous. Gout can be severe enough in some cases to cause malaise or even low-grade fever. 

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Physical Examination

Infectious tenosynovitis

Patients with PFT can present at any time after a penetrating injury. Initial inspection may reveal an erythematous, swollen digit. The patient may guard the hand because of exquisite tenderness and may be resistant to demonstrating active motion. Kanavel signs are observed with varying frequency and include the following:

  • Semiflexed digit at rest
  • Uniform swelling of the entire digit
  • Tenderness along the flexor tendon sheath
  • Exquisite pain along the volar surface of the digit with passive extension

The presence of these signs and their routine use to confirm a diagnosis of flexor tenosynovitis has been a topic of debate. Whereas uniform swellling is a sensitive finding, [11] other infectious and inflammatory processes also cause diffuse swelling; therefore, this finding may not differentiate cellulitis or dorsal finger abscesses from PFT. [39] ​ Some authors believe pain with passive extension to be the most reproducible sign [40] ; others have not found this to be the case.

More recent study has shown that these signs have considerable sensitivity but lack specificity on an individual basis. [39] Furthermore, these signs may be entirely absent in cases of early presentation, chronic infection, immunocompromise, or recent antibiotic administration.

One critical misunderstanding has to do with so-called fusiform swelling. The term fusiform refers to a spindle-shaped enlargement that is often seen in patients with rheumatoid tenosynovitis. [39] Kanavel never used this term to describe the swelling encountered in PFT, instead describing it as uniform. [39] This point becomes clinically relevant insofar as it may provide the clinician with a subtle feature that can differentiate between causes of tenosynovitis.

Additional clinical features of gonococcal tenosynovitis include the following:

  • Fever is common
  • Dermatitis is also common (occurring in approximately two thirds of disseminated gonococcal tenosynovitis cases); it is characterized by hemorrhagic macules or papules on the distal extremities or trunk

Idiopathic or stenosing tenosynovitis

Trigger digits are often confirmed by replicating the describe locking of the affected finger. If popping or locking cannot be demonstrated on active or passive flexion of the digit, then the examination becomes slightly more nuanced. A nodule, representing focal swelling of the tendon proximal to the A1 pulley, may be palpated in the palm. 

Patients with de Quervain tenosynovitis will typically have swelling at the first dorsal comparment. Palpation of the retinaculum is painful. Two eponymous tests have been described to aid with diagnosis and will generate characteristic pain at the first dorsal compartment [41] :

  • The Finkelstein maneuver is performed by having the patient passively deviate the wrist ulnarly; the thumb is then grasped by the examiner and flexed into the palm
  • The Eichoff maneuver (see the image below) is performed by having the patient close the fist around a flexed thumb; the wrist is then passively deviated ulnarly by the examiner
Eichoff test is performed by having patient make f Eichoff test is performed by having patient make fist with thumb inside fingers. Clinician then applies ulnar deviation of wrist to reproduce presenting symptoms of dorsolateral wrist pain.

One study using asymptomatic volunteers found the Eichoff maneuver to generate more false positives. [42]  

Inflammatory tenosynovitis

As mentioned previously, inflammatory flexor tenosynovitis usually is the result of an identifiable underlying disease process. Findings similar to those found in PFT may eventually present. In inflammatory flexor tenosynovitis, swelling is the most common initial finding. The hallmark of this condition is a difference in active, as opposed to passive, flexion. As the tissue expands and impingement occurs, pain and restricted motion ensue. Delayed presentations can have the appearance of fulminant flexor tenosynovitis with all Kanavel signs or may involve tendon rupture if the patient delays seeking treatment long enough.

Patients with RA will most frequently have involvement of the small joints (eg, metacarpophalangeal [MCP], proximal interphalangeal [PIP], or metatarsophalangeal [MTP] joints). It may be difficult to distinguish articular findings from tenosynovitis. Rheumatoid nodules may be present in 25% of those with RA, fewer in the first year of their disease progression. Tenosynovitis may frequently involve the extensor tendons. 

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