2

GUIDE TO THE DIAGNOSIS OF

WORK-RELATED MUSCULOSKELETAL
DISORDERS
Work-related musculoskeletal injuries are one of the most common occupational
health problems for which physicians are consulted. There is solid scientific evidence that
these injuries may be occupational in origin.
This guide was designed to help physicians interpret the results of a medical
examination. By combining the standard clinical assessment procedure with guidelines
concerning the identification of etiological factors, it helps physicians identify the cause
of injury.

De Quervain’s
AUTHORS

Louis Patry holds a degree in medicine from Laval University and

a diploma in ergonomics from the Conservatoire National des Arts
et Metiers de Paris (CNAM). He is a specialist in occupational medi-
cine, an associate member of the Royal College of Physicians and
Surgeons of Canada, a professor in McGill University’s Department
of Epidemiology and Biostatistics and Occupational Health, and con-
sulting physician to the Direction de la santé publique (Public Health
Department), first in Québec City and currently at the Montréal-
Centre board.
Tenosynovitis
Michel Rossignol holds degrees in biochemistry and medicine
from the University of Sherbrooke, in epidemiology and community Louis PATRY, Occupational Medecine Physician, Ergonomist
health from McGill University, and in occupational medicine from Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist
John Hopkins University. He is a professor in McGill University’s
Department of Epidemiology and Biostatistics and Occupational Marie-Jeanne COSTA, Nurse, Ergonomist
Health, co-director of the Centre for Clinical Epidemiology of the
Jewish General Hospital of Montréal, and physician-epidemiologist
Martine BAILLARGEON, Plastic Surgeon
at the Montréal-Centre board of the Direction de la santé publique
(Public Health Department).

Marie-Jeanne Costa holds a nursing degree from the Institut

d’études paramédicales de Liège and a degree in ergonomics from
the École Pratique des Hautes Études de Paris. She is an ergonomics
consultant and has collaborated on several studies of CTDs. She is
particularly interested in the development of participatory ergonom-
ics, specifically in the problem-resolution and diagnostic processes.

Martine Baillargeon holds a degree in medicine from the

Université de Montréal. She is a plastic surgeon and associate mem-
ber of the Royal College of Physicians and Surgeons of Canada.
After years of practising surgery she is now consulting physician,
mainly in the field of musculoskeletal injuries affecting the upper
limb, at the Montréal-Centre board of the Direction de la santé
publique (Public Health Board).
GUIDE TO THE DIAGNOSIS OF
WORK-RELATED MUSCULOSKELETAL
DISORDERS

De Quervain’s
Tenosynovitis
Louis PATRY, Occupational Medecine Physician, Ergonomist
Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist
Marie-Jeanne COSTA, Nurse, Ergonomist
Martine BAILLARGEON, Plastic Surgeon
 Canadian Cataloguing in Publication Data
Main entry under title:
Guide to the diagnosis of work-related musculoskeletal injuries
Translation of: Guide pour le diagnostic des lésions musculo-squelettiques
attribuables au travail répétitif.
Includes bibliographical references.
Contents: 1. Carpal tunnel syndrome – 2. De Quervain’s tenosynovitis – 3. Shoulder
tendinitis.
Co-published by: Institut de recherche en santé et en sécurité du travail du Québec.
ISBN 2-921146-70-3 (v. 1) – ISBN 2-921146-71-1 (v. 2) – ISBN 2-921146-72-X (v. 3)
1. Musculoskeletal system – Wounds and injuries – Diagnosis. 2. Overuse injuries –
Diagnosis. 3. Carpal tunnel syndrome – Diagnosis. 4. Tenosynovitis – Diagnosis.
5. Tendinitis – Diagnosis. 6. Occupational diseases – Diagnosis. I. Patry, Louis. II. IRSST
(Quebec). III. Workplace Safety & Insurance Board.
RC925.7.G8413 1998 616.7’075 C98-940950-3

Translation: Les Services Organon, Steven Sacks

Graphic design: Gérard Beaudry
Illustrations: Marjolaine Rondeau, Medical Illustration Department
of the Laval University Hospital Centre (CHUL)
Max Stiebel, Instructional Communications Centre (ICC),
McGill University
Rear-cover photographs: Gil Jacques
Legal deposit – Bibliothèque nationale du Québec, 1998
Legal deposit – National Library of Canada, 1998
ISBN 2-921146-71-1 Éditions MultiMondes (Original edition: ISBN 2-921146-38-X)
© Éditions MultiMondes, 1998
Éditions MultiMondes Institut de recherche en santé
930, rue Pouliot et en sécurité du travail
Sainte-Foy (Québec) 505, boul. de Maisonneuve Ouest
Canada G1V 3N9 Montréal (Québec)
Tel.: (418) 651-3885 Canada H3A 3C2
Fax: (418) 651-6822 Tel: (514) 288-1551
Fax: (514) 288-7636
Régie régionale de la santé
et des services sociaux – Montréal-Centre
Direction de la santé publique
1301, rue Sherbrooke Est
Montréal (Québec)
Canada H2L 1M3
Tel.: (514) 528-2400
Fax: (514) 528-2459
 PREFACE

The diagnosis of cumulative trauma disorders (CTDs) presents many unique problems,
especially for physicians. The absence of precise criteria upon which to establish a clin-
ical diagnosis of CTD or decide whether a musculoskeletal injury is related to occu-
pational factors was noted by several members of the advisory committee supporting
an international expert group mandated by the IRSST to review the literature on CTDs*.
To remedy this situation, in 1992 the IRSST asked a group of researchers to develop
diagnostic guides for carpal tunnel syndrome, De Quervain’s tenosynovitis, and ten-
dinitis of the shoulder.

The project team was initially composed of Louis Patry, occupational medecine phy-
sician and ergonomist, and Michel Rossignol, occupational medecine physician and epide-
miologist, but quickly grew and increased the scope of its expertise through the ad-
dition of Marie-Jeanne Costa, a nurse with ergonomics training, and Martine Baillargeon,
a plastic surgeon. All four team members participated in the drafting of the guides.

These guides were designed to help physicians arrive at a clinical diagnosis and
identify the most probable etiological agents. It should be noted that these guides were
not designed for administrative or legal purposes and that their reliability has not been
evaluated by the researchers.

The publication of these guides designed specifically for physicians is one more ad-
vance in the IRSST’s efforts to shed light on the phenomenon of cumulative trauma
disorders and provide specialists with appropriate tools with which to prevent these
injuries and reduce related risk factors.

Jean Yves Savoie

Director general
Institut de recherche en santé et en sécurité du travail du Québec

* Hagberg, M., Silverstein, B., Wells, R., Smith, M.J., Hendrick, H.W., Carayon, P., Pérusse, M. (1995), Work related muscu-
loskeletal disorders (WMSDs): a reference book for prevention, scientific editors: Kuorinka, I., Forcier, L., publishers Taylor
and Francis, London, 421 pages.
 INTRODUCTION

This guide is the second in a series of practical summaries of current medical knowl-
edge on musculoskeletal injuries with well-documented occupational etiology, namely:
– carpal tunnel syndrome (CTS)
– De Quervain’s tenosynovitis
– tendinitis of the shoulder

When occupational in origin, these injuries are often referred to as “CTDs”, a term
applicable to “problems and diseases of the musculoskeletal system that include, among
their causes, some factor related to work” (Hagberg et al., 1995). Whatever term is used
to designate them—occupational overuse syndrome (OOS), repetitive strain injuries (RSI)
or cumulative trauma disorders (CTDs) in English, troubles musculo-squelettiques (TMS),
lésions musculo-squelettiques (LMS), lésions musculo-tendineuses (LMS), lésions mus-
culo-tendineuses liées aux tâches répétitives, or pathologies d’hyper-sollicitation in
French—their defining characteristic is the presence of an injury caused by biomechanical
strain due to tension, pressure, or friction which is excessively forceful, repetitive, or
prolonged.

This guide is designed for physicians who are called upon in the course of their
practice to diagnose musculoskeletal injuries and establish the extent to which these
injuries are caused by their patient’s work. Its goal is to help physicians arrive at clin-
ical and etiological diagnoses. To this end, the guide first reviews the anatomical, phys-
iopathological, and etiological knowledge upon which diagnosis depends. This is fol-
lowed by guidelines for the evaluation of symptoms, the conduct of the clinical
examination, and the control of potential risk factors related to the development of the
injury.

Musculoskeletal injuries may have many causes. For carpal tunnel syndrome (CTS),
De Quervain’s tenosynovitis, and tendinitis of the shoulder, these include not only oc-
cupational, sports-related, recreational, and household activities, but also specific health
problems and conditions. This guide was prepared in response to requests from phy-
sicians, increasingly preoccupied by CTDs, for information and support on this sub-
ject. Although the approach taken emphasizes the documentation of potential occu-
pational risk factors—a subject little discussed in formal medical training—it does not
neglect the evaluation of other potential causes of De Quervain’s tenosynovitis.

This guide is meant to be used in a clinical setting. To help physicians collect the
information they need to diagnosis the injury and establish its causes, it therefore in- vii
cludes a series of questions, presented in readily identifiable text boxes, for them to
ask their patients. These questions were derived from psycho-physical scales used by
ergonomists to subjectively evaluate workload (Sinclair, 1992) and medical question-
naires developed for the diagnosis of CTS and the evaluation of functional capacity
(Katz et al., 1994; Levine et al., 1993; Rossignol et al., 1995).
 Should however a physician remain unable to come to a definitive conclusion about
the work-relatedness of an injury after consulting this guide, she or he should continue
to seek information which will enable her or him to better evaluate the occupational
musculoskeletal load to which her or his patient is subjected.

Finally, it should be noted that this guide does not address the issues of multiple
injuries and the psychosocial aspects of musculoskeletal injuries, important as they may
be for the global evaluation of the patient.

viii
 TABLE OF CONTENTS

Chapter 1 – General Considerations

Introduction and Terminology ..................................................................................... 1
Epidemiology................................................................................................................. 1
Anatomical Review........................................................................................................ 1
Pathophysiology ............................................................................................................ 1

Chapter 2 – Etiology
General Considerations................................................................................................. 3
Work-relatedness of Musculoskeletal Strain ................................................................ 3

Chapter 3 – Differential Diagnosis

Thumb carpometacarpal osteoarthrosis ....................................................................... 5
Intersection Syndrome .................................................................................................. 6
Wartenberg’s Syndrome ................................................................................................ 6
Brachioradialis Insertion Tendinitis (Insertion of the Brachioradialis)....................... 7
Tendinitis of the Extensor Digitorum Communis........................................................ 7

Chapter 4 – Clinical Considerations

Symptoms ...................................................................................................................... 9
Location of Symptoms (Where?)............................................................................ 9
Onset of Symptoms (When?) ................................................................................. 9
Characteristics of Onset (How?)............................................................................. 9
Impact on Activities of Daily Living........................................................................... 10

Chapter 5 – Recording of Information on Exposure Factors

Occupational History .................................................................................................. 11
Previous Work....................................................................................................... 11
Current Work......................................................................................................... 12
Current Work and Organisational Factors ........................................................... 14
Sports-related, Recreational, And Household Activities............................................ 15

Chapter 6 – Clinical Examination

ix
Physical Examination .................................................................................................. 17
Observation........................................................................................................... 17
Palpation................................................................................................................ 17
Assessment of Range of Movement..................................................................... 17
 Dynamic Movements against Resistance ............................................................. 17
Diagnostic Tests .................................................................................................... 18

Chapter 7 – Summary of the Evaluation .................................................................... 19

Chapter 8 – Guidelines for Therapeutic and Preventive Interventions

Therapeutic Guidelines ............................................................................................... 21
Prevention Guidelines................................................................................................. 22

Conclusion........................................................................................................................ 23

Bibliography .................................................................................................................... 25

List of Figures
Figure 1.1 Insertion and Action of the Tendons of the Extensor Pollicis Brevis
and Abductor Pollicis Longus.......................................................................... 2
Figure 3.1 Test for Carpometacarpal Osteoarthrosis of the Thumb ............................... 5
Figure 3.2 Test for the Intersection Syndrome................................................................. 6
Figure 3.3 Test for Wartenberg’s Syndrome ..................................................................... 6
Figure 3.4 Test of the Brachioradialis............................................................................... 7
Figure 3.5 Test of the Extensor Digitorum Communis .................................................... 7
Figure 6.1 Groove of the Radial Styloid Process, First Dorsal Compartment
of the Wrist ..................................................................................................... 17
Figure 6.2 Test of the Abductor Pollicis Longus ............................................................ 18
Figure 6.3 Test of the Extensor Pollicis Brevis............................................................... 18
Figure 6.4 Finkelstein’s Test ............................................................................................ 18
Figure 8.1 Therapeutic Intervention Flow-chart ............................................................ 21

List of Table
Table 8.1 Preventive Approach...................................................................................... 22

List of Boxes
Box 2.1 Most Common Stressful Movements of the Abductor Pollicis Longus
and Extensor Pollicis Brevis ............................................................................ 4
Box 4.1 Symptoms Reported by the Patient................................................................. 9
Box 4.2 Presentation and Clinical Severity of Symptoms.......................................... 10
Box 4.3 Questions about Activities of Daily Living ................................................... 10
Box 5.1 Questions about Previous Work.................................................................... 11
Box 5.2 General Questions on Occupational Activity and Associated Symptoms.... 12
x Box 5.3 Questions about Activities that Cause Pain in the Hands or Wrist ............. 13
Box 5.4 Questions about Organisational Factors at Work......................................... 14
Box 5.5 Questions about Sports, Recreational, and Household
Activities Involving the Hands or Wrist ........................................................ 15
Box 7.1 Clinical Aspects .............................................................................................. 19
 1 General Considerations
INTRODUCTION AND TERMINOLOGY
De Quervain’s tenosynovitis or tendinitis was first
described in 1895 by Fritz De Quervain, a Swiss sur-
geon. Prior to this, the first use of the terms “te-
nosynovitis” and “crepitating peritendinitis” to des-
cribe injuries to the tendons and surrounding
tissues was by Velpeau in 1825. This condition is
a wrist tendinitis with inflammation of the tendon
sheaths of the abductor pollicis longus and exten-
sor pollicis brevis.
EPIDEMIOLOGY
De Quervain’s tenosynovitis is the most common
tenosynovitis affecting the dorsal tendons of the
wrist. It is usually diagnosed in individuals between
30 and 50 years of age and is ten times more prev-
alent among women than men (Dupuis, 1986).
American and Scandinavian studies examining the
relation between work activities and De Quervain’s
tenosynovitis have rarely distinguished between this
condition and other type of tendinitis of the wrist
and hands. Epidemiological studies have demon-
strated that workers in the meat processing and
manufacturing industries run a higher risk of de-
veloping tendinitis of the hand and wrist: perform-
ing highly repetitive work increases the relative risk
of developing De Quervain’s tenosynovitis to 3.3,
while performing work requiring the exertion of
great force increases it to 6.1. Among individuals
performing work that is both highly repetitive and
forceful, the relative risk is 29 (Hagberg et al., 1995).
ANATOMICAL REVIEW
The tendons of the forearm are relatively long, ex-
tending beyond the wrist to cover the dorsal aspect
of the hand and thumb. The tendons of the abductor
pollicis longus and extensor pollicis brevis both run
through the groove of the radial styloid process in
the first of the six dorsal compartments of the wrist
and have their insertion at the base of the first me-
tacarpal and the proximal phalanx of the thumb
(Figure 1.1).
These muscles, individually and jointly, extend
and abduct the trapezometacarpal joint and extend
the metacarpophalangeal joint. They are also active
during radial deviation and, to a lesser extent,
flexion of the wrist (Kendall et al., 1988). Both are
innervated by the posterior interosseous branch of
the radial nerve, which originates mostly in the C6,
C7, and C8 roots.
PATHOPHYSIOLOGY
De Quervain’s tenosynovitis is a stenosing tenosyno-
vitis involving inflammation of the tendon sheath
of the extensor pollicis brevis and abductor polli-
cis longus (Dupuis, 1986; Hagberg et al., 1995). The
rigidity of the structures and limited space within
the wrist compartment favour the development of
tenosynovitis.
1
 Guide to the Diagnosis of Work-Related
Muskuloskeletal Disorders

Figure 1.1
Insertion and Action of the Tendons of the Extensor Pollicis Brevis
and Abductor Pollicis Longus

Extensor pollicis brevis Abductor pollicis longus

Tenosynovitis may result from trauma or from
excessive friction between the tendon and sur-
rounding tissues during movements of the thumb
and wrist. The thickness of the synovial membranes
is an indication of the stage of the tendinitis. As the
inflammation progresses, the tendon tends to thin
out and become more friable, and stenosis increases.
In the final stages, the sheath of the first dorsal com-
partment thickens, becomes fibrous, and impinges
on the space of the fibro-osseous groove. This may
result in “trigger finger”, a chronic form of De
Quervain’s tenosynovitis.

2
 2 Etiology
GENERAL CONSIDERATIONS
Tendinitis and tenosynovitis may occur when
muscle and tendon structures are subjected to:
– regular biomechanical strain which, over the
long term, exceeds the limits of the tendons and
synovial membranes
– intense or unusual biomechanical strain (re-
sumption of working activities after an absence,
increase in production rates, modification of
tasks, intense practice of a sport or musical ins-
trument)
– local trauma
Tendinitis and tenosynovitis of the upper limb
may also be related to:
– metabolic diseases (diabetes mellitus, hypothy-
roidism, gout, ankylosing spondylitis, various col-
lagenoses)
– infection such tuberculosis or a bacterial infection
– specific conditions such as pregnancy
De Quervain’s tenosynovitis may coexist with
carpal tunnel syndrome and “trigger finger”.
Tenosynovitis affecting the dorsal tendons of the
wrist may be of two types:
– Tenosynovitisis with effusion is of infectious or
rheumatoid origin. In the latter case, it is indica-
tive of rheumatoid arthritis and may presage po-
lyarthritis (Dupuis, 1986).
– De Quervain’s tenosynovitis is one of the most
common forms of the stenosing tenosynovitises,
inflammatory conditions whose most common
cause is microtrauma. The palmar aspect of the
flexor digitorum profundus tendons may be in-
volved, and the condition may be congenital or
secondary to rheumatoid arthritis (Dupuis,
1986).
WORK-RELATEDNESS OF MUSCULOSKELETAL
STRAIN
Excluding accidents, the primary pathophysiological
cause of De Quervain’s tenosynovitis is biomechan-
ical strain on the tendons of the abductor pollicis
longus and extensor pollicis brevis in the groove
of the radial styloid process as a result of physical
activity.
As noted in the section on epidemiology, mus-
culoskeletal strain associated with actions that are
highly repetitive or forceful or both is an important
cause of hand and wrist tendinitises, including De
Quervain’s tenosynovitis (Hagberg et al., 1995). De
Quervain’s tenosynovitis is also associated with gras-
ping objects with the fingers spread, rotation of the
wrist, and pronation-supination of the forearm
(Kuorinka and Koskinen, 1979; Kurppa et al., 1991;
Kroemer, 1989). Wrist movements requiring a
pinch grip and frequent hand movements with the
wrist flexed and thumb abducted generate great
strain on the tendons of the abductor pollicis lon-
gus and extensor pollicis brevis.
Finally, factors such as the use of gloves and ex-
posure to cold or vibration increase the risk of de-
veloping this condition. Box 2.1 illustrates the move- 3
ments frequently associated with De Quervain’s
tenosynovitis.
The symptoms of De Quervain’s tenosynovitis may
 Guide to the Diagnosis of Work-Related
Muskuloskeletal Disorders

Box 2.1

Most Common Stressful Movements of the Abductor Pollicis

Longus and Extensor Pollicis Brevis

Repeated application of pressure while flexing Loaded abduction or extension

the distal phalanx of the thumb of the thumb

Wrist movements during normal Loaded flexion-extension

or pinch prehension of the wrist

Application of thumb pressure with the wrist deviated

Cofactors

– Strain on the thumb:

• during wrist movements
• while maintaining pressure on the palm or the hand
• use of gloves
4 • exposure to cold or vibration
 3 Differential Diagnosis

be confused with those of several other pathologi- Figure 3.1

cal conditions, including: Test for Carpometacarpal
– carpometacarpal osteoarthrosis of the thumb Osteoarthrosis of the Thumb
– intersection syndrome
– Wartenberg’s syndrome
– brachioradialis insertion tendinitis
– tenosynovitis of the extensor digitorum com-
munis

THUMB CARPOMETACARPAL
OSTEOARTHROSIS

Clinical Presentation
Osteoarthrosis of the trapezometacarpal joint and
usually affects women aged 50-70 years (Figure 3.1).
It is accompanied by local deformity, crepitation, and
pain of variable intensity that is unrelated to radio-
logical changes (Dupuis, 1986).

Probable causes
– trauma
– age- and sex-related factors

Diagnostic Test
Simultaneous axial compression and rotation of the
thumb will elicit pain at the trapezometacarpal joint.

INTERSECTION SYNDROME

5
 Guide to the Diagnosis of Work-Related
Muskuloskeletal Disorders
Figure 3.2
Test for the Intersection Syndrome
Figure 3.3
Test for Wartenberg’s Syndrome
6 dial styloid process while the patient maintains the
Clinical Presentation
This syndrome is caused by inflammation at the
point where the tendons of the extensor carpo-
radialis longus and brevis muscles of the second
compartment of the extensors intersect the sheaths
of the abductor pollicis longus and extensor polli-
cis brevis (Figure 3.2).
Probable Causes
– repetitive finger-pinch prehension while flexing
and extending the wrist or supinating the fore-
arm
– direct trauma
Diagnostic Test
Palpation will reveal a painful area and crepitation
with swelling on the radial side approximately three
finger-widths above the wrist (Pujol, 1993).
WARTENBERG’S SYNDROME
This syndrome is caused by compression of the dis-
tal sensory branch of the radial nerve (Figure 3.3).
Clinical Presentation
– pain or numbness over the distal third of the fore-
arm, increased by ulnar deviation
– discomfort while writing
– discomfort while grasping objects or using a
pinch grip
Possible Causes of Compression
– external trauma, falls, twisting of the forearm
– repetitive or forceful pronation
– compression by a bracelet or watch
– compression by soft-tissue disorders (synovial
cyst, tumour, subcutaneous haematoma)
Diagnostic Tests
Symptoms may be elicited by applying pressure over
an area two finger-widths wide proximal to the ra-
forearm pronated and the wrist in ulnar deviation
(Figure 3.3). The test is considered positive if symp-
toms occur in less than one minute. Finkelstein’s test
may also be positive (See Figure 6.4, page 18).
BRACHIORADIALIS INSERTION TENDINITIS
(INSERTION OF THE BRACHIORADIALIS) Figure 3.4
Test of the Brachioradialis
Clinical Presentation
Resisted elbow flexion* and application of pressure
on the radial styloid process both elicit pain over
the radial styloid process.

Probable Causes
– Performing repeated finger-pinch prehensions
with the wrist supinated or extended

Diagnostic Test
Resisted movement of the brachioradialis elicits pain
at its insertion on the radial styloid process (Fig-
ure 3.4).

TENDINITIS OF THE EXTENSOR DIGITORUM

COMMUNIS

Clinical Presentation
Pain is present on the radial side of the dorsal as-
pect of the wrist, and may be accompanied by swell-
ing. Figure 3.5
Test of the Extensor Digitorum Communis
Probable Causes
– Extension movements
– Sustained static pronation associated with grasp-
ing of objects

Diagnostic Test
Resisted extension elicits the symptoms and indicates
the presence of tendinitis of the extensor digitorum
communis (Figure 3.5).

* The term “resisted movement” refers to a movement made while

force is applied in the opposite direction.

DE QUERVAIN’S TENOSYNOVITIS
 4 Clinical Considerations

SYMPTOMS ceded by a prepathogenic period during which en-

The following questions are essential in establishing
the medical history of patient presenting with symp-
toms suggestive of De Quervain’s tenosynovitis:
– Where do you feel pain?
– When did the pain start?
– What did the pain first feel like and what does
it feel like now?
Location of Symptoms (Where?)
De Quervain’s tenosynovitis presents as pain in the
region of the apophysis of the radial styloid pro-
cess. Swelling, antalgic radial deviation of the hand,
and local inflammation (erythema and warm skin)
may be present in long-standing cases.
vironmental or other pathophysiological factors are
assumed to trigger a pathological condition
(Hagberg et al., 1995).
Characteristics of Onset (How?)
The onset of symptoms may be sudden or progres-
sive, and may be caused by accidents or activities
involving the hand or wrist. To facilitate identifica-
tion of the underlying causal factors, patients
should be asked to describe in detail the circum-
stances surrounding the appearance of their symp-
toms. Symptoms which intensify during a given ac-
tivity and disappear at rest or when the patient is
away from work strongly suggest an extrinsic cause
(musculoskeletal strain) (Porter et al., 1992).

Onset of Symptoms (When?)
Physicians should determine the time elapsed bet-
ween the onset of symptoms and the current consul-
tation. Patients should be asked the precise reason
for their consultation. Symptoms are usually pre-
A staging scale for evaluating the severity of the
symptoms associated with hand and wrist activities
is proposed in Box 4.2.

Box 4.1

Symptoms Reported by the Patient

– Pain near the apophysis of the radial styloid radiating to the thumb or forearm
– Increased pain upon mobilisation of the thumb with the wrist flexed and in ul-
9
nar deviation
– Weakness and pain during grasping
 Guide to the Diagnosis of Work-Related
Muskuloskeletal Disorders

Box 4.2

Presentation and Clinical Severity of Symptoms

Clinical presentation Severity Symptoms

Symptoms caused by 0 None during these activities

forceful or repetitive
1 slight Only after intense and repetitive activities
movements of the wrist
and the thumb 2 moderate Only after light or occasional activities
3 severe Present even at rest
Source: Adapted from Mahoney et al., 1992

IMPACT ON ACTIVITIES OF DAILY LIVING

In addition to pain, patients may suffers a dimini- tasks of daily living. Box 4.3 lists a series of ques-
shed ability to perform pinching activities with the tions which will help patients pinpoint the extent of
thumb, which hinders them from performing certain their disability.

Box 4.3

Questions about Activities of Daily Living

Which hand is your dominant hand? Right ❐ Left ❐
Never Sometimes Often Always
Do you experience difficulty:
– writing with a pencil or pen
– buttoning a shirt
– turning a key in a lock
– picking up and holding objects with your hand
– opening a car door
– unscrewing the cover of a jar
– performing twisting motions (e.g. wringing)

10
 5 Recording of Information
on Exposure Factors

Tendinitis of the hand and wrist—such as De
Quervain’s tenosynovitis—has been reported to be
associated with forceful or repetitive occupational
activities, with the risk of developing tendinitis si-
gnificantly increased when exposure is to activities
that are both forceful and repetitive (Hagberg et al.,
1995). Information on environmental cofactors
such as exposure to cold and vibration should also
be gathered.
necessary to characterise the occupational, sports-
related, and household activities that may have con-
tributed to the development of tendinitis or teno-
synovitis.
Previous Work
The patient’s occupational history provides infor-
mation on the extent of previous exposure to work-
related musculoskeletal strain of the upper limb.

OCCUPATIONAL HISTORY
To establish that a case of De Quervain’s tenosyno-
vitis is caused by biomechanical requirements it is

Box 5.1

Questions about Previous Occupations

Work performed Starting date and duration Hours per day Risk factors or
in months or years cofactors*

* See Box 2.1

11
 Guide to the Diagnosis of Work-Related
Muskuloskeletal Disorders

Current Work
The description of current work should allow the
physician to form a good idea of the patient’s work
and the conditions under which it is performed. As
it is generally difficult for physicians to visit the work-
place, this guide presents series of questions des-
igned to help them:
– obtain accurate information on the general na-
ture of the work (Box 5.2)
– determine the presence of specific biomechani-
cal requirements which favour the development
of De Quervain’s tenosynovitis (Boxes 5.3 and
5.5)
– evaluate the contribution of organisational fac-
tors (Box 5.4)
There is a wide range of repetitive occupational
activities. Box 5.3 lists common activities which are
related to the development of De Quervain’s teno-
synovitis. If there is little or no correspondence bet-
ween the patient’s activities and those listed, a use-
ful strategy may be to ask her or him to describe
working activities or movements and evaluate their
biomechanical characteristics (duration, frequency

Box 5.2

General Questions on Occupational Activity

and Associated Symptoms
– Is your current job full- or part-time?
– Which hand do you use the most at work?
– Did your pain result from an accident or an abrupt, sudden or unusual
movement?
– Did your pain appear progressively?
• If so, how long did it take to appear and what did it feel like?
– Which activities and movements aggravate your symptoms?

12
 Box 5.3

Questions about Activities that Cause Pain in the Hands or Wrist

Activity Hours Frequency of movements Force exerted
per day low medium high low medium high
– Applying pressure with the thumb
– Maintaining grasping positions
– Wrist flexion, extension, or rotation
– Manipulation of small objects
with the fingers or hand
– Exerting force to hold or grasp
objects
– Use of hand tools (screwdrivers,
knives, etc.)
– Use of vibrating or percussion tools
(drills, drill presses, sanders, etc.)

Other (describe)

Comments

Cofactors with musculoskeletal load Never Occasionnally Regularly

– Wearing gloves at work
– Exposure to cold

13

DE QUERVAIN’S TENOSYNOVITIS
 Guide to the Diagnosis of Work-Related
Muskuloskeletal Disorders

and force).

CURRENT WORK AND ORGANISATIONAL

FACTORS
Certain factors related to the nature and organisa-

Box 5.4

Questions about Organisational Factors at Work

During your work: Never Occasionnally Regularly
– Do you feed a machine at
a constant rhythm?

– Do you feel time or production

pressure?

– Does your work need uninterrupted

attention?

– Do you find your work monotonous?

– Can you vary your work rhythm?

– Do you always work at the same

workstation?

Comments

14
tion of work may favour the development of
musculoskeletal disorders (Box 5.4).
Sports-related, recreational, and household activi-
SPORTS-RELATED, RECREATIONAL, AND ties may contribute to the development of De
HOUSEHOLD ACTIVITIES Quervain’s tenosynovitis. It is therefore important
to establish the intensity with which these activities
are practised and whether the onset of pain in the
Box 5.5

Questions about Sports, Recreational, and Household

Activities Involving the Hands or Wrist
Activity Hours per week Risk factors or cofactors*

* See Box 2.1

15

DE QUERVAIN’S TENOSYNOVITIS
 6 Clinical Examination

hand or wrist has caused the patient to reduce their Figure 6.1
practise. Groove of the Radial Styloid Process,
First Dorsal Compartment of the Wrist
PHYSICAL EXAMINATION
The clinical examination should allow the physician
to confirm a diagnosis of De Quervain’s tenosyno-
vitis and eliminate other disorders that cause symp-
toms affecting the radial side of the wrist. The phys-
ical examination is made up of the following stages:
observation, palpation, assessment of the joint’s range
of movement, evaluation of resisted movements, and
diagnostic tests.

Observation – crepitus (sound of wet leather) in the first dor-

Appearance of the upper limb:
– deviation, deformity, antalgic posture or position
– comparison of the two limbs
State of the tissues of the wrist and hand:
– tissue trophicity
– tissue integrity (thickening of the sheath, swell-
ing, and ulcerations may indicate the existence
of occupational strain)
Palpation
Depending on the severity of the condition, pal-
pation may reveal:
– painful swelling of the wrist-hand region
– thickening of the tendons
– formation of cysts or tendinous nodules
sal compartment, audible with or without a stetho-
scope upon mobilisation of the wrist
Assessment of Range of Movement
The joint’s mobility is assessed through measurement
of the amplitude of the following movements:
– extension and abduction of the thumb
– extension of the thumb with the distal phalanx
flexed
– flexion and extension of the wrist
– radial and ulnar deviation of the wrist
– pronation and supination of the wrist
Dynamic Movements against Resistance
Tenosynovitis-related pain is most evident during iso-
17
 Guide to the Diagnosis of Work-Related
Muskuloskeletal Disorders

Figure 6.2 Figure 6.3

Test of the Abductor Pollicis Longus Test of the Extensor Pollicis Brevis

metric efforts against resistance. This can be elicit-

ed by exerting an opposing force while the patient
abducts or extends the thumb (Figures 6.2 and 6.3).
Diagnostic Tests
Finkelstein’s test (Figure 6.4) is performed with the
hand in a fist, the thumb tucked under the fingers,
and the hand in passive ulnar deviation. Intense pain
in the area of the radial styloid process constitutes
a positive result. A positive result may also be ob-
tained in cases of carpometacarpal osteoarthrosis of

Figure 6.4
Finkelstein’s Test

18
 7 Summary of the Evaluation

Box 7.1

Clinical Aspects
Are the symptoms located over the radial styloid process? YES ❏ NO ❏
SEVERITY OF COMPLAINTS None Slight Moderate Severe
Reported Symptoms
– Frequency and intensity of symptoms (p. 9)
– Disruption of the activities of daily living (p. 10)
Physical Examination
– Reduction of joint’s range of movement (p. 17)
– Reduction of strength (p. 17-18)
– Positive results on Finkelstein’s test (p. 18)
Medical History and Specific Conditions
Yes No
– Specific pathologies or conditions (p. 3) ❏ ❏
Differential Diagnosis
– Arthrosis or other tendinitis (p. 5) ❏ ❏
Musculoskeletal Load None Slight Moderate Severe
– Previous work (p. 11)
– Current work (p. 12-13-14)
– Sports-related, recreational, or household activities
(p. 15)

DIAGNOSIS AND EVALUATION OF THE RELATION TO WORK 19

 8 Guidelines for Therapeutic
and Preventive Intervention

the thumb, Wartenberg’s syndrome, and intersection sures.

syndrome.
Diagnostic guides can also help guide case mana- THERAPEUTIC GUIDELINES
gement and the implementation of preventive mea-
The algorithm presented in Figure 8.1 illustrates the

Figure 8.1
Therapeutic Intervention Flow-chart

Rehabilitation
– Progressive mobilisation
– Muscle strengthening
– Functional reeducation
Improvement

Treatment Preventives measures

– Modification of activities Improvement Ergonomic interventions
– NSAIDs*
to modify risk factors
– Rest for 3-6 weeks

– Hydrocortisone injection
No improvement – Modification of activities

No improvement

– Consider surgery

* NSAID: non-steroid anti-inflammatory drugs

21
 Guide to the Diagnosis of Work-Related
Muskuloskeletal Disorders

stages to be followed in treating De Quervain’s te-

nosynovitis.
of musculoskeletal strain underlying De Quervain’s
tenosynovitis, it may prove useful to propose pre-
PREVENTION GUIDELINES ventive measures affecting high-risk activities.
Table 8.1 presents general guidelines for preven-
In cases where it is possible to identify the sources
tive measures which take into account the diagno-
sis and extent of musculoskeletal strain. The ap-

Table 8.1
Preventive Approach
Diagnosis Musculoskeletal Strain
Significant Not significant
+ –
Evidence of De Quervain’s
tenosynovitis + – Modification of activities – Treatment of causal factors
– Reduction of musculoskeletal load – Modification of activities
– Corrective ergonomic interventions

No evidence of De Quervain’s – – Reduction of musculoskeletal load – Information of risk factors

tenosynovitis – Corrective ergonomic interventions

22
 CONCLUSION

plication of these measures is essential to prevent deterioration or recurrence of the

injury, or aggravation of the symptoms upon return to work.

This guide was designed to help physicians, who in recent years have been faced
with an increase in the number of consultations for musculoskeletal problems of pos-
sible occupational etiology. More specifically, its goals were to facilitate and improve
the clinical and etiological diagnosis of musculoskeletal problems. Its approach em-
phasizes the usefulness of patient-provided information in understanding the circum-
stances surrounding the onset of symptoms.

Physicians have a key role to play in the implementation of measures designed to

reduce musculoskeletal injuries, especially those due to extrinsic factors. Through their

23
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29

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