Margaret D., a 45-year old pianist and professor at a music school in New York, had been preparing for a European concert for a year and was thus practicing more than usual. A month before she was due to depart for Europe, she began experiencing a constant and severe pain in her left wrist. The pain, which was sharp, originated near the base of her thumb and gradually spread farther back into her forearm. When she played the piano or tried to grasp or pinch an object, she felt a sharp pain in her wrist. She also felt some numbness at the back of her thumb and index finger, and found a fluid-filled cyst on her left wrist. Overall, she had difficulty moving that thumb and wrist. She was extremely nervous and upset when she consulted me, fearing she might have to cancel her European concert.
Upon examining her, I found that her left wrist was swollen and extremely tender, especially at the base of the thumb. Margaret was unable to bend her wrist or grasp a book or a cup. Believing that she had de Quervain tenosynovitis, I performed the ‘Finkelstein test’ to determine the source of Margaret’s pain. I asked her to hold her thumb in the palm of her hand and bend her wrist toward the little finger. Margaret felt immediate exacerbation of the pain, which confirmed my diagnosis of de Quervain tenosynovitis.
De Quervain tenosynovitis affects two tendons: the extensor pollicis brevis and the abductor pollicis longus, which are located on the lateral side of the wrist. These run parallel to each other and pass through the wrist in the synovial sheath. This sheath enables the tendons to exercise their function: i.e. flexing and extending the thumb, like when you make a fist.
Some doctors believe the cause of de Quervain tenosynovitis is unknown. Others believe that it can be caused by repetitive exercise such as playing piano, like in Margaret’s case. Overuse of the two tendons can cause wrist pain, swelling, numbness or a tingling sensation when the nerve is pinched. The differential diagnosis also includes osteoarthritis of the first scarpometacarpal joint: i.e. the osteoarthritis at the base of the thumb.
There are various ways of treating this condition:
- Western medicine:
- Non-steroid anti-inflammatory drugs such as ibuprofen, naproxen, Aleve, etc.
- Steroid injections, which are often extremely effective, however, the side effect is that steroid might cause the tendon become fragile and easily reinjuried.
- Natural treatment:
- Immobilization of the thumb by using a spica splint, which fixes the thumb in place, promotes total rest, and avoids any thumb movements. 2. Hot/cold compresses can be effective. First apply a heating pad to the affected area to induce blood flow to the affected thumb and wrist, which will flush away the inflammatory factors. Next, apply ice packs to drive away the inflammatory fluids.
2.Acupuncture. The three most important points to utilize in this treatment are
- Large Intestine 4 He Gu, which serves to increase the endorphin secretion in the brain. It can thus synchronize with local points to decrease the pain signals from the brain.
- Large Intestine 5 Yang Xi and San Jiao 4 Yang Chi. LI 5 is the point located exactly in-between the tendons of the extensor pollicis brevis and the abductor pollicis longus of the distal insertion. SJ 4 is adjacent to the LI 5, and will help the healing effects of LI5. Heating this area will increase the amount of blood flow and wash away the inflammation. Electrically stimulating the two needles will continually increase the energy flow to the area to decrease the feeling of pain.
- Large intestine 11 Qu Chi. LI 11 is the point along the same meridian of LI5 and helps decrease the pain by activating energy from the distal meridian.
|1||He Gu||LI 4||See table 3-1/Pic 3-4||See table 3-1|
|2||Yang Xi||LI 5||On the radial side of the wrist, when the thumb is tilted upwards, it is in the depression between the tendons of m. extensor pollicis longus and brevis||Headache, redness, pain and swelling of the eye, toothache, sore throat, pain of the wrist|
|3||Yang Chi||SJ 4||On the transverse crease of the dorsum of wrist, in the depression lateral to the tendon of m. extensor digitiorum communis. See Pic 11-1.||Pain in the arm, shoulder and wrist, malaria, deafness, thirst.|
|4||Qu Chi||LI 11||See table 4-1/Pic 4-2||See table 4-1|
Margaret received acupuncture treatment three times a week for four weeks then came in twice a week for an additional six visits with the electrical stimulation and heated needle treatments. She also wore the spica splint and used an ice massage treatment immediately after practicing piano. Her pain decreased significantly and she went to Europe for her piano tour. As a reward to me, she brought her CDs recorded in her Europe trip to me. She had very successful performance.
Tips for acupuncturists:
- In addition to the above points, you may add a few Arshi points along the insertional tendons of extensor pollicis brevis and abductor pollicis longus. Note that the distal tendons are located in the lateral wrists, and are also called the “snuff box”.
- Recommend that the patient wear the spica splint, which will immobilize the patient’s wrist and accelerate the healing process.
Tips for patients:
- The sooner treatment is commenced, the better chance you have of recovering; you should not wait to consult the doctor.
- Resting and immobilization are necessary. Many physicians think the cause of this condition is idiopathic (unknown), but my observation is that mechanical repetitions of the thumb cause this condition.
- After acupuncture and heating and electrical stimulation, it is best to apply ice to the wrist, which in turn helps decrease the inflammation.