de quervain's tenosynovitis...quervain’s tenosynovitis, and tendinitis of the shoulder, these...

Louis PATRY, Occupational Medecine Physician, ErgonomistMichel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist

Marie-Jeanne COSTA, Nurse, ErgonomistMartine BAILLARGEON, Plastic Surgeon

GUIDE TO THE DIAGNOSIS OFWORK-RELATED MUSCULOSKELETAL

DISORDERS2Work-related musculoskeletal injuries are one of the most common occupational

health problems for which physicians are consulted. There is solid scientific evidence thatthese injuries may be occupational in origin.

This guide was designed to help physicians interpret the results of a medicalexamination. By combining the standard clinical assessment procedure with guidelinesconcerning the identification of etiological factors, it helps physicians identify the causeof injury.

AUTHORS

Louis Patry holds a degree in medicine from Laval University anda diploma in ergonomics from the Conservatoire National des Artset Metiers de Paris (CNAM). He is a specialist in occupational medi-cine, an associate member of the Royal College of Physicians andSurgeons of Canada, a professor in McGill University’s Departmentof Epidemiology and Biostatistics and Occupational Health, and con-sulting physician to the Direction de la santé publique (Public HealthDepartment), first in Québec City and currently at the Montréal-Centre board.

Michel Rossignol holds degrees in biochemistry and medicinefrom the University of Sherbrooke, in epidemiology and communityhealth from McGill University, and in occupational medicine fromJohn Hopkins University. He is a professor in McGill University’sDepartment of Epidemiology and Biostatistics and OccupationalHealth, co-director of the Centre for Clinical Epidemiology of theJewish General Hospital of Montréal, and physician-epidemiologistat the Montréal-Centre board of the Direction de la santé publique(Public Health Department).

Marie-Jeanne Costa holds a nursing degree from the Institutd’études paramédicales de Liège and a degree in ergonomics fromthe École Pratique des Hautes Études de Paris. She is an ergonomicsconsultant and has collaborated on several studies of CTDs. She isparticularly interested in the development of participatory ergonom-ics, specifically in the problem-resolution and diagnostic processes.

Martine Baillargeon holds a degree in medicine from theUniversité de Montréal. She is a plastic surgeon and associate mem-ber of the Royal College of Physicians and Surgeons of Canada.After years of practising surgery she is now consulting physician,mainly in the field of musculoskeletal injuries affecting the upperlimb, at the Montréal-Centre board of the Direction de la santépublique (Public Health Board).

De Quervain’sTenosynovitisDe Quervain’sTenosynovitis

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Excerpt of the full publication


DISORDERS

Carpal TunnelSyndrome



De Quervain’sTenosynovitis





Translation: Les Services Organon, Steven Sacks

Graphic design: Gérard Beaudry

Illustrations: Marjolaine Rondeau, Medical Illustration Department of the Laval University Hospital Centre (CHUL) Max Stiebel, Instructional Communications Centre (ICC), McGill University

Rear-cover photographs: Gil Jacques

Legal deposit – Bibliothèque nationale du Québec, 1998Legal deposit – National Library of Canada, 1998ISBN 2-921146-71-1 Éditions MultiMondes (Original edition: ISBN 2-921146-38-X)© Éditions MultiMondes, 1998

Éditions MultiMondes Institut de recherche en santé 930, rue Pouliot et en sécurité du travailSainte-Foy (Québec) 505, boul. de Maisonneuve OuestCanada G1V 3N9 Montréal (Québec)Tel.: (418) 651-3885 Canada H3A 3C2Fax: (418) 651-6822 Tel: (514) 288-1551 Fax: (514) 288-7636

Régie régionale de la santé et des services sociaux – Montréal-Centre Direction de la santé publique 1301, rue Sherbrooke Est Montréal (Québec) Canada H2L 1M3 Tel.: (514) 528-2400 Fax: (514) 528-2459

Canadian Cataloguing in Publication Data

Main entry under title:Guide to the diagnosis of work-related musculoskeletal injuries

Translation of: Guide pour le diagnostic des lésions musculo-squelettiques attribuables au travail répétitif. Includes bibliographical references. Contents: 1. Carpal tunnel syndrome – 2. De Quervain’s tenosynovitis – 3. Shoulder tendinitis. Co-published by: Institut de recherche en santé et en sécurité du travail du Québec. ISBN 2-921146-70-3 (v. 1) – ISBN 2-921146-71-1 (v. 2) – ISBN 2-921146-72-X (v. 3)1. Musculoskeletal system – Wounds and injuries – Diagnosis. 2. Overuse injuries – Diagnosis. 3. Carpal tunnel syndrome – Diagnosis. 4. Tenosynovitis – Diagnosis. 5. Tendinitis – Diagnosis. 6. Occupational diseases – Diagnosis. I. Patry, Louis. II. IRSST (Quebec). III. Workplace Safety & Insurance Board.RC925.7.G8413 1998 616.7’075 C98-940950-3



v

preface

The diagnosis of cumulative trauma disorders (CTDs) presents many unique problems, especially for physicians. The absence of precise criteria upon which to establish a clin ical diagnosis of CTD or decide whether a musculoskeletal injury is related to occupational factors was noted by several members of the advisory committee supporting an international expert group mandated by the IRSST to review the literature on CTDs*. To remedy this situation, in 1992 the IRSST asked a group of researchers to develop diagnostic guides for carpal tunnel syndrome, De Quervain’s tenosynovitis, and tendinitis of the shoulder.

The project team was initially composed of Louis Patry, occupational medecine phy sician and ergonomist, and Michel Rossignol, occupational medecine physician and epide miologist, but quickly grew and increased the scope of its expertise through the addition of Marie-Jeanne Costa, a nurse with ergonomics training, and Martine Baillargeon, a plastic surgeon. All four team members participated in the drafting of the guides.

These guides were designed to help physicians arrive at a clinical diagnosis and identify the most probable etiological agents. It should be noted that these guides were not designed for administrative or legal purposes and that their reliability has not been eval uated by the resear-chers.

The publication of these guides designed specifically for physicians is one more advance in the IRSST’s efforts to shed light on the phenomenon of cumulative trauma disorders and provide specialists with appropriate tools with which to prevent these injuries and reduce related risk factors.

Jean Yves Savoie

Director general Institut de recherche en santé et en sécurité du travail du Québec

* Hagberg, M., Silverstein, B., Wells, r., Smith, M.J., Hendrick, H.W., carayon, p., pérusse, M. (1995), Work related muscu-loskeletal disorders (WMSDs): a refer ence book for prevention, scientific editors: Kuorinka, I., forcier, L., publishers Taylor and francis, London, 421 pages.



vii

InTroducTIon

This guide is the second in a series of practical summaries of current medical knowl edge on musculoskeletal injuries with well-documented occupational etiology, namely:

– carpal tunnel syndrome (CTS) – De Quervain’s tenosynovitis – tendinitis of the shoulder

When occupational in origin, these injuries are often referred to as “CTDs”, a term applica-ble to “problems and diseases of the musculoskeletal system that include, among their causes, some factor related to work” (Hagberg et al., 1995). Whatever term is used to designate them—occupational overuse syndrome (OOS), repetitive strain injuries (RSI) or cumulative trauma di-sorders (CTDs) in English, troubles musculo-squelettiques (TMS), lésions musculo-squelettiques (LMS), lésions musculo-tendineuses (LMS), lésions musculo-tendineuses liées aux tâches répéti-tives, or patho logies d’hyper-sollicitation in French—their defining characteristic is the presence of an injury caused by bio mechanical strain due to tension, pressure, or friction which is exces-sively forceful, repetitive, or prolonged.

This guide is designed for physicians who are called upon in the course of their practice to diagnose musculoskeletal injuries and establish the extent to which these injuries are caused by their patient’s work. Its goal is to help physicians arrive at clin ical and etiological diagnoses. To this end, the guide first reviews the anatomical, phys iopathological, and etiological knowledge upon which diagnosis depends. This is followed by guidelines for the evaluation of symptoms, the conduct of the clinical examination, and the control of potential risk factors related to the development of the injury.

Musculoskeletal injuries may have many causes. For carpal tunnel syndrome (CTS), De Quervain’s tenosynovitis, and tendinitis of the shoulder, these include not only occupational, sports-related, recreational, and household activities, but also specific health prob lems and condi-tions. This guide was prepared in response to requests from physicians, increasingly preoccupied by CTDs, for information and support on this subject. Although the approach taken emphasizes the documentation of potential occupational risk factors—a subject little discussed in formal medical training—it does not neglect the eval uation of other potential causes of De Quervain’s tenosynovitis.

This guide is meant to be used in a clinical setting. To help physicians collect the information they need to diagnosis the injury and establish its causes, it therefore includes a series of questions, presented in readily identifiable text boxes, for them to ask their patients. These questions were derived from psycho-physical scales used by ergonomists to subjectively evaluate workload (Sinclair, 1992) and medical questionnaires developed for the diagnosis of CTS and the evaluation of functional capacity (Katz et al., 1994; Levine et al., 1993; Rossignol et al., 1995).



viii

Should however a physician remain unable to come to a definitive conclusion about the work-relatedness of an injury after consulting this guide, she or he should con tinue to seek information which will enable her or him to better evaluate the occupational musculoskeletal load to which her or his patient is subjected.

Finally, it should be noted that this guide does not address the issues of multiple injuries and the psychosocial aspects of musculoskeletal injuries, important as they may be for the global evaluation of the patient.



ix

TaBLe of conTenTS

Chapter 1 – General Considerations

Introduction and Terminology .......................................................................................................... 1

Epidemiology ........................................................................................................................................ 1

Anatomical Review .............................................................................................................................. 1

Pathophysiology ................................................................................................................................... 1

Chapter 2 – Etiology

General Considerations ....................................................................................................................... 3

Work-relatedness of Musculoskeletal Strain .................................................................................... 3

Chapter 3 – Differential Diagnosis

Thumb carpometacarpal osteoarthrosis ........................................................................................... 5

Intersection Syndrome ........................................................................................................................ 6

Wartenberg’s Syndrome ....................................................................................................................... 6

Brachioradialis Insertion Tendinitis (Insertion of the Brachioradialis) ....................................... 7

Tendinitis of the Extensor Digitorum Communis ......................................................................... 7

Chapter 4 – Clinical Considerations

Symptoms .............................................................................................................................................. 9

Location of Symptoms (Where?) .............................................................................................. 9

Onset of Symptoms (When?) .................................................................................................... 9

Characteristics of Onset (How?) ............................................................................................... 9

Impact on Activities of Daily Living .............................................................................................. 10

Chapter 5 – Recording of Information on Exposure Factors

Occupational History ........................................................................................................................ 11

Previous Work ............................................................................................................................ 11

Current Work .............................................................................................................................. 12

Current Work and Organisational Factors ............................................................................. 14

Sports-related, Recreational, And Household Activities.............................................................. 15

Chapter 6 – Clinical Examination

Physical Examination ........................................................................................................................ 17

Observation ................................................................................................................................. 17

Palpation ...................................................................................................................................... 17

Assessment of Range of Movement ...................................................................................... 17



x

Dynamic Movements against Resistance ................................................................................ 17

Diagnostic Tests ......................................................................................................................... 18

Chapter 7 – Summary of the Evaluation ......................................................................................... 19

Chapter 8 – Guidelines for Therapeutic and Preventive Interventions

Therapeutic Guidelines ..................................................................................................................... 21

Prevention Guidelines ....................................................................................................................... 22

Conclusion ................................................................................................................................................. 23

Bibliography ............................................................................................................................................. 25

List of Figures

Figure 1.1 Insertion and Action of the Tendons of the Extensor Pollicis Brevis and Abductor Pollicis Longus ............................................................................................ 2

Figure 3.1 Test for Carpometacarpal Osteoarthrosis of the Thumb ............................................. 5

Figure 3.2 Test for the Intersection Syndrome................................................................................... 6

Figure 3.3 Test for Wartenberg’s Syndrome ........................................................................................ 6

Figure 3.4 Test of the Brachioradialis .................................................................................................. 7

Figure 3.5 Test of the Extensor Digitorum Communis ................................................................... 7

Figure 6.1 Groove of the Radial Styloid Process, First Dorsal Compartment of the Wrist ......................................................................................................................... 17

Figure 6.2 Test of the Abductor Pollicis Longus ............................................................................. 18

Figure 6.3 Test of the Extensor Pollicis Brevis ................................................................................ 18

Figure 6.4 Finkelstein’s Test ................................................................................................................. 18

Figure 8.1 Therapeutic Intervention Flow-chart .............................................................................. 21

List of Table

Table 8.1 Preventive Approach ......................................................................................................... 22

List of Boxes

Box 2.1 Most Common Stressful Movements of the Abductor Pollicis Longus and Extensor Pollicis Brevis ............................................................................................... 4

Box 4.1 Symptoms Reported by the Patient ................................................................................... 9

Box 4.2 Presentation and Clinical Severity of Symptoms .......................................................... 10

Box 4.3 Questions about Activities of Daily Living ................................................................... 10

Box 5.1 Questions about Previous Work ...................................................................................... 11

Box 5.2 General Questions on Occupational Activity and Associated Symptoms ................. 12

Box 5.3 Questions about Activities that Cause Pain in the Hands or Wrist ........................... 13

Box 5.4 Questions about Organisational Factors at Work ......................................................... 14

Box 5.5 Questions about Sports, Recreational, and Household Activities Involving the Hands or Wrist ......................................................................... 15

Box 7.1 Clinical Aspects ................................................................................................................... 19



1

IntroductIon And termInology

De Quervain’s tenosynovitis or tendinitis was first described in 1895 by Fritz De Quervain, a Swiss surgeon. Prior to this, the first use of the terms “tenosynovitis” and “crepitating peritendinitis” to describe injuries to the tendons and surrounding tissues was by Velpeau in 1825. This condition is a wrist tendinitis with inflammation of the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis.

epIdemIology

De Quervain’s tenosynovitis is the most common tenosynovitis affecting the dorsal tendons of the wrist. It is usually diagnosed in individuals between 30 and 50 years of age and is ten times more prev alent among women than men (Dupuis, 1986). American and Scandinavian studies examining the relation between work activities and De Quervain’s tenosynovitis have rarely distinguished between this condition and other type of tendinitis of the wrist and hands. Epidemiological studies have demon strated that workers in the meat processing and man u facturing industries run a higher risk of de vel oping tendinitis of the hand and wrist: performing highly repetitive work increases the relative risk of developing De Quervain’s tenosynovitis to 3.3, while performing work requiring the exertion of great force increases it to 6.1. Among individuals performing work that is both highly repetitive and forceful, the relative risk is 29 (Hagberg et al., 1995).

AnAtomIcAl revIew

The tendons of the forearm are relatively long, extending beyond the wrist to cover the dorsal aspect of the hand and thumb. The tendons of the abductor pollicis longus and extensor pollicis brevis both run through the groove of the radial styloid process in the first of the six dorsal com partments of the wrist and have their insertion at the base of the first metacarpal and the proximal phalanx of the thumb (Figure 1.1).

These muscles, individually and jointly, extend and abduct the trapezometacarpal joint and extend the metacarpophalangeal joint. They are also active during radial deviation and, to a lesser extent, flexion of the wrist (Kendall et al., 1988). Both are innervated by the posterior interosseous branch of the radial nerve, which originates mostly in the C6, C7, and C8 roots.

pAthophysIology

De Quervain’s tenosynovitis is a stenosing tenosyno vitis involving inflammation of the tendon sheath of the extensor pollicis brevis and abductor pollicis longus (Dupuis, 1986; Hagberg et al., 1995). The rigidity of the structures and limited space within the wrist compartment favour the de velopment of tenosynovitis.

General Considerations1

Tenosynovitis Inter.indd 1 02/04/08 15:44:28


2

Guide to the Diagnosis of Work-RelatedMuskuloskeletal Disorders

Tenosynovitis may result from trauma or from excessive friction between the tendon and sur rounding tissues during movements of the thumb and wrist. The thickness of the synovial membranes is an indication of the stage of the tendinitis. As the inflammation progresses, the tendon tends to thin out and become more friable,

and stenosis increases. In the final stages, the sheath of the first dorsal compartment thickens, becomes fibrous, and impinges on the space of the fibroosseous groove. This may result in “trigger finger”, a chronic form of De Quervain’s tenosynovitis.

Figure 1.1

Insertion and Action of the Tendons of the Extensor Pollicis Brevis and Abductor Pollicis Longus

Extensor pollicis brevis Abductor pollicis longus

Tenosynovitis Inter.indd 2 02/04/08 15:44:29





DISORDERS2Work-related musculoskeletal injuries are one of the most common occupational

health problems for which physicians are consulted. There is solid scientific evidence thatthese injuries may be occupational in origin.

This guide was designed to help physicians interpret the results of a medicalexamination. By combining the standard clinical assessment procedure with guidelinesconcerning the identification of etiological factors, it helps physicians identify the causeof injury.

AUTHORS

Louis Patry holds a degree in medicine from Laval University anda diploma in ergonomics from the Conservatoire National des Artset Metiers de Paris (CNAM). He is a specialist in occupational medi-cine, an associate member of the Royal College of Physicians andSurgeons of Canada, a professor in McGill University’s Departmentof Epidemiology and Biostatistics and Occupational Health, and con-sulting physician to the Direction de la santé publique (Public HealthDepartment), first in Québec City and currently at the Montréal-Centre board.

Michel Rossignol holds degrees in biochemistry and medicinefrom the University of Sherbrooke, in epidemiology and communityhealth from McGill University, and in occupational medicine fromJohn Hopkins University. He is a professor in McGill University’sDepartment of Epidemiology and Biostatistics and OccupationalHealth, co-director of the Centre for Clinical Epidemiology of theJewish General Hospital of Montréal, and physician-epidemiologistat the Montréal-Centre board of the Direction de la santé publique(Public Health Department).

Marie-Jeanne Costa holds a nursing degree from the Institutd’études paramédicales de Liège and a degree in ergonomics fromthe École Pratique des Hautes Études de Paris. She is an ergonomicsconsultant and has collaborated on several studies of CTDs. She isparticularly interested in the development of participatory ergonom-ics, specifically in the problem-resolution and diagnostic processes.

Martine Baillargeon holds a degree in medicine from theUniversité de Montréal. She is a plastic surgeon and associate mem-ber of the Royal College of Physicians and Surgeons of Canada.After years of practising surgery she is now consulting physician,mainly in the field of musculoskeletal injuries affecting the upperlimb, at the Montréal-Centre board of the Direction de la santépublique (Public Health Board).

De Quervain’sTenosynovitisDe Quervain’sTenosynovitis

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de quervain's tenosynovitis...quervain’s tenosynovitis, and tendinitis of the shoulder, these...

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