The cardinal feature of flexor tenosynovitis is pain along the tendon sheath, with associated swelling around the joint adjacent. The finger is usually flexed slightly and there is pain on passive movement along the tendon.

In infectious tenosynovitis there may be associated fever. In gonococcal tenosynovitis, not associated penile or vaginal discharge occurs and the wrist, hand and sometimes the ankle are the most common sites. In traumatic cases the site of inoculation may be overtly infected, but many times there is no obvious wound [7].

• Pain

  Trigger fingers may be painful but just as often there may be no pain — just the locking or catching sensation. [loptonline.com]

  Patients typically present with pain which is worsened by activity, edema of the affected tendons, and pain along the tendon course on stretching of the tendon. [amboss.com]

  Painful thumb and/or wrist movements. Squeaking/clicking of the painful area during movement. What can I do? Rest – refrain from doing the repetitive actions which cause the pain. Protect the thumb by wearing a splint. [tbihealth.co.nz]

  If you feel pain over the tendons to the thumb, your problem may be de Quervain's tenosynovitis. [advantagephysiotherapy.com]

  Modalities such as electrotherapy and cold laser therapy will be used to reduce inflammation and pain. [healthfitchiro.com]

• Swelling

  Non-surgical therapy includes avoiding activities that increase pain and swelling, applying ice, using a splint to support and immobilize the hand, and physical therapy. Anti-inflammatory drugs are helpful in relieving pain and swelling. [orthonw.com]

  De Quervain tenosynovitis is a condition that causes pain and swelling at the base of the thumb and the thumb side of the wrist. [uofmhealth.org]

  Ultrasound The synovial membrane is not identified unless there is a pathological swelling. [radiopaedia.org]

  When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend. [massgeneral.org]

  Anti-inflammatory medications may also help control the swelling of the tenosynovium and ease symptoms. These medications include common over-the-counter medications such as ibuprofen and aspirin. [advantagephysiotherapy.com]

• Severe Pain

  They are: tenderness to touch along the flexor aspect of the finger, fusiform enlargement of the affected finger, the finger being held in slight flexion at rest, and severe pain with passive extension.[2][3] Fever may also be present but is uncommon. [en.wikipedia.org]

  DI AGNOS I S  Tenderness over & limited to the flexor sheath  Symmetrical enlargement of the digit (“fusiform”)  Severe pain on passive extension of the finger (> proximally)  Flexed posture of the involved digit Kanavel’s cardinal signs 7. [slideshare.net]

  Signs and symptoms The cardinal symptom is severe recurrent twinges of pain. At first, the symptoms occur above all when the joint is moved, later it also hurts at rest. [medi.de]

• Finger Pain

  We report a case of a 65-year-old woman receiving chronic anticoagulation who presented with acute onset of severe long finger pain and was supratherapeutic on Coumadin. Her examination was consistent with early septic flexor tenosynovitis. [ncbi.nlm.nih.gov]

  For this test your doctor will ask you to make a fist with your fingers covering the thumb and bend the wrist towards the little finger. Pain during this movement will confirm the condition. [orthonw.com]

  Fusiform swelling (sausage finger) Pain with passive extension *this is the earliest finding It is usually caused by some sort of inoculation, but this can be something very small and the patient may not be aware that he/she had ever been injured (can [sketchymedicine.com]

  Pain Finger Stiffness and Soreness Finger Taping Truths Torn A2 Finger Pulley Torn A3 and A4 Finger Pulleys Trigger Thumb Syndrome Trigger Finger Syndrome [rockandice.com]

• Localized Pain

  History and Symptoms of de Quervain’s Tenosynovitis De Quervain’s tenosynovitis can have a gradual or sudden onset of localized pain or tenderness over the thumb side of the wrist which is most noticeable with thumb and wrist motion. [healthfitchiro.com]

  The most common clinical presentation was subacute localized pain, swelling, and erythema consistent with tenosynovitis. The diagnosis was delayed by a median of 6 months (range, 0-48 mo). [ncbi.nlm.nih.gov]

• Wrist Pain

  […] heavy objects Chronic illnesses such as rheumatoid arthritis and diabetes Pregnancy Symptoms of De Quervain Tenosynovitis Common signs and symptoms of de Quervain tenosynovitis include: Wrist pain on the thumb side Thumb and wrist pain with twisting [uofmhealth.org]

  This can lead to altered biomechanics of the wrist accompanied by pain. [physio-pedia.com]

  DeQuervain's tenosynovitis is a common cause of radial-sided wrist pain. Symptoms result from a narrow first dorsal compartment and associated tendinosis of the enclosed extensor pollicis brevis and/or abductor pollicis longus (APL). [ncbi.nlm.nih.gov]

  […] deviation of the wrist with the fist closed over the flexed thumb illicits pain over the dorsoradial aspect of the wrist. [radsource.us]

• Joint Tenderness

  If you develop this condition, you may have the following symptoms: joint stiffness, making it difficult to move joint swelling joint pain joint tenderness redness of the skin that overlies the tendon in question Some people may develop a fever. [healthline.com]

  Symptoms of tenosynovitis can include: Difficulty moving a joint and pain Swelling in the area of the affected joint Tenderness or pain around a joint Redness running along the length of the tendon The most common type of tenosynovitis is de Quervain’ [abilityrehabilitation.com]

• Morning Stiffness

  Hand dysfunction was evaluated by a grip-Health Assessment Questionnaire (HAQ) and visual analog scale of morning stiffness (MS-VAS). [ncbi.nlm.nih.gov]

  Patients who progressed to RA had experienced arthralgia and morning stiffness more frequently than patients who did not develop RA, possibly because all patients who developed RA had tenosyovitis in more than 2 areas. [rheumatologyadvisor.com]

  ACR criteria definitions Morning stiffness: documented self-reported morning stiffness lasting ⩾1 h. [academic.oup.com]

  A summary of currently available data reveals that tenosynovitis is related to the presence of joint swelling, joint tenderness, morning stiffness and functional impairments in RA and in earlier disease phases (online supplementary table). [ard.bmj.com]

• Tendon Disorder

  Peroneal tendon disorders, including the tendon sheath inflammatory condition tenosynovitis, are a major cause of chronic lateral ankle pain. [ncbi.nlm.nih.gov]

  Some people may be hereditary predisposed to tendon disorders. Symptoms of Tenosynovitis and Tenovaginitis The symptoms appear as: Pain which is present at rest, but sharply exacerbated by the use of the tendon. Narrowing of the tendon sheath. [musclesandjoints.com]

  [abstract] Rees JD, Wilson AM, Wolman RL; Current concepts in the management of tendon disorders. Rheumatology (Oxford). 2006 May;45(5):508-21. Epub 2006 Feb 20. [orthohyd.com]

• Arthralgia

  Patients who progressed to RA had experienced arthralgia and morning stiffness more frequently than patients who did not develop RA, possibly because all patients who developed RA had tenosyovitis in more than 2 areas. [rheumatologyadvisor.com]

  Local inflammation and fibrosis may affect the dermis, connective tissue, muscle and bone, giving rise to arthralgias, tenosynovitis, contracture, undergrowth of the limb, and nodulosis. [academic.oup.com]

  Dermatitis-arthritis syndrome presents with arthralgia, tenosynovitis, and painless non-pruritic (non-itchy) dermatitis. Symptoms of tenosynovitis include pain, swelling and difficulty moving the particular joint where the inflammation occurs. [fi.bab.la]

  […] development of clinical arthritis and erosions.16 The notion that tenosynovitis is a very early feature of RA is further supported by the consistent finding that tenosynovitis is an independent predictor for developing RA in patients with clinically suspect arthralgia [ard.bmj.com]

Laboratory diagnosis

• The diagnosis may be made on clinical grounds. If there is associated discharge then a swab for gram stain and culture should be sent. Aspiration may also be required. The samples should be sent for exam for the usual bacteria including fungal causes and mycobacterium. 
• If there is an associated joint effusion it should be aspirated and sent for white cell count, glucose levels, gram stain and cultures. 
• Other tests like a complete cell count should be done if an infectious cause is suspected. Other tests such as rheumatoid factor and other autoimmune markers should be asked for if there is a suspicion. 
• A biopsy should be done if the cause is not found to rule out causes such as mycobacterium which has a protracted culture time.

Imaging

Plain radiographs should be done to rule out bone involvement. Magnetic resonance imaging (MRI) is an accurate modality for diagnosis.

Usually the treatment includes surgery and antibiotics. For stage 1, irrigation and drainage are necessary. Stage 2 or 3 may be treated with surgical debridement and irrigation, amputation if necessary. Depending on the results of fluid and gram stain, antibiotics should be started promptly, a drug that covers Staphylococcus aureus and streptococci will be advisable; this includes ciprofloxacin or a third generation cephalosporin. Vancomycin may be used if a methicillin-resistant species is suspected.

The inflammatory causes respond to anti-inflammatory drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) and steroids, but an infectious etiology must be ruled out. The involved joint should be immobilised [8] [9] [10].

Infectious causes who present early and get treatment, will have an excellent outcome. Those who have chronic infection and disseminated disease will have a poorer outcome. Poor outcomes include loss of range of movement and tendon rupture. Other comorbidities such as a decreased immunity or diabetes are a poor prognostic markers, and tend to have multiple tendons and joints involved.

Most of the time the cause is not known, but the etiology may be divided into infectious and non-infectious.

Infectious 

• Streptococcus and Staphylococcus aureus (most common)
• Mycobacterium tuberculosis
• Pseudomonas aeruginosa
• Nesseria gonorrhoeae (secondary infection from the genital tract, rectum or pharynx) 

Non-infectious

• Rheumatoid arthritis 
• Systemic lupus erythematosus
• Diabetes mellitus
• Ankylosing spondylitis
• Overuse 
• Sarcoidosis [1] [2] [3]

There is very little data on the incidence of this condition, but it has been noted that up to one third of the patients are diabetic. Gonococcal tenosynovitis is usually common in the young sexually active individuals. Also this condition is very common in rheumatoid arthritis sufferers [4].

Infectious

The infection occurs by various mechanisms: Trauma with inoculation into the tendon, contagious spread from infected adjacent soft tissues, and through the blood stream. Most infections will occur acutely after inoculation except for a few organisms such as mycobacterium which may have a subacute presentation. Usually animal bites and lacerations are associated with polymicrobial infections including gram negative bacteria. Different forms of trauma have associated bacteria, such as puncture wounds form thorns and trees may result in fungal infections, while animal bites may give rise to polymicrobial infections with Pasteurella multocida and others [5]. Infections to tendon from other sites via hematogenous spread, is common for Mycobacterium and Nesseria gonorrhoeae.

The infections usually progresses in stages:

• Stage 1: Distension of the tendon sheath with an exudate.
• Stage 2: Distension of the tendon sheath with an purulent fluid.
• Stage 3: Septic necrosis [6]

Non-Infectious

This occurs due to a different mechanism. There is fibrous proliferation, until there is impingement and constriction of movement.

Prompt treatment of the underlying cause is the best mode to avoid complications. Since most cases of infectious causes are related to trauma, necessary protective gear and equipment should be used at potentially dangerous sites. For gonococcal infections, protected intercourse is the best prevention.

The most common sites for tenosynovitis are the shoulder, the tendon of the long head of the biceps, popliteus tendon, Achilles tendon and the abductor pollicis longus. It is thought that continuous microtears and degenerative changes are the most common cause of the condition.

• Definition: Tenosynovitis is a disease that affects the tendons in your body. Tendons are the strong band that connect your muscles to your bones to allow movement. The most common places are the hands and shoulder.
• Cause: There are two main causes, infection and overuse. Other causes may be due to underlying diseases that may affect your tendons such as rheumatoid arthritis. Infections are caused by direct inoculation via trauma. 
• Symptoms: There will be pain around the site of the diseased tendon, with pain on movement. There also may be a discharge if there is associated trauma like from an animal bite.
• Diagnosis: Usually diagnosis is clinical but extra tests will be required to find out the cause especially if the cause if infectious. The doctor will take sample form the infected site for tests. The may be other blood tests to find out other underlying cause. Your doctor may order X-rays to make sure the bone is not infected. They may also order a magnetic resonance image (MRI) of the affected site 
• Treatment: The treatment for infected tendons is urgent surgery and antibiotics to kill the infection. The type of surgery and extent will depend how bad the infection is. For non-infectious causes the doctor will prescribe anti-inflammatory drugs or steroids to help reduce the pain and discomfort. You will also be told to rest the joint and a sling may be ordered for you.

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2. Small LN, Ross JJ. Suppurative tenosynovitis and septic bursitis. Infect Dis Clin North Am 2005; 19:991.
3. Mateo L, Rufí G, Nolla JM, Alcaide F. Mycobacterium chelonae tenosynovitis of the hand. Semin Arthritis Rheum 2004; 34:617.
4. Kour AK, Looi KP, Phone MH, Pho RW. Hand infections in patients with diabetes. Clin Orthop Relat Res 1996; :238.
5. Goldstein EJ. Bite wounds and infection. Clin Infect Dis. Mar 1992;14(3):633-8.
6. Nikkhah D, Rodrigues J, Osman K, Dejager L. Pyogenic flexor tenosynovitis: one year's experience at a UK hand unit and a review of the current literature. Hand Surg 2012; 17:199.
7. Pang HN, Teoh LC, Yam AK, et al. Factors affecting the prognosis of pyogenic flexor tenosynovitis. J Bone Joint Surg Am 2007; 89:1742.
8. Gosain AK, Markison RE. Catheter irrigation for treatment of pyogenic closed space infections of the hand. Br J Plast Surg. May-Jun 1991;44(4):270-3.
9. Harris PA, Nanchahal J. Closed continuous irrigation in the treatment of hand infections. J Hand Surg Br. Jun 1999;24(3):328-33.
10. Kanavel, AB. Infections of the hand: a guide to the surgical treatment of acute and chronic suppurative processes of the fingers, hand, and forearm. Lea and Febiger, Philadelphia, 1912.