ATTENTION!!! The physician responsible for the patient’s treatment must be informed of the MEDICAL MASSAGE PROTOCOLs that will be used in manual therapy, and the practitioner must obtain the physician’s permission prior to the initiation of such therapy.
This video is a presentation of the MEDICAL MASSAGE PROTOCOL in cases of De Quervain’s Disease. It is based on scientific publications reviewed in Medical Massage, Volume I. Please refer to pp. 431-435 of the Medical Massage, Vol. I textbook to learn more about pathology, clinical symptoms and diagnostic evaluation of tissue in cases of De Quervain’s Disease.
In the videos, we will repeat each technique and approach only two or three times to save time and space. Follow the time guidelines shown at the beginning of each step.
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EVALUATION OF THE PATIENT WITH De QUERVAIN’S DISEASE (QD). STYLOIDITIS
QD is a result of the trauma or repetitive motions in the first metacarpophalangeal joint (i.e. thumb movements). Those who have such professions such as car mechanics, hair stylist, computer programmer, massage practitioners are the most vulnerable.
There are several others less common reasons such as Irritation of the brachial plexus (origin of the radial nerve) by the anterior scalene (see Anterior Scalene Muscle Syndrome) or pectoralis minor muscle (see Pectoralis Minor Muscle Syndrome).
The evaluation of the patient with QD is simple, because the main symptoms is pain which greatly increases during thumb movements. Another equally important sign is weakness of the thumb prehension. In severe case the patients are unable to execute even simple tasks by the thumb because of the intensity of the pain.
Clinical picture of QD consists of two major components: inflammation (tendinitis) of the tendons of abductor pollicis longus and extensor pollicis brevis muscles AND/OR inflammation in the periosteum (active periostal trigger points) in the styloid process of the radius. QD may include either both components or only one with the same clinical outcomes.
Thus, the difficulties in the evaluation of the patient with QD lie in correct examination of each component.
Evaluation of the Tendinitis
Movement Test (MT)
This is a very simple informative test. Ask the patient to slowly re-create the movements which trigger pain in the base of the thumb and pay attention what movement is affected the most. The next part is to ask the patient to separately execute extension (first part of the video below) and abduction (second part of the video below) of the thumb against resistance using the unaffected thumb (if pathology is unilateral) as a control. The practitioner should examine the weakness of the movement on the affected side as compared to the normal thumb.
MT examines the weakness of the both muscles as a result of tendinitis rather than tendinitis itself. MT allows to decide how much time the practitioner should concentrate on the muscle bellies before start to work on the tendon(s) itself.
Compression Test for the Tendinitis (CT)
The CT is direct application of pressure on the inflamed tendons. The video below shows the application of CT.
CT gives very important information for the upcoming treatment. If the patient feels very acute pain, even during application of mild pressure, the practitioner should be very careful and gradual during the treatment, especially during application of cross-fiber friction.
Finkelstein’s Test (FT)
The practitioner places the patient’s hand on the ulnar side of the forearm. The practitioner passively flexes the thumb and applies passive ulnar deviation. If this maneuver causes acute pain on the radial surface of the wrist joint, FT is considered positive.
Evaluation of Radial Styloiditis
Compression Test for Radial Styloiditis (CTR)
CTR is a very simple and informative procedure, but it should be executed correctly. The video below presents the application of the CTR.
Initial part or preparation is the most important part of the CTR. If it is not done correctly the CTR becomes Compression Test for the Tendinitis (see above). As you may see on the first part of the video before the pressure is applied to the styloid process of the radius the practitioner must move the tendons of the abductor pollicis longus and extensor pollicis brevis muscles (dashed lines in the video) medially. Thus direct pressure to the styloid process of the radius must be applied only if the practitioner is on the bone, i.e. the skin is only tissue which separates the practitioner’s finger and bone. Also, pay attention to the direction of the pressure applied to the styloid process of the radius.
In the difference between the Radial Styloiditis and Ulnar Styloiditis the patient with Ulnar Styloiditis feels pain in the ulnar side of the wrist joint. The simplest way to examine a case of Ulnar Styloiditis is the application of the CT.
Compression Test for Ulnar Styloiditis (CTU)
CTU is much simpler because the styloid process of the ulna lies directly under the skin and is very easy to access. The video below shows the application of CTU.
In the video the solid line indicates the head of the ulna and white arrow indicates the direction of compression. Pay attention to the direction of the pressure applied to the styloid process of the ulna.
MEDICAL MASSAGE PROTOCOL IN CASES OF De QUERVAIN’S DISEASE
Duration: approximately 20 to 30 minutes
Step 1. Work on the abductor pollicis longus and extensor pollicis brevis muscles
Duration: 5 min
Pressure: below the pain threshold
Begin with strong squeezing effleurage along both muscles. Pay attention to the postion of the patient’s forearm.
Next is the application of the kneading of both muscles. Be sure to use the other hand as counterresistance while applying the one-handed kneading variant.
Step 2. Work along the tendons of both muscles
a. Electric vibration
Duration: 1 min
Begin with the application of electric vibration in the permanent, mobile mode along both tendons.
b. Apply friction along, followed by across, the tendons
Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
While applying cross-fiber friction, be sure to stabilize the wrist joint and the forearm as shown in the video.
c. Friction along, followed by across, both tendons over the styloid process of the radius
Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)
First, place the wrist into ulnar deviation by pulling the thumb ground wards as shown at the very beginning of the video. In this position both tendons are on the styloid process of the radius. Apply friction along the tendons, and after this switch to cross-fiber friction.
During the application of cross-fiber friction, the tendons may slip and intensely rub against the styloid process of the radius. To prevent this, the practitioner must stabilize the tendons before the application of cross-fiber friction.
This stabilization is performed by using the index finger and thumb of the passive hand to stretch the skin and compress it against the radius, while the thumb of the active hand applies cross-fiber friction.
d. Passive stretching of the abductor pollicis longus and extensor pollicis brevis muscles
Duration: 1 min
At the end of this step, apply passive stretching of both muscles simultaneously during the patient’s prolonged exhalation.
Place the hand on the edge of the table, grasp the patient’s thumb, and during his or her prolonged exhalation, pull the wrist into ulnar deviation (again, groundwards). Keep the thumb in one line with both tendons.
Press the forearm against the table using your other hand to provide counterresistance to the passive stretch of both muscles.
Step 3. Work on the periosteum of the radius and the first metacarpal bone
Duration: 7 min
Pressure: above the pain threshold (as much as the patient is able to handle)
At the beginning of the video, the position of both tendons over the styloid process is shown.
To effectively work on the styloid process of the radius, the practitioner should push both tendons to the side using the tip of the thumb. This will render accessible the tip of the styloid process where intense friction and compression should be applied. Do not let the tendons slip back, because they will get caught between the bone and the thumb and can get traumatized!
The white arrow indicates the direction of the application of pressure. Pay attention to the position of the thumb in the video. It must be exactly against the tip of the styloid process. Also, notice the necessity of the stabilization of the entire hand by the pulling of the thumb.
The second part of the video presents periostal massage on the first metacarpal bone. Please notice the position of the right thumb along the lateral side of the first metacarpal bone.
Be sure that the thumb is exactly on the bone and that there is no soft tissue, except skin, between the bone and the thumb.
At the end of the video, the practitioner works along the medial surface of the first metacarpal bone using the right index finger. Again, pay attention to the position of the index finger.
Full Protocol: