Tendons connect bones and muscles and serve to transmit force: When a muscle contracts (contraction), the pull on the tendon moves the bone connected to it – a movement occurs. In various parts of the body, our tendons are surrounded by protective sheaths of connective tissue called tendon sheaths. Overuse or improper use of the attaching muscles can lead to inflammatory irritation of these tendon sheaths: The affected person suffers from an acute Tendovaginitis, medical term tendovaginitis.
Most often, this disease occurs in people who work with computer screens in the wrist area. In running athletes, tendovaginitis also occurs in the foot or lower leg. Patients suffering from tendovaginitis can only move their hand with pain. They are severely restricted professionally and in their everyday activities.
As a rule, tendovaginitis heals completely after adequate immobilization, appropriate pain medication and accompanying physiotherapy. Only in exceptional cases is it necessary for the specialist to remove pronounced constrictions within the tendon sheath by means of a surgical intervention.
To prevent recurrent tendon sheathitis, the doctors at the joint clinic advise patients individually on possible changes to their work situation and leisure activities.
What is tendovaginitis (tendonitis of the hand)??
Synonyms for tendon sheath inflammation:
- Tendovaginitis
- Tenosynovialitis
- Peritendinitis
- Paratendinitis
- in the English language area: tenosynovitis
Tendovaginitis is most common in the hand, but it can also occur in the foot or forearm. Tendon sheaths form a protective sheath around individual tendons and prevent the tendons from rubbing against the surrounding tissue and wearing out.
Tendon sheaths are found in places where tendons run very close to hard bony structures. On the hand, tendons run close to the finger bones for optimal power transmission. The tendons are embedded within their sheaths in a viscous synovial fluid, which allows the tendon to glide smoothly within its covering.
If a tendon sheath is subjected to too much stress, symptoms such as swelling and inflammation develop. The tendon itself may also undergo inflammatory changes. At some point, the fluid film in the tendon sheath is no longer sufficient for the sliding movement of the tendon. Sometimes the thickened tendon even gets "stuck" in its sheathing.
Due to the inflammation, the surfaces of the tendon and tendon sheath change and can become irregular and rough. Typically, patients hear and feel rubbing during movements. The doctor then speaks of tendovaginitis crepitans.
Symptoms: How to recognize tendovaginitis?
Symptoms of tendonitis:
- Pain at the affected tendon, initially only during movement, later also at rest
- Inflammatory swelling, redness and heating
- radiating pressure pain
- restricted mobility
- possibly. grinding noise and rubbing sensation in tendovaginitis crepitans
Patients with tendonitis typically see a doctor because of their stabbing and pulling pain, especially in the area of the affected tendon sheath. Along the course of the tendon and muscle, the affected person feels a pressure pain. The attached joint feels overheated and is swollen and reddened.
Which joint can be affected by tendovaginitis?
- The wrist in cases of tendon sheath inflammation of the hand tendons or, less commonly, the forearm muscles
- the ankle joint in case of inflammation of the tendon sheaths in the area of the Achilles tendon
At the beginning of the disease, the hand hurts or the tendon is inflamed. the foot only during movement. Over time, pain and symptoms develop, from which patients suffer even at rest or at night.
Special forms of tendovaginitis of the hand:
Tendovaginitis of the hand can cause very different manifestations and symptoms, depending on which tendons and fingers are affected by the inflammation. The two most common special forms of tendovaginitis of the hand are briefly explained below.
Snapping finger or fasting finger (tendovaginitis stenosans, digitus saltans)
The flexor tendons of the palm of the hand can thicken with inflammation due to overload. Then the flexor tendon no longer slides smoothly through its annular ligament, which guides it close to the finger bone. The knot-like thickened tendon can still be bent, but can only be stretched again with additional force: A fasting finger (tendovaginitis stenosans) develops. The left picture shows the extensibility of the fingers in healthy individuals. In the middle picture, extension of the fingers after bending is only partially possible (grade 2); on the right, active extension is impossible (grade 3).© ellepigrafica, Adobe Stock
If the flexor tendons of the fingers in the palm of the hand are affected by tendon sheath inflammation, this is referred to as fast finger or snap finger.
On the underside of the hand, there are eyelet-shaped annular ligaments in which the flexor muscles are guided close to the finger bones. In the case of the snap finger, these tendons and their tendon sheaths are thickened in a nodular fashion. When bending, the nodules slide down through the ring ligaments. If the finger is to be stretched again, greater force is required to move the knot upwards through the tight annular ligament – the finger "snaps" back into extension in a rapid movement.
Quervain’s disease or "housewife’s thumb" (tendovaginitis de Quervain)
If tendovaginitis affects the wrist area where the thumb muscles run, it is called tendovaginitis de Quervain or "housewives thumb". This involves the short thumb extensor muscle (Musculus extensor pollicis brevis) and the long thumb abductor muscle (Musculus abductor pollicis longus). These can become inflamed and swollen with overwork or monotonous exercise.
Women are about 8 times more likely than men to suffer from Quervain’s disease, which is more common after the age of 40. The first year of life occurs.
What are the possible causes of tendonitis??
Causes and risk factors of tendon sheath inflammation:
- Acute overuse of tendons in the hand, forearm or foot e Misuse and overuse of tendons
- monotonous, repetitive motion sequences
- underlying diseases such as rheumatism, gout, diabetes, arthrosis
- Pregnancy, lactation, menopause
Basically, tendonitis is caused either by acute overuse of the tendons and tendon sheaths or by chronic overuse. Causes are mostly monotonous motion sequences.
Only very rarely is tendovaginitis caused by a bacterial infection. As a rule, overloading and incorrect loading are the triggers for the inflammatory changes.
Renovation work in the house or a strenuous move, working at the computer for a long time, typing on the cell phone or frequently playing music with an instrument – for many people these are the typical causes of tendovaginitis of the hand. Certain occupational groups, such as gardeners, construction workers or physiotherapists, are particularly at risk of developing tendonitis because their hands perform the same or similar movements every day.
In the case of excessive screen work or the operation of small electronic devices, an RSI syndrome or "mouse arm" can occur. In the case of mouse arm, there are no anatomical changes yet, as in the case of tendonitis.
Running athletes, ballet dancers, skiers and amateur athletes with unsuitable footwear may experience Achilles tendon irritation and inflammation of the tibial or fibular muscles. The result can be tendonitis in the ankle area.
In addition, according to scientific literature, various underlying diseases such as rheumatoid arthritis, diabetes mellitus or gout promote inflammation of the tendons and tendon sheaths. Tendon sheath inflammation can also occur more frequently during pregnancy or during menopause. Likewise, arthritic changes of the finger joints can be accompanied by similar symptoms as tendovaginitis. Therefore, it is especially important that the orthopedic specialist makes an accurate diagnosis.
The most common cause of acute tendovaginitis is overuse and improper strain on the hand. A temporary immobilization helps in most cases. The tendonitis heals completely. © Robert Kneschke, Adobe Stock
Diagnosis: What examinations does the doctor perform if he suspects tendovaginitis??
In most cases, a discussion and physical examination by the primary care physician or orthopedic surgeon are sufficient to reliably diagnose tendonitis.
The basis of every therapy: the doctor-patient discussion
The doctor clarifies the exact origin of the pain and takes the patient’s medical history (anamnesis). He might ask the following questions in conversation:
- What is your profession??
- Work a lot on the PC?
- Which hobbies do you pursue?
- Play an instrument?
- Have you already been diagnosed with diseases such as diabetes, arthritis or rheumatism?
- Have you moved recently or have you done any heavy physical work?
- How long have you been suffering from the discomfort?
- During which movements do you have pain? Do these also occur at rest or only with movement?
Functional tests of the hand in tendovaginitis
He then performs some movement and function tests to determine the exact extent of the movement restrictions. How far can the patient bend the fingertips in the direction of the palm?? Can all fingers touch the thumb with the tip?
For example, the so-called Finkelstein test is considered proof of the presence of Quervain’s disease: the patient hits the affected thumb into the other fingers, forming a fist. If the hand is bent at the wrist in the direction of the ulna (ulna), a patient with Quervain’s disease feels a sharp pain on the side of the thumb.
Imaging procedures: Ultrasound is usually sufficient
In most cases, an ultrasound examination (sonography) is sufficient to visualize the tendons in the case of tendovaginitis. A radiological examination is only necessary if the treating physician suspects bony changes behind the patient’s complaints.
If the patient suffers from an additional underlying disease, such as diabetes or gout, a laboratory analysis of the blood helps to clarify the condition. The blood test can also reliably exclude a bacterial cause of inflammation.
Conservative treatment for tendovaginitis
Non-surgical therapy for tendonitis:
- Rest and possibly. Immobilization by means of splint: cooling, electrotherapy
- Analgesic, anti-inflammatory drugs (tablets, ointments) e Injection of preparations containing cortisone
For the treatment of tendon sheath inflammation, the non-surgical measures are in the first place. They lead to a complete and complication-free healing of this painful disease in the majority of patients.
Rest and immobilization
A splint that encloses the hand and wrist can be used to immobilize the tendonitis. In this way, the patient avoids unnecessary painful movements. However, the hand must not be kept immobile in the splint for too long, as the tendons could shorten. © nancy dressel, Adobe Stock
Initially, patients should completely avoid the triggering movements or situations.
To prevent inflammation from recurring at ever shorter intervals and becoming chronic, it is often necessary to adjust working conditions. At computer workstations, ergonomically shaped computer mice and special hand rests help to relieve the finger tendons and prevent renewed inflammation.
The specialists at the Joint Clinic will be happy to advise patients on changes to their work situation or on how to reduce the pain. recreational activities. Here, too, it may be necessary to make one’s own activities more joint-friendly, to optimize technique or to switch to other hobbies.
To immobilize the painful joint, a specially made splint (orthosis) can be of good service. With it, patients avoid unnecessary movements with the injured hand or. The injured foot.
But be careful: The immobilization in a splint may only last a short time and must be discussed with the treating physician! If the tendons are spared for too long, they can shorten and restrict hand or foot movement.
Physical therapy: cold applications and electrotherapy
Cooling the inflamed tendon and the painful muscle process can help to alleviate the discomfort in patients with pronounced signs of inflammation. Swelling and pain go down.
In the case of cold applications in the form of compresses or ice, patients must bear in mind that direct skin contact can cause damage to the tissue. For this reason, the physiotherapists at the Joint Clinic use so-called cryo-cuff cooling devices, for example. This involves placing a cuff with cold fluid flowing through it on the diseased joint.
Accompanying light stretching exercises help to maintain mobility and strengthen the tendons. The treating physician decides individually whether additional electrotherapeutic applications such as shock wave therapy or iontophoresis have a positive effect.
Medicinal therapy
Anti-inflammatory and pain-relieving drugs from the group of non-steroidal anti-inflammatory drugs (NSAIDs) can reduce the discomfort of a patient with tendonitis. Active ingredients include, for example, ibuprofen and diclofenac, which the patient can choose to apply as a tablet or ointment directly to the painful area. The lowest possible dose is determined in consultation with the doctor.
Injection of anti-inflammatory cortisone
If the hoped-for success with conventional treatment of tendovaginitis fails to materialize, it is possible to inject a cortisone-containing preparation combined with a local anesthetic directly into the inflamed tendon. This treatment method is called infiltration.
In many cases, infiltration quickly relieves pain symptoms. The inflammation recedes quickly. The specialists make sure that the injection is never made directly into the tendon, but only into its immediate vicinity. In a preliminary discussion, the specialists decide together with the patient about the chances of success and the risks of this intervention.
Local injection of low-dose anesthetic and cortisone into the area of the inflamed tendon or. Tendon sheath relieves pain and has a decongestant effect. © lesterman, Adobe Stock
Physiotherapy and exercises for tendonitis
In the acute stage, physiotherapy is also about controlling the signs of inflammation. Measures that support and improve the metabolism and thus the nutritional situation in the affected area are particularly suitable. This includes manual lymphatic drainage as well as the ZRT therapy applied in the associated joint rehab. These measures stimulate and accelerate the healing process. When the acute phase slowly subsides, the patient can begin gentle stretching and hand exercises to improve mobility. As a general rule, never work into the pain.
Training phase and prevention
Continuous, monotonous movements are not only bad in case of existing tendonitis. The following exercises are particularly suitable for adding variety to the load on the fingers and wrist. Important: Do not use these exercises in the acute phase. However, they are helpful in restoring mobility after the acute phase has subsided. In addition, the exercises prevent tendonitis from recurring. The exercises can also be performed as a short hand workout at work during breaks.
Exercise 1: Stretching the fingers with plasticine
Exercise goal: Mobilization of the fingers into extension.
Starting position: Place the plasticine on the table. Now place the hand on the kneading mass.
Execution: go with the fingertips into the plasticine and then stretch out the fingers against the resistance of the plasticine.
Repeat the exercise 10 times per affected hand. This corresponds to one set. Perform 2-3 sets with about 60 seconds rest between each set. Exercise at least 2 to 3 times per week.
Stretch your fingers against the resistance of the plasticine. © Joint Clinic
Exercise 2: Reverse finger extension
Exercise objective: Activation of the extensor muscles of the fingers and mobilization of the fingers into extension.
Starting position: place your hand with the back of your hand on the table.
Execution: Stretch your fingers and try to touch the table top with your fingertips. Hold the tension for 5 seconds and then return to the starting position.
Repeat the exercise 10 to 15 times per affected hand. This corresponds to one set. Perform 2-3 sets with approximately 30 seconds rest between each set. Exercise at least 2 to 3 times a week.
The hand rests loosely on the table with the back of the hand. © Joint Clinic
Bring the fingers into extension to touch the table top. © Joint Clinic
Exercise 3: Passive mobilization of the fingers
Support the stretching of the little finger with the other hand. © Joint Clinic
Objective of the exercise: passive end-degree mobilization of the finger joints into extension.
Starting position: Rest the elbow of the affected arm on the table.
Execution: Stretch the little finger. Support this movement with the other hand to bring your finger even further into extension until you feel a pulling sensation. However, the pulling should not be painful. Hold this position for at least 30 seconds and repeat the exercise 2-3 times. Then mobilize the other fingers in the same way. Exercise at least 2 to 3 times per week.
Exercise 4: Finger extension against resistance
Exercise goal: Activation of the extensor muscles of the fingers.
Starting position: Clench the affected hand into a fist. Place the other hand congruently over it.
Execution: Now slowly stretch the fingers of the affected hand while keeping the knuckles bent. The hand on top offers resistance adapted to the movement. Adjusted in this case means that the movement is made more difficult, but not prevented.
Repeat the exercise 10 times per affected hand. This corresponds to one set. Perform 2-3 sets with about 60 seconds rest between each set. Practice at least 2 to 3 times a week.
The unaffected hand encloses the affected hand. © Joint Clinic
Bring the fingers of the affected hand into extension and work against the resistance of the other hand. © Joint Clinic
Exercise 5: Fist opening
Exercise goal: mobilization and strengthening of the fingers.
Starting position: Place the affected hand in any position with sufficient freedom of movement.
Execution: Clench a fist. Then open the hand until you reach maximum extension in the fingers and palm of the hand. Hold this position for 5 seconds and close the hand into a fist again.
Repeat the exercise 10 to 15 times for each affected hand. This corresponds to one set. Perform 2-3 sets with about 30 seconds rest between each set. Exercise at least 2 to 3 times per week.
Clench a fist. © Joint Clinic
Open the hand again and stretch the fingers maximally. © Joint Clinic
Exercise 6: Finger and thumb play
Exercise objective: Coordination training for the hand muscles.
Starting position: rest the elbow on a table top and hold the hand in a slightly open position.
Execution: Touch the tip of the thumb to all other four fingertips one after the other. This corresponds to one pass.
Repeat 10 times. This corresponds to one set. Perform 2-3 sets with about 30 seconds rest between each set. Practice at least 2 to 3 times a week.
Touch all the fingertips one after the other with your thumb. © Joint Clinic
© Joint Clinic
Exercise 7: Self-massage of the thumb and hand muscles
Exercise goal: loosening and blood circulation improvement of the hand and thumb muscles.
Starting position: The affected hand lies on the table with the palm facing upwards.
Execution: Now look for the painful points on the ball of the thumb and the palm of the hand with the other hand. Once you have found them, apply pressure to these points with your fingers. Keep the pressure until the pain and tension in the affected area subsides. It is also possible to massage the corresponding areas with light circular movements.
The palm of your hand points upwards. © Joint Clinic
Apply light pressure to the painful points. © Joint Clinic
Exercise 8: Stretching the wrist flexors
Stretching of the wrist flexors. © Joint Clinic
Exercise goal: mobilization and tension reduction.
Starting position: extend your affected arm in front of your body. Make sure that the elbow is extended. The underside of the forearm points upwards during this process.
Execution: With the other hand gently pull your wrist into a bent position. Feel the pull in your elbow as you do this. A slight stretching pain is normal. Hold this position. When the pain subsides, move further into elbow extension.
Hold this stretch for 20 to 30 seconds and repeat the exercise 2-3 times. Practice once a day to ensure good success.
Exercise 9: Stretching the wrist extensors
Exercise goal: mobilization and tension reduction.
Starting position: The affected arm is in front of the body. Clench a fist and angle your wrist forward. Rotate it to the little finger side.
Execution: Now clasp your other hand with your free hand. Slowly move your arm and elbow into extension. Feel the pull in your elbow while doing this. A slight stretching pain is normal. Hold this position. When the pain subsides, move further into elbow extension.
Hold this stretch for 20 to 30 seconds and repeat the exercise 2 to 3 times. Practice once a day to ensure good success.
Clench your fist. © Joint Clinic
Angle wrist forward. © Joint Clinic
Reach around the other hand with your free hand. © Joint Clinic
Slowly move arm and elbow into extension. © Joint Clinic
When to operate for tendon sheath inflammation?
Only in a few cases do the various options of conservative treatment fail to improve the symptoms or tendonitis recurs again and again. Then the treating orthopedist discusses the possibilities of surgical intervention with the patient. In the operation, which is often performed on an outpatient basis, the doctor cuts through part or all of the tendon sheath and helps the constricted tendon regain sufficient room to move. The surgeon can simultaneously remove inflamed and thickened tendon tissue and help the patient to be largely pain-free.
Prognosis of tendon sheath inflammation
An acute tendovaginitis, the cause of which is, for example, an overload of the hand tendons due to excessive computer work, should be completely healed after a few days. Provided the patient rests the hand, avoids the triggering movement, and cools as needed or takes pain medication in adjusted doses.
If the affected person has been suffering from pain and limited mobility for weeks or even months, chronic tendovaginitis has probably developed. In this case, conservative therapy also takes longer and surgical intervention may be necessary.
Frequently asked patient questions about tendonitis to PD Dr. med. Bastian Marquab of the Joint Clinic Freiburg
Where exactly does it hurt with tendonitis?
With an inflamed tendon sheath at the wrist, the patient experiences pulling and stabbing pain, especially when moving the joint. There is often a pressure pain along the affected tendon and muscle on the forearm.
How do tendonitis and carpal tunnel syndrome differ??
In carpal tunnel syndrome, the metacarpal nerve is pinched and is also supplied with too little blood. Carpal tunnel syndrome is often manifested by a feeling of "fingers falling asleep," initially especially at night. Tingling and numbness may also occur in the hand when cycling or using the telephone. Tendonitis is caused by overuse or improper use of a hand or feet and causes stabbing pain in the joint.
For an exact clarification, we carry out a measurement of the nerve conductivity (electroneurography) in the joint clinic. This test provides information about how quickly an impulse is conducted to an area of skin that is supplied by the metacarpal nerve.
How long does tendovaginitis last??
Acute tendovaginitis is very painful and hinders the affected person at work and in their leisure time, but it heals after a few weeks with consistent rest and changes in movement patterns without any late effects. If there is already chronic inflammation of the tendon sheaths, it can take several months for the hand to heal completely with the help of conservative therapy. In addition, together with the patient, we doctors must consider exactly where the causes of the overload lie and find alternatives.
How does an inflamed tendon feel??
The affected tendon may be thickened and painful with manual pressure. Sometimes a rubbing and grinding can be felt and heard when the inflamed tendon sheath is moved. The surrounding joint area is often swollen and reddened. The patient can only move his hand or the affected foot with pain.
What medications help with tendovaginitis?
It makes sense for patients with tendovaginitis to take pain-relieving and anti-inflammatory medication to accompany conservative therapy. Non-steroidal anti-inflammatory drugs (NSAIDs) with the active ingredients diclofenac or ibuprofen are particularly suitable here. The patient can take these as tablets or apply them locally to the affected region as an ointment.
In addition, at the Joint Clinic we offer the possibility of injecting cortisone and a local anesthetic specifically into the sliding bearing around the tendon. Cortisone inhibits the inflammatory process. However, it should only be used once in this form.
Should I spare the hand with tendon sheath inflammation or rather move it?
In acute tendonitis, the patient must avoid any unnecessary movement of the hand. The pain almost forces patients to rest their hand. In the first period and especially for the night we recommend wearing a splint. In parallel, the patient can take painkillers from the group of NSAIDs if necessary and cool the hand and joint. The patient must wear the splint only for a short time to prevent the tendon from sticking to the inflamed tendon sheath and restricting movement in the long term.
How long am I on sick leave with tendovaginitis??
The duration of the inability to work depends primarily on the profession and the trigger of the tendovaginitis. In any case, the hand or joint should be treated. the foot should heal completely and subsequently not be exposed to the same stressful movements. Patients can obtain more detailed information from their attending physician.
When can I resume sports after tendovaginitis?
I always point out to my patients that the tendon sheath inflammation must be completely healed before they can play tennis or go climbing again. We also consider in advance what they need to change about their activities: Muscles and tendons must be sufficiently warmed up before training, the equipment should be professionally adapted and the right technique is also enormously important. Some patients take their condition as an opportunity to undergo special technique training and avoid harmful movements.
When can I drive again after a tendon sheath inflammation?
As soon as the pain has subsided and the mobility of the wrist is no longer impaired, the patients can get back behind the wheel. Caution is advised when wearing a splint: In principle, driving a car with a wrist splint is allowed, but the driver must be able to grip the steering wheel firmly at all times. Especially if the splint includes the thumb, patients should better refrain from driving a car.
Which doctor should I go to with tendonitis??
The first path probably leads most patients to their family doctor. To clarify whether the problem is tendonitis, carpal tunnel syndrome, arthritic wear and tear or changes in the bone structure of the hand, the patient should also consult an orthopedic specialist as soon as possible. An acute inflammation can quickly become chronic. The orthopedist has extensive experience in non-surgical therapies and the aftercare.
I can get tendonitis more than once?
Unfortunately yes. Once you have had tendonitis and in the best case know the cause, you should immediately try to eliminate the triggering stress. Otherwise, there is always a risk of painful overuse of the tendons.
For example, you can change to an ergonomically shaped computer mouse or put a supporting pillow under your hand to relieve the stressed tendons. If you have Achilles tendonitis, go to a shoe store for individual advice.
How to prevent tenosynovitis?
Especially at work, you should avoid monotonous and constantly repetitive motion sequences or at least interrupt them frequently: Take breaks from movement when working at a computer screen, make sure you have an ergonomic sitting and hand posture, and get yourself an ergonomically shaped PC mouse or a pad for a relaxed hand position. Some patients report that it has helped them to apply kinesio tapes to the compromised hand. The constant stimulus activates the muscles just under the skin and reminds you to take relaxation breaks and stretch your hands.