Tenosynovitis

What is Tenosynovitis?

Tenosynovitis refers to the inflammation of a part of the body called the synovium, which is a fluid-filled area within the protective covering of our tendons, known as the tendon sheath. This condition often leads to pain, swelling, and difficulty in moving the affected area. Although it can occur in any tendon that has a sheath, it is mainly found in the hand, wrist, and foot.

Understanding the structure of a tendon can help us grasp the causes, treatment, and potential complications of tenosynovitis. A tendon is a tough, flexible band of tissues that connects muscles to bones. The sheath is a protective layer around the tendon, like a tunnel, which is especially evident in the hand.

The tendons in the hand play a crucial role in our ability to grip, grasp and make precise movements. These tendons run through the wrist, across the palm, and into tunnels formed by their sheaths on the insides of each finger or “digit”. Inside these tunnels, the tendons are surrounded by what’s known as a synovial sheath or bursa. Together, the tunnel and this bursa form the protective tendon sheath.

The tendon sheath serves two main purposes:

1. The synovial fluid inside the sheath nourishes the tendon and acts as a lubricant, facilitating the smooth movement of the tendon, thereby reducing the damage caused by excessive friction.

2. The sheath also serves as an anchor point for the tendon to ensure it doesn’t bulge out when we move our fingers, a situation known as ‘bowstringing.’ Essentially, in our hands, these sheaths help keep tendons in their correct place against the bones of our fingers and their joints.

What Causes Tenosynovitis?

Tenosynovitis is a condition that can be split into two main groups: the type caused by infection and the type that isn’t. The non-infective type can be due to autoimmune issues, overuse, or it could have no clear cause, also known as idiopathic.

Autoimmune

An autoimmune disease such as rheumatoid arthritis could cause tenosynovitis. In fact, up to 87 percent of people with rheumatoid arthritis show signs of tenosynovitis in MRI scans. Rheumatoid arthritis tends to target areas in our bodies with synovial linings. Since the sheath, or the protective layer of a tendon, contains synovial tissue, it could play a major role in the disease’s progression and the patient’s symptoms. Though this link has been demonstrated in mice, more research is required in humans. Another autoimmune condition, Psoriasis, is also commonly linked to tenosynovitis.

Overuse

Overuse or repetitive strain can also lead to tenosynovitis. This often results from repetitive movements that cause inflammation of the synovial sheath, a protective layer around our tendons. For instance, spending long hours on a computer and making repetitive hand movements can put a strain on the fingers, wrist, and forearm. This repeated movement over time can irritate the tendon and lead to tenosynovitis.

Idiopathic

Sometimes, there’s no specific reason why someone develops tenosynovitis. In these cases, the condition is termed idiopathic, as there’s no known cause.

Infective

On the other hand, tenosynovitis can also be caused by harmful pathogens, or disease-causing bacteria or viruses, that grows within the tendon sheaths. These pathogens can reach the sheaths directly, for example, through an injury, or they can spread from other nearby or distant infections. Commonly found pathogens in cases of infective tenosynovitis include Staphylococcus aureus and MRSA, as well as bacteria like Staphylococcus epidermidis, beta-hemolytic Streptococcus, Pseudomonas aeruginosa. The bacteria Eikinella can be present in cases related to human bites and Pasturella multocida in animal bites.

Risk Factors and Frequency for Tenosynovitis

Tenosynovitis is a common condition that affects different people in different ways depending on the cause. In the general population, between 1.7 to 2.6% of people experience a certain type of tenosynovitis. However, this number increases dramatically for people with diabetes, with 10 to 20% affected. For those who have infections on their hands, only between 2.5 and 9.4% will also develop infectious tenosynovitis. People with rheumatoid arthritis are particularly at risk, with more than half experiencing symptoms.

Tenosynovitis is a common condition with rates varying depending on the cause.
In the general population, 1.7 to 2.6% of people develop a specific type of tenosynovitis.
For those with diabetes, this rate rises to between 10 and 20%.
Of those experiencing hand infections, 2.5 to 9.4% will develop infectious tenosynovitis.
People with rheumatoid arthritis are notably at risk, with 55% reporting symptoms.

Signs and Symptoms of Tenosynovitis

Tenosynovitis is a condition that can be triggered by different things, and the treatment largely depends on the cause. A detailed medical history is required to understand the possible causes. It could be due to an injury, infection, an ongoing arthritis issue, or an autoimmune disorder. Symptoms would vary based on the cause but typically include swelling, pain, redness, and difficulty moving the affected joint.

For infectious tenosynovitis, there are specific signs to watch out for, known as “Kanavel signs”. These include:

Tenderness of the flexor sheath
Enlargement of the affected tendon in an even pattern
Contracture of the affected tendon
Pain when attempting to straighten the tendon

While these signs can often indicate infectious tenosynovitis, they do not always mean the condition is present. If tenosynovitis is due to rheumatoid arthritis, there could be nodules or hand deformities, while crystalline causes might reveal the presence of tophi. Sometimes, the physical examination might not reveal much, especially in cases of chronic overuse injury. In some severe cases, tenosynovitis can lead to visible contracture deformities and an inability to relax the tendon.

Another form of tenosynovitis, known as stenosing tenosynovitis, happens when the flexor tendon becomes larger compared to the A1 pulley, a small band around the tendon. It results in the joint “catching” or “locking”. If it happens in the fingers, it’s called “trigger finger”, leading to flexion contractures at the PIP joints. In the thumb, stenosing tenosynovitis affects the extensor pollicis brevis and abductor pollicis longus, resulting in PIP contractures, often accompanied by a positive Finklestein test. This type is known as de Quervain tenosynovitis.

Testing for Tenosynovitis

If your doctor suspects you have tenosynovitis, which means inflammation of the lining of a tendon, they might conduct laboratory tests. Although lab tests aren’t always necessary, they can be very helpful in figuring out what’s causing your tenosynovitis. For instance, if an infection is suspected, your doctor might check for increased white blood cells or bacteria in the blood. If an autoinflammatory disease, a type of condition caused by abnormal regulation of the immune system, is suspected, specific markers or signs of the disease might be searched for. Sometimes, looking at samples under a microscope can help distinguish between different types of conditions that may look similar.

Imaging tests can also provide useful information. A basic X-ray might show hardening of the synovial membrane, which is the lining of the joints, or signs of inflammation around the bone. However, X-rays might not always reveal something unusual. Computed tomography, commonly known as a CT scan, can be useful for seeing any changes in bone structure, such as erosions or structural anomalies. However, CT scans are not very good at showing soft tissue inflammation in the tendon and its sheath.

An ultrasound is another imaging technique that can reveal more detail, especially in the hands. It can show texture changes in some tendons and blurry tendon edges. It can also show tendon thickening in some fingers, cysts in the tendon sheath, and other abnormalities in the joints where the fingers connect to the hand.

If more detailed images are needed or if an ultrasound cannot provide clear pictures, your doctor might decide to use an MRI. This can be particularly useful if there’s a concern for an infection, as an MRI with contrast, which is a special dye that helps highlight certain areas in the images, may help to visualize if an abscess, or a collection of pus, is present. The appearance of tenosynovitis on an MRI can vary depending on what’s causing it, but commonly, there may be swelling around the tendon and increased thickening of certain tendons. In those with rheumatoid arthritis, a type of autoimmune disease, there may even be changes in the bone marrow signal even before symptoms of tenosynovitis appear.

Treatment Options for Tenosynovitis

Infectious tenosynovitis is a condition affecting the protective sheath that surrounds your tendons, usually caused by an infection. When treating this condition, knowing the exact cause helps determine the best treatment. However, when that cause isn’t known, broad-spectrum antibiotics are often used as a general treatment.

Treatment length can depend on several factors such as clinical findings, the presence or absence of bacteria in the bloodstream, and the source of the infection. In cases of early-stage infectious tenosynovitis (stage 1), irrigating or washing out the tendon sheath may help. Some studies have shown that directing therapy through a catheter or small tube leads to better outcomes than open irrigation.

For severe cases of infectious tenosynovitis (stages 2 and 3), debridement may be needed – a surgical procedure that involves removing infected or damaged tissue.

Tenosynovitis can also be caused by noninfectious factors, such as injury or overuse. These cases are usually treated differently and can often be managed with non-steroidal anti-inflammatory drugs like naproxen. This is usually accompanied by modifying certain activities that cause pain, using a splint, and injections of glucocorticoids (a type of steroid).

If the inflammation doesn’t improve after a trial of non-steroidal anti-inflammatory drugs, medications that help regulate the immune system (known as disease-modifying antirheumatic drugs) might be used.

If the condition persists despite these conservative treatments after 3 to 6 months, surgery may be necessary. The surgical procedure could involve relieving pressure on the affected tendons and removing inflammatory tissues.

Several health issues can resemble or lead to tenosynovitis. Here are some common ones:

Cellulitis or a soft tissue infection can imitate the symptoms of tenosynovitis, causing swelling and pain that make the affected joint tough to move.
Diseases connected to the joints like osteoarthritis, rheumatoid arthritis, pseudogout, psoriatic arthritis, and gout.
Recent or old injuries, including bone or tendon damage, can often resemble stenosing tenosynovitis, a particular type of tenosynovitis.
Dupuytren contractures, which is a thicken and tighten of the tissue under the skin in the hand, can also look like a case of stenosing tenosynovitis. This can cause the fingers to lock, making movement difficult.

What to expect with Tenosynovitis

In infectious tenosynovitis, which is an inflammation of the sheath that surrounds a tendon often due to infection, the best results generally come from early treatment with antibiotics and clearing the area of any harmful material when necessary. The chances of not getting better are higher when factors such as an infection with the bacteria Streptococcus pyogenes or multiple agents, delay in antibiotic treatment, pus in the tissue, diabetes, kidney failure, and issues with peripheral blood vessels (blood vessels supplying areas apart from the brain and heart) are present. Particularly bad outcomes are associated with necrosis (death of body tissue) and destruction in Stage 3 disease, with a 59% rate of having to amputate the affected limb.

For non-infectious tenosynovitis, outcomes can vary greatly depending on the cause. Yet, patients suffering from the stenosing form, a type that results in constrained movement, have a generally good outcome. Reports state that 93% see improvement in symptoms relating to fingers within 6 to 10 weeks of wearing a thermoplastic splint, a type of brace made of heat-modifiable plastic, with 54% achieving full recovery. If the problem persists despite initial treatment, about half the patients who use steroid medicines find relief lasting for over a year. Patients undergoing surgery also generally do well, with symptoms recurring in only 4.6% of cases. However, patients with diabetes are a special group and often do not respond very well to steroid medicine or surgery.

Possible Complications When Diagnosed with Tenosynovitis

Infections in the lining of the tendon, also known as infectious/pyogenic tenosynovitis, can result in up to 38% of patients experiencing complications. These may include long-term finger stiffness, changes to the shape of the bones or tendons, spreading of infection deeper into the hand, death of the tendon tissues, scarring, and in extreme cases, amputation might be needed.

For patients dealing with the non-infectious type of this disease, it could turn into the stenosing form, causing prolonged muscle tightness and bending deformities that need surgical intervention. However, treating non-infectious tenosynovitis can also lead to complications, specifically in patients who need surgery. These complications could range from infections and nerve damage to deformities of the flexor tendon and tissue scarring.

Possible Complications:

Long-term finger stiffness
Bone or tendon deformation
Deeper hand infection
Tendon necrosis (death of tendon tissues)
Tissue scarring
Amputation
Chronic muscle tightness
Bending deformities
Nerve damage
Flexor tendon deformities

Preventing Tenosynovitis

To prevent infectious tenosynovitis, a condition that causes inflammation in the protective sheath around a tendon, it’s crucial to steer clear of situations that might increase the risk of getting an infection in the hands. Recognizing the early signs of this condition, which can include soreness, pain, stiffness, or swelling in a finger, can make a big difference in recovering successfully.

If you’re dealing with non-infectious tenosynovitis, it’s important to identify and avoid any activities that might worsen your symptoms. Additionally, good preventative care can help manage this condition, especially if you have another health issue that could be contributing to the tenosynovitis.

Frequently asked questions

The prognosis for tenosynovitis depends on the type and cause of the condition: - For infectious tenosynovitis, early treatment with antibiotics and clearing the area of harmful material generally leads to the best results. However, factors such as certain infections, delay in antibiotic treatment, pus in the tissue, diabetes, kidney failure, and issues with peripheral blood vessels can increase the chances of not getting better. Particularly bad outcomes are associated with necrosis and destruction in Stage 3 disease, with a 59% rate of amputation. - For non-infectious tenosynovitis, outcomes can vary greatly depending on the cause. Patients with the stenosing form, which results in constrained movement, generally have a good outcome. Wearing a thermoplastic splint can lead to improvement in symptoms for 93% of patients within 6 to 10 weeks, with 54% achieving full recovery. Steroid medicines and surgery can also be effective treatments.

Tenosynovitis can be caused by various factors such as autoimmune diseases, overuse or repetitive strain, and sometimes there is no known cause (idiopathic). It can also be caused by infection from harmful pathogens.

The signs and symptoms of Tenosynovitis can vary depending on the cause, but typically include: - Swelling - Pain - Redness - Difficulty moving the affected joint For infectious tenosynovitis, there are specific signs known as "Kanavel signs" to watch out for, which include: - Tenderness of the flexor sheath - Enlargement of the affected tendon in an even pattern - Contracture of the affected tendon - Pain when attempting to straighten the tendon If tenosynovitis is due to rheumatoid arthritis, there may be additional symptoms such as nodules or hand deformities. Crystalline causes of tenosynovitis might reveal the presence of tophi. In some cases, the physical examination might not reveal much, especially in chronic overuse injuries. Severe cases of tenosynovitis can lead to visible contracture deformities and an inability to relax the tendon. There is also a specific form of tenosynovitis called stenosing tenosynovitis, which can result in joint "catching" or "locking". In the fingers, it is known as "trigger finger" and can lead to flexion contractures at the PIP joints. In the thumb, stenosing tenosynovitis affects specific tendons and can result in PIP contractures, often accompanied by a positive Finklestein test. This type is known as de Quervain tenosynovitis.

The types of tests that may be ordered to properly diagnose tenosynovitis include: - Laboratory tests: These can help determine the cause of tenosynovitis, such as checking for increased white blood cells or bacteria in the blood if an infection is suspected, or searching for specific markers or signs of an autoinflammatory disease. - Imaging tests: X-rays can show signs of inflammation or hardening of the synovial membrane, while CT scans can reveal changes in bone structure. Ultrasounds can provide more detail, especially in the hands, showing texture changes in tendons, tendon thickening, and abnormalities in the joints. MRI with contrast can help visualize if an abscess is present and can show swelling and thickening of tendons. - Other diagnostic procedures: In some cases, looking at samples under a microscope can help distinguish between different types of conditions that may look similar.

Cellulitis, diseases connected to the joints (such as osteoarthritis, rheumatoid arthritis, pseudogout, psoriatic arthritis, and gout), recent or old injuries (including bone or tendon damage), and Dupuytren contractures.

When treating Tenosynovitis, there can be several possible side effects or complications. These include: - Long-term finger stiffness - Bone or tendon deformation - Deeper hand infection - Tendon necrosis (death of tendon tissues) - Tissue scarring - Amputation - Chronic muscle tightness - Bending deformities - Nerve damage - Flexor tendon deformities

You should see an orthopedic doctor or a rheumatologist for Tenosynovitis.

Tenosynovitis is a common condition with rates varying depending on the cause.

Tenosynovitis can be treated in different ways depending on the cause. If the tenosynovitis is caused by an infection, broad-spectrum antibiotics are often used. The length of treatment can vary based on factors such as clinical findings, presence of bacteria in the bloodstream, and the source of the infection. In early-stage cases, irrigating or washing out the tendon sheath may be helpful. For severe cases, surgical debridement may be necessary to remove infected or damaged tissue. Noninfectious cases of tenosynovitis, caused by factors like injury or overuse, are usually treated with non-steroidal anti-inflammatory drugs, activity modification, splinting, and glucocorticoid injections. If inflammation persists despite conservative treatments, disease-modifying antirheumatic drugs may be used. Surgery may be necessary if the condition persists after 3 to 6 months of conservative treatment.

Tenosynovitis refers to the inflammation of the synovium, which is a fluid-filled area within the protective covering of tendons known as the tendon sheath.