Hand therapy versus corticosteroid injections in the treatment of de Quervain's disease: A systematic review and meta-analysis

De Quervain Tendinopathy: Anatomical Prognostic Indicators of Corticosteroid Injection Success

BACKGROUND

Anatomical variations of the first extensor compartment can affect de Quervain tendinopathy outcomes. Our study aimed to identify the anatomical prognostic indicators of symptom recurrence following a corticosteroid (CS) injection and to assess the efficacy of CS injections.

METHODS

Fifty consecutive patients received a single CS injection for de Quervain tendinopathy. Ultrasound imaging was used to assess anatomical factors of the first extensor tendon compartment of the wrist. The primary outcome was recurrence after six weeks and six months and the identification of the anatomical prognostic indicators of the recurrence. The Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Visual Analogue Scale (VAS) for pain were evaluated as secondary outcomes.

RESULTS

Fifteen patients (30%) experienced symptom recurrence within six weeks. The intracompartmental septum and the number of tendon slips were associated with higher recurrence rates (adjusted odds ratio for the septum: 18.39, p = 0.045; adjusted odds ratio for each additional tendon slip: 24.68, p < 0.01). The mean DASH score improved from 74.1 ± 5 to 19.3 ± 25.3, and the mean VAS for pain from 8.5 ± 0.8 to 2 ± 2.7 (p < 0.01 for both scores). Five patients experienced minor adverse events with spontaneous improvement.

CONCLUSIONS

CS injections are a viable treatment for de Quervain tendinopathy. Anatomical variations can predict treatment success. Counseling patients based on these factors can help guide treatment decisions, including surgical options.

Advancements in de Quervain Tenosynovitis Management: A Comprehensive Network Meta-Analysis

PURPOSE

This study presents a network meta-analysis aimed at evaluating nonsurgical treatment modalities for de Quervain tenosynovitis. The primary objective was to assess the comparative effectiveness of nonsurgical treatment options.

METHODS

The systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Searches were performed in multiple databases, and studies meeting predefined criteria were included. Data extraction, risk of bias assessment, and statistical analysis were carried out to compare treatment modalities. The analysis was categorized into short-term (within six weeks), medium-term (six weeks up to six months), and long-term (one year) follow-up.

RESULTS

The analysis included 14 randomized controlled trials encompassing various treatment modalities for de Quervain tenosynovitis. In the short-term, extracorporeal shockwave therapy demonstrated statistically significant improvement in visual analog scale pain scores compared with placebo. Extracorporeal shockwave therapy also ranked highest in the treatment options based on its treatment effects. Corticosteroid injections (CSIs) combined with casting and laser therapy with orthosis showed favorable outcomes. Corticosteroid injection alone, platelet-rich plasma injections alone, acupuncture, and orthosis alone did not significantly differ from placebo in visual analog scale pain score. In the medium-term, extracorporeal shockwave therapy remained the top-ranking option for visual analog scale pain score, followed by CSI with casting. In the long-term (one year), CSI alone and platelet-rich plasma injections demonstrated sustained pain relief. Combining CSI with orthosis also appeared promising when compared with CSI alone.

CONCLUSIONS

Corticosteroid injection with a short duration of immobilization remains the primary and effective treatment for de Quervain tenosynovitis. Extracorporeal shockwave therapy can be considered a secondary option. Alternative treatment modalities, such as isolated therapeutic injection, should be approached with caution because they did not show substantial benefits over placebo.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Corticosteroid injection versus immobilisation for the treatment of De Quervain's tenosynovitis: A systematic review and meta-analysis

OBJECTIVE

De Quervain's tenosynovitis causes pain and impairment of thumb function. Conservative treatments comprise corticosteroid injection and immobilization, and it is unclear which offers greater efficacy. Previous reviews were limited by the small number of included studies; thus an updated review and meta-analysis is warranted.

METHODS

A systematic review of the PubMed, Embase, and Web of Science databases was conducted. Randomized control trials comparing corticosteroid injection to immobilization were included. Two authors screened articles, extracted data, and assessed the risk of bias of included studies. Meta-analyses using the random-effects model were conducted, calculating pooled relative risks and mean differences with 95% confidence intervals.

RESULTS

16 studies comprising 1206 patients were included. Corticosteroid injection showed greater treatment success than immobilization (relative risk: 1.61; 95% confidence interval: 1.21-2.15). Combining treatments demonstrated greater efficacy than immobilization (relative risk: 2.15; 95% confidence interval: 1.77-2.62) or injection alone (relative risk: 1.23; 95% confidence interval: 1.12-1.34). Pain and disability scores were lower with injection than immobilization and with combined treatment than with either alone.

CONCLUSION

Corticosteroid injection is more effective than immobilization for De Quervain's tenosynovitis, and combining the two treatments provides additional benefit. We recommend corticosteroid injection in first line treatment and immobilization as adjuvant therapy. Further research is required regarding optimal corticosteroid and local anesthetic formulations.

De Quervain's Tenosynovitis: As Seen from the Perspective of the Patient

Purpose

Patient preferences and expectations following both nonsurgical and operative treatment of de Quervain's tenosynovitis are unclear. In this study, we aim to better delineate patient preferences for initial management of de Quervain's tenosynovitis. For patients considering surgical treatment, we hope to identify which factors of surgical care are most important for patients to receive counseling.

Methods

An online crowdsourcing platform, Amazon Mechanical Turk, was used to recruit study participants. Study participants were then led through a clinical scenario pertaining to de Quervain's tenosynovitis. They were then asked a series of questions regarding initial treatment options, important factors to consider during surgery, and postoperative expectations. A Likert scale was used for responses. Descriptive statistics and one-way analysis of variance were used to assess survey responses.

Results

In total, 199 survey responses were included, and 84% of respondents chose nonsurgical modalities for initial treatment of de Quervain's tenosynovitis. Survey items asking about the importance of cost, risks of surgery, expected recovery time, and expected pain level following surgery revealed that all factors were considered important to respondents. There were no differences between groups in the one-way analysis of variance.

Conclusions

Providers should remain cognizant that patients presenting with de Quervain's tenosynovitis may favor initial nonsurgical management. The vast majority of respondents rated the importance of cost, risks of surgery, expected recovery time, and expected pain level as having some level of importance when considering surgical care. When discussing outcomes of surgery, respondents were nearly divided on what would be considered a successful outcome of surgery. This suggests that treating physicians may benefit from clarifying expected outcomes during surgical discussions.

Type of study/level of evidence

Diagnostics IIb.

A scoping review to map evidence regarding key domains and questions in the management of non-traumatic wrist disorders

Introduction

Non-traumatic wrist disorders (NTWD) are commonly encountered yet sparse resources exist to aid management. This study aimed to produce a literature map regarding diagnosis, management, pathways of care and outcome measures for NTWDs in the United Kingdom.

Methods

An interdisciplinary team of clinicians and academic researchers used Joanna Briggs Institute guidelines and the PRISMA ScR checklist in this scoping review. A mixed stakeholder group of patients and healthcare professionals identified 16 questions of importance to which the literature was mapped. An a-priori search strategy of both published and non-published material from five electronic databases and grey literature resources identified records. Two reviewers independently screened records for inclusion using explicit eligibility criteria with oversight from a third. Data extraction through narrative synthesis, charting and summary was performed independently by two reviewers.

Results

Of 185 studies meeting eligibility criteria, diagnoses of wrist pain, De Quervain's syndrome and ulna-sided pain were encountered most frequently, with uncontrolled non-randomised trial or cohort study being the most frequently used methodology. Diagnostic methods used included subjective questioning, self-reported pain, palpation and special tests. Best practice guidelines were found from three sources for two NTWD conditions. Seventeen types of conservative management, and 20 different patient-reported outcome measures were suggested for NTWD.

Conclusion

Substantial gaps in evidence exist in all parts of the patient journey for NTWD when mapped against an analytic framework (AF). Opportunities exist for future rigorous primary studies to address these gaps and the preliminary concerns about the quality of the literature regarding NTWD.

Management of de Quervain Tenosynovitis: A Systematic Review and Network Meta-Analysis

Importance

There is a plethora of treatment options for patients with de Quervain tenosynovitis (DQT), but there are limited data on their effectiveness and no definitive management guidelines.

Objective

To assess and compare the effectiveness associated with available treatment options for DQT to guide musculoskeletal practitioners and inform guidelines.

Data Sources

Medline, Embase, PubMed, Cochrane Central, Scopus, OpenGrey.eu, and WorldCat.org were searched for published studies, and the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, The European Union Clinical Trials Register, and the ISRCTN registry were searched for unpublished and ongoing studies from inception to August 2022.

Study Selection

All randomized clinical trials assessing the effectiveness of any intervention for the management of DQT.

Data Extraction and Synthesis

This study was prospectively registered on PROSPERO and conducted and reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions (PRISMA-NMA) and PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSIST) guidance. The Cochrane Risk of Bias tool and the Grading of Recommendations, Assessment, Development, and Evaluations tool were used for risk of bias and certainty of evidence assessment for each outcome.

Main Outcomes and Measures

Pairwise and network meta-analyses were performed for patient-reported pain using a visual analogue scale (VAS) and for function using the quick disabilities of the arm, shoulder, and hand (Q-DASH) scale. Mean differences (MD) with their 95% CIs were calculated for the pairwise meta-analyses.

Results

A total of 30 studies with 1663 patients (mean [SD] age, 46 [7] years; 80% female) were included, of which 19 studies were included in quantitative analyses. From the pairwise meta-analyses, based on evidence of moderate certainty, adding thumb spica immobilization for 3 to 4 weeks to a corticosteroid injection (CSI) was associated with statistically but not clinically significant functional benefits in the short-term (MD, 10.5 [95% CI, 6.8-14.1] points) and mid-term (MD, 9.4 [95% CI, 7.0-11.9] points). In the network meta-analysis, interventions that included ultrasonography-guided CSI ranked at the top for pain. CSI with thumb spica immobilization had the highest probability of being the most effective intervention for short- and mid-term function.

Conclusions and Relevance

This network meta-analysis found that adding a short period of thumb spica immobilization to CSI was associated with statistically but not clinically significant short- and mid-term benefits. These findings suggest that administration of CSI followed by 3 to 4 weeks immobilization should be considered as a first-line treatment for patients with DQT.

De Quervain's Disease: A Discourse on Etiology, Diagnosis, and Treatment

Since Fritz De Quervain first postulated stenosing tenosynovitis within the radial dorsum of the wrist, much research has been conducted to provide further insights. De Quervain's Disease (DQD) is a condition that affects the tendons that control the movement of the thumb, specifically the abductor pollicis longus and extensor pollicis brevis. Numerous studies have shown that structural divergence from normal anatomy is partly related to contingency for developing DQD. Even though this condition was discovered many years ago, its exact etiology remains a subject of debate. Two schools of thought exist, one that contends an inflammatory-mediated pathway and the other degenerative changes. Substantial evidence exists for both theories, thus necessitating further studies into the etiology of DQD. Classically, Finkelstein's and Eichhoff's tests have been used as the physical examinations of choice for clinically diagnosing this condition. However, these tests have been shown to have low specificity, hence, the emergence of the wrist hyperflexion and abduction of the thumb test. Evidence also suggests that ultrasonography may become a critical diagnostic tool, especially to identify anatomical variations before invasive treatment, reducing the risk of further complications. The management of DQD is typically conservative, with escalation to steroid injections before surgery is indicated. Future research into this disease should focus on establishing a clearer picture of how anatomical variations and other pathological and occupational factors may interplay to bring about this condition. While current research has suggested possible novel approaches for diagnosing and treating DQD, more studies are required to gain greater insights into the effectiveness of these interventions.

Acupuncture for de Quervain's tenosynovitis: A randomized controlled trial

BACKGROUND

Acupuncture has been an alternative approach for de Quervain's tenosynovitis (DQt), but trial evidence is still lacking.

PURPOSE

This study aimed to assess the efficacy of acupuncture in patients with DQt.

STUDY DESIGN

A randomized controlled trial.

METHODS

A total of 68 subjects with DQt were recruited from outpatients of Department of Orthopaedics and Traumatology, and Chinese medicine clinics, The University of Hong Kong, and were randomized into the acupuncture group (n = 34) and the waitlist group (n = 34). Subjects in the acupuncture group received 5 acupuncture sessions over 2 weeks, followed by a 10-week follow-up. The waitlist control group received assessments only in the first 6 weeks of the waiting period and received the same acupuncture treatment and follow-up as the treatment group in the next 12 weeks. The primary outcome was the general pain intensity using the Visual Analogue Scale (VAS) at the end of treatment (week 2). Secondary outcomes were grip and pinch strengths of affected hands, the quick Disabilities of the Arm, Shoulder and Hand Score (Q-DASH), and the World Health Organization Quality of Life-brief Questionnaire (WHOQOL-BREF) at weeks 2 and 6.

RESULTS

From baseline to 2 weeks, the mean VAS score decreased by 19.5 points in the acupuncture group and by 3.4 points in the waitlist group. The difference for acupuncture vs waitlist control was -16.2 points (95% CI, -26.7 to -5.6, p = 0.003). Acupuncture effects sustained for 10 weeks (mean difference compared with baseline, -30.6; 95% CI, -39.6 to -21.7). Secondary outcomes showed that acupuncture reduced pain intensity, improved grip and pinch strength of affected hands, and Q-DASH scores, but not the scores of WHOQOL-BREF in patients. No serious adverse event occurred during the study period.

CONCLUSIONS

Our findings support that 2-week of acupuncture is safe and effective in the reduction of pain intensity, and improvement of strengths and disabilities of hand in DQt patients. Acupuncture also has long-term effects on DQt.

TRIAL REGISTRATION

This study was registered at clinicaltrials.gov (NCT03472443).

Common Hand Conditions: A Review

Importance

Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and basilar (carpometacarpal) joint arthritis of the thumb can be associated with significant disability.

Observations

Carpal tunnel syndrome is characterized by numbness and tingling in the thumb and the index, middle, and radial ring fingers and by weakness of thumb opposition when severe. It is more common in women and people who are obese, have diabetes, and work in occupations involving use of keyboards, computer mouse, heavy machinery, or vibrating manual tools. The Durkan physical examination maneuver, consisting of firm digital pressure across the carpal tunnel to reproduce symptoms, is 64% sensitive and 83% specific for carpal tunnel syndrome. People with suspected proximal compression or other compressive neuropathies should undergo electrodiagnostic testing, which is approximately more than 80% sensitive and 95% specific for carpal tunnel syndrome. Splinting or steroid injection may temporarily relieve symptoms. Patients who do not respond to conservative therapies may undergo open or endoscopic carpal tunnel release for definitive treatment. Trigger finger, which involves abnormal resistance to smooth flexion and extension ("triggering") of the affected finger, affects up to 20% of adults with diabetes and approximately 2% of the general population. Steroid injection is the first-line therapy but is less efficacious in people with insulin-dependent diabetes. People with diabetes and those with recurrent symptoms may benefit from early surgical release. de Quervain tenosynovitis, consisting of swelling of the extensor tendons at the wrist, is more common in women than in men. People with frequent mobile phone use are at increased risk. The median age of onset is 40 to 59 years. Steroid injections relieve symptoms in approximately 72% of patients, particularly when combined with immobilization. People with recurrent symptoms may be considered for surgical release of the first dorsal extensor compartment. Thumb carpometacarpal joint arthritis affects approximately 33% of postmenopausal women, according to radiographic evidence of carpometacarpal arthritis. Approximately 20% of patients require treatment for pain and disability. Nonsurgical interventions (immobilization, steroid injection, and pain medication) relieve pain but do not alter disease progression. Surgery may be appropriate for patients unresponsive to conservative treatments.

Conclusions and Relevance

Carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, and thumb carpometacarpal joint arthritis can be associated with significant disability. First-line treatment for each condition consists of steroid injection, immobilization, or both. For patients who do not respond to noninvasive therapy or for progressive disease despite conservative therapy, surgical treatment is safe and effective.

CMC Mimickers: Differential Diagnosis and Work-Up for Radial-Sided Wrist Pain

In patients with radial-sided wrist pain, a myriad of possible etiologies exists and as such, a detailed history, examination, and, where indicated, imaging is obtained to try and aid with its diagnosis. The purpose of this article is to provide an overview of radial-sided wrist pain, diagnostic modalities and discuss current treatment options. More detailed information is out-of-scope for this article and if needed, we would guide the reader to seek out other selected texts, as indicated.

A Systematic Review of the Efficacy of Corticosteroid Injections of Tendon Sheaths, Excluding Stenosing Tenosynovitis of the Wrist and Hand

OBJECTIVE

Corticosteroid injections into tendon sheaths are common in clinical practice for treatment of a variety of tendon disorders. Previous systematic reviews have been performed on injections for stenosing tenosynovitis (DeQuervain tenosynovitis and trigger finger), but little high-level evidence remains for other tendon sheath injections. This systematic review analyzes the available literature on improvements in pain and function after these injections.

DESIGN

This systematic review of MEDLINE and Embase databases, as well as article bibliographies, examined studies of adult tendon sheath injections, excluding DeQuervain and trigger finger injections. Studies with and without comparison groups were examined. Risk of bias assessment was additionally performed.

RESULTS

Abstracts from 1293 records were screened, and 187 full-text articles were reviewed. Seven articles met final inclusion criteria, of which five were prospective trials and none were compared with a placebo. The proximal biceps, peroneal, finger flexor, and posterior tibialis tendons were explicitly examined. All articles reported at least short-term improvements in pain, and some reported improvement in function.

CONCLUSIONS

Low-quality studies exist that suggest tendon sheath injections may provide at least short-term improvement in pain. Controlled studies are required to fully demonstrate efficacy.

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm

BACKGROUND

Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes.

METHODS

A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria.

RESULTS

A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports.

CONCLUSIONS

A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

Conservative management of De Quervain's tendinopathy with an orthopedic manual physical therapy approach emphasizing first CMC manipulation: a retrospective case series

De Quervain's tendinopathy (DQT) is a musculoskeletal disorder that limits hand function of affected individuals. Management of DQT can include splinting, activity modification, medications, corticosteroid injections, physical therapist management, and surgery. There is limited evidence to support the combination of manual therapy and exercise interventions within an Orthopedic Manual Physical Therapy (OMPT) approach when managing patients with DQT. Three patients identified with DQT underwent a multi-modal treatment regimen including carpometacarpal (CMC) thrust and non-thrust manipulation, end range radiocarpal mobilization, mobilization with movement (MWM), strengthening exercises, and grip proprioception training. Outcomes were assessed using the numeric pain rating scale (NPRS), Jamar hand dynamometer grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire. These measures were administered at baseline and discharge. Each patient demonstrated improvements in all outcome measures and required ten visits or less to reach a satisfactory outcome. The NPRS improved by a mean of 7.1 points on a 0-10 scale, Quick DASH improved by an average of 37.1%, and grip strength improved by a mean of 27.6 pounds. Each patient was able to return to daily tasks without pain and all improvements were maintained at six month follow-up. An impairment based OMPT management approach was effective in managing three patients with DQT. The inclusion of first CMC manipulation within this multi-modal approach may enhance conservative management of patients with DQT. Because a cause and effect relationship cannot be inferred from a case series, further research is recommended to investigate the efficacy of this management approach.

Nonsurgical Treatment of De Quervain Tenosynovitis: A Prospective Randomized Trial

Background: De Quervain tenosynovitis is commonly seen in patients who perform repetitive wrist ulnar deviation with thumb abduction and extension. Previous studies comparing nonsurgical options have contributed to a lack of consensus about ideal management. This study's purpose was to analyze results in prospectively randomized patients treated with either corticosteroid injection (CSI) alone versus CSI with immobilization. Methods: Radial sided wrist pain, first dorsal compartment tenderness, and positive Finkelstein test were used to define De Quervain. Pain score of 4 or higher on a visual analog scale (VAS) was utilized for inclusion. Following exclusion criteria, patients underwent randomization into groups: (1) CSI alone; or (2) CSI with 3 weeks of immobilization. We followed at 3 weeks and 6 months for further evaluation, where resolution of symptoms and improvements in VAS and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were assessed to evaluate treatment success. Results: Nine patients with CSI alone and 11 patients with CSI and immobilization were followed. At 6 months in both groups, patients experienced significant improvement in VAS and DASH scores, while 88% of patients with CSI alone and 73% of patients with CSI and immobilization experienced complete resolution of at least 2 out of 3 of their pretreatment symptoms. Between groups, outcomes were comparable except for resolution of radial-sided wrist pain, which was superior in patients with CSI alone (100% vs 64%). Conclusions: Immobilization following injection increases costs, may hinder activities of daily living, and did not contribute to improved patient outcomes in this study. Further prospective studies are warranted.

Occupational Therapists' Role in Perinatal Care: A Health Promotion Approach

This article establishes and examines occupational therapists' role in perinatal care and proposes a health promotion approach for new and expectant mothers. The author demonstrates the importance of maintaining meaningful occupational engagement during this critical life stage by incorporating evidence from orthopedic, rehabilitation, and hand therapy research. New and expectant mothers are at high risk for upper extremity (UE) conditions such as carpal tunnel syndrome, De Quervain's tenosynovitis, and tendinosis of the UE. Occupational therapists with basic knowledge of hand therapy are well prepared to manage these conditions conservatively. An occupation-based model and framework are presented to ensure a holistic view of the target population. Topics pertinent to this population include postural techniques, repetitive tasks, patient education, and strengthening related to the perinatal period.

Analysing orthotic designs for de Quervain's disease based on in vivo gliding distance of extensor pollicis brevis tendon

Background/Aims:

To reconsider orthotic designs used for de Quervain's disease based on in vivo information obtained from ultrasound images.

Methods:

The hands (n=40) of 20 healthy adult men and women participants with no history of thumb injury or deformation were examined. A two-dimensional tissue tracking system was used to quantitatively measure in vivo gliding distance in the extensor pollicis brevis tendon during thumb interphalangeal joint autonomic movement while wearing a thumb spica orthosis.

Findings:

Results revealed anatomical variations in the insertion of the extensor pollicis brevis tendon in 9 (22.5%) hands. A septum was noted in the first dorsal compartment of the extensor tendon in 23 (57.5%) hands. Multiple comparison testing of gliding distance across four groups, classified by the presence or absence of anatomical variations and/or septa using Tukey's test, revealed significant differences for gliding distance between groups with and without anatomical variations, regardless of whether septa were observed (p=0.01).

Conclusions:

It is necessary to evaluate physical characteristics such as septa and anatomical variations based on advanced screening with ultrasound examinations before considering thumb fixation range for patients in the acute inflammation phase or those exhibiting recurrence of de Quervain's disease.