Written by:
Erika Serafin, OTR/L
Virtual Hand to Shoulder Fellow ‘23/’24
To the unknowing eye, De Quervain Tenosynovitis and Intersection Syndrome can appear identical. However, having appropriate information on each diagnosis can aid clinicians in appropriately and accurately distinguishing between the two. It is important as practitioners that we can distinguish between these diagnoses to provide proper care to our patients. This blog entry will primarily discuss the differences between each diagnosis regarding anatomy and symptoms as well as conservative treatments for De Quervain Tenosynovitis and Intersection Syndrome.
De Quervain Tenosynovitis is defined as “…an overuse pathology involving impaired gliding of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons as they pass through the first dorsal compartment on the radial side of the wrist” (McQueen & Pemberton, 2020, p. 316). If a patient is diagnosed with this condition, it could be due to “…forceful or repetitive grasp combined with wrist ulnar deviation, repetitive thumb abduction, and/or repetitive thumb metacarpophalangeal (MP) joint flexion” (McQueen & Pemberton, 2020, p. 316). The APL and EPB tendons are the two main tendons that are affected by De Quervain Tenosynovitis as mentioned above. The importance of these tendons is that they are the main tendons of the thumb and aid in moving the thumb away from the index finger (APL) and allow the joints of the thumb to be straightened (EPB) (Pidgeon, 2022).
Intersection Syndrome is defined as “…a condition that affects the first and second compartments of the dorsal wrist extensors” (Michols & Kiel, 2024). If a patient is diagnosed with this condition, it is often believed to have resulted from “…repetitive friction at the junction in which the tendons of the first dorsal compartment cross over the second, creating tenosynovitis” (Michols & Kiel, 2024). However, Intersection Syndrome can be broken down into Distal Intersection Syndrome and Proximal Intersection Syndrome. Distal Intersection Syndrome “…relates to tenosynovitis of the extensor pollicis longus (EPL) tendon (3rd extensor compartment), where it crosses the extensor carpi radialis longus (ECRL) and brevis (ECRB) tendons (2nd extensor compartment). It is distinct from intersection syndrome which occurs more proximally in the forearm at the intersection of the first and second extensor compartments (Rasuli, 2024). Proximal Intersection Syndrome is “…an overuse tenosynovitis that occurs around the intersection of the first extensor compartment (abductor pollicis longus and extensor pollicis brevis) and second extensor compartment (extensor carpi radialis longus and extensor carpi radialis brevis) within the forearm” (Sharma, 2022).
One crucial difference between De Quervain Tenosynovitis and Intersection Syndrome is the placement of pain. Intersection Syndrome pain is felt “…proximal and dorsal to the radial styloid, or also noted anatomically by 4 cm – 6 cm proximal to Lister’s tubercle” (Michols & Kiel, 2024). De Quervain Tenosynovitis pain is felt over the thumb side of the wrist and “The pain may appear either gradually or suddenly… starts in the wrist can travel up the forearm… usually worse when the hand and thumb are in use” (Pidgeon, 2022). Pain is felt with De Quervain Tenosynovitis because “Any swelling of the tendons and/or thickening of the sheath can result in a situation where the tendons no longer fit well inside the sheath. This results in increased friction and pain with certain thumb and wrist movements” (Pidgeon, 2022).
One distinct way to test if a patient’s pain is De Quervain Tenosynovitis or Intersection Syndrome is the Finkelstein test. If test results are positive, then it is De Quervain Tenosynovitis, because the Finkelstein test will often produce a negative result for Intersection Syndrome (Chatterjee & Vyas, 2016). The clinician can also perform palpation over the first dorsal compartment and resisted APL to test for De Quervain Tenosynovitis (McQueen & Pemberton, 2020, pg. 316). Regarding Intersection Syndrome, it is stated that “Resisted pronation that leads to the patient’s pain, along with the palpable finding of crepitus 2 to 3 cm proximal to the radial styloid, can differentiate tenosynovitis of De Quervain syndrome from intersection syndrome” (Michols & Kiel, 2024). Ultrasound can also be utilized to confirm Intersection Syndrome by looking for the “…ideal image… in the transverse plane on short axis. The finding correlating to the diagnosis is a hypoechoic area between the 2 dorsal compartments” (Michols & Kiel, 2024).
Conservative treatments for De Quervain Tenosynovitis may include an orthosis, activity modification, progressive strengthening and stretching, as well as Corticosteroid injections (McQueen & Pemberton, 2020, pg. 316). The orthosis appropriate would be “A forearm-based thumb spica orthosis that places the wrist in neutral and thumb in opposition is recommended to assist with pain management by preventing thumb MP joint flexion and wrist ulnar deviation” (McQueen & Pemberton, 2020, pg. 316). The focus of activity modifications should be on “…avoidance of repetitive or sustained loading of the APL and EPB tendons” (McQueen & Pemberton, 2020, pg. 316).
Conservative treatments for Intersection Syndrome may include “…rest and activity modification” (Michols & Kiel, 2024). Ice and a temporary splint for protection and comfort during the night can also be utilized as conservative management of Intersection Syndrome (Michols & Kiel, 2024). Although there is “…no compelling evidence-based rehab protocol for intersection syndrome at this time…” some may opt for stretching or eccentric strengthening as part of rehabilitation (Michols & Kiel, 2024). It is also important to note that if conservative treatments do not work, “…corticosteroid injection under ultrasound guidance can be utilized” (Michols & Kiel, 2024). When receiving the corticosteroid injection, “Using the in-plane or out-of-plane needle injection technique, guide the needle to where the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis) is crossed over the second dorsal compartment (extensor carpi radialis brevis/extensor carpi radialis long)” (Michols & Kiel, 2024). After the injection is given, “…the patient should pronate and supinate the wrist while the clinician observes for crepitus and tenderness with palpation. Resolution of the pain can also help solidify the diagnosis” (Michols & Kiel, 2024).
References
Chatterjee, R., & Vyas, J. (2016). Diagnosis and management of intersection syndrome as a
cause of overuse wrist pain. BMJ Case Reports, 1-5. doi:10.1136/bcr-2016-216988
McQueen, K. S., & Pemberton, T. (2020). Elbow, wrist, and hand tendinopathies. In Cooper's
Fundamentals of Hand Therapy (3rd ed., pp. 311-319). St. Louis, MO: Elsevier.
Michols, N. J., & Kiel, J. (2024). StatPearls [Internet]. StatPearls Publishing. Retrieved
August 14, 2024, from https://www.ncbi.nlm.nih.gov/books/NBK430899/
Pidgeon, T. S. (2022, February). De Quervain's tenosynovitis symptoms and treatment –
orthoinfo - AAOS. Retrieved August 14, 2024, from
Rasuli, B. (2024, February 29). Distal intersection syndrome. Retrieved August 14,
Sharma, R. (2022, November 22). Proximal intersection syndrome. Retrieved August 14,