Finkelstein’s test: A biomechanical analysis

doi:10.1016/j.jhsa.2004.07.001

The Journal of Hand Surgery

Volume 30, Issue 1, January 2005, Pages 130-135

https://doi.org/10.1016/j.jhsa.2004.07.001 Get rights and content

Purpose

Finkelstein’s test is the classic diagnostic test for de Quervain’s disease. Finkelstein hypothesized that the entry of the muscle bellies of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons into the first extensor compartment was responsible for the findings observed in his now eponymous test. We agree with Finkelstein’s hypothesis and further hypothesize that this position would induce measurable bulk (muscle mass within the retinaculum) and tethering (stretching of synovial tissue) effects within the compartment. To test this latter hypothesis we measured the excursion and gliding resistance of the EPB and APL tendons within the first compartment.

Methods

Fifteen fresh-frozen cadavers were used. Gliding resistance and excursion were measured in 4 different wrist positions, including the wrist position of Finkelstein’s test (30° ulnar deviation). The bulk and tethering effect was calculated based on the mean gliding resistance over the tendon proximal/distal excursion cycle and the gliding resistance at the terminal distal excursion.

Results

The EPB tendon excursion was significantly more distal in 30° ulnar deviation than in 60° extension. Additionally the bulk and tethering resistance was significantly greater in 30° ulnar deviation compared with 60° extension. For the APL tendon there was no significant difference in either the tendon excursion or the bulk and tethering resistance between 30° ulnar deviation and 60° extension.

Conclusions

We showed that in the position of Finkelstein’s test the EPB tendon is significantly more distal and has significantly greater bulk and tethering effect compared with the other EPB positions. This is not the case for the APL tendon in the position of Finkelstein’s test. These results suggest that an abnormal Finkelstein’s test reflects differences of the EPB more than it does the APL.

Section snippets

Materials and methods

We used a device to measure tendon gliding resistance that previously has been described and validated.5, 6 The measurement system consisted of one mechanical actuator with a linear potentiometer, 2 tensile load transducers, and a movable mechanical pulley to satisfy the need for 3-dimensional wrist motion. The mechanical actuator was a small linear slide, driven by a precision-geared direct current motor. By regulating the voltage the speed of movement could be adjusted. The load transducers

Excursion

The results are shown in Figure 3. There was a significant effect owing to wrist position (p < .05) for both tendons. The EPB tendon excursion was significantly more distal (ie, bringing the muscle bellies further under the extensor retinaculum) in 30U than in 60E. For the APL tendon there was no significant difference in the position of the tendon excursion between these 2 positions.

Resistance

The gliding resistances for the EPB tendon are shown in Figure 4. The mean gliding resistance of the EPB tendon

Discussion

Anatomically the musculotendinous junction of the EPB is close to the first compartment. In Finkelstein’s test, when the thumb is in full flexion and the wrist is in ulnar deviation, the EPB muscle belly is pulled into the first compartment (Fig. 6), resulting in a bulk effect. The synovial tissue around the EPB and APL tendons also might be stretched in the Finkelstein testing position, causing a tethering effect. Both bulk and tethering effects may induce pain by directly stretching synovial

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Incomplete release of the first dorsal compartment—a diagnostic test
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S.W. Wolfe
DeQuervain’s disease
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J Bone Joint Surg
(1930)

There are more references available in the full text version of this article.

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De Quervain syndrome typically presents as pain and tenderness over the radial styloid, with pain exacerbated by wrist and thumb movements, particularly ulnar deviation.35,37 On physical examination, symptoms can be reproduced with the Finkelstein test (ulnar deviation with the thumb adducted).39 The first DC, similar to other superficial structures of the hand, is best viewed using a high-frequency linear-array transducer.
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Diagnosis required radial wrist pain exacerbated by resisted thumb extension, Finkelstein's test, or Eichoff's test. As well as being valid and reliable, these tests represent the most commonly employed diagnostic measures for de Quervain's disease.30,31 To reflect the condition's widespread nature, no restrictions were placed upon age or gender.
Systematic review with meta-analysis.
Although corticosteroid injections are often cited as best practice in the treatment of de Quervain's disease, no reviews have compared their effectiveness to a multimodal definition of hand therapy.
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Combined orthosis/corticosteroid injection approaches are more effective than either intervention alone in the treatment of de Quervain's disease.
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Analysis of the musculoskeletal loading of the thumb during pipetting - A pilot study
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It has been hypothesized that the development of de Quervan's disease, a stenosing tenosynovitis of the first dorsal compartment of the wrist, is associated with repeated overstretching of EPB and APL tendons, causing accumulative injury to the gliding mechanism (e.g., Finkelstein, 1930; Keon-Cohen, 1951). This hypothesis has been supported by the Finkelstein's test (Finkelstein, 1930), a classic diagnostic test for de Quervain's disease, in which the EPB and APL tendons are stretched in a particular thumb/wrist position to reproduce the patient's pain (Kutsumi et al., 2005). In the pipetting task, about 70% of the pushing power was generated from the CMC joint (Wu et al., 2012) and the CMC motions were generated mainly by the EPB and APL.
Previous epidemiological studies indicate that the use of thumb-push mechanical pipettes is associated with musculoskeletal disorders (MSDs) in the hand. The goal of the current study was to analyze the loading in the muscle–tendon units in the thumb during pipetting. The hand is modeled as a multi-body linkage system and includes four fingers (index, long, ring, and little finger), a thumb, and a palm segment. Since the current study is focused on the thumb, the model includes only nine muscles attached to the thumb via tendons. The time-histories of joint angles and push force at the pipette plunger during pipetting were determined experimentally and used as model input; whereas forces in the muscle–tendon units in the thumb were calculated via an inverse dynamic approach combined with an optimization procedure. Results indicate that all nine muscles have force outputs during pipetting, and the maximal force was in the abductor pollicis brevis (APB). The ratio of the mean peak muscle force to the mean peak push force during the dispensing cycle was approximately 2.3, which is comparable to values observed in grasping tasks in the literature. The analysis method and results in the current study provide a mechanistic understanding of MSD risk factors associated with pipetting, and may be useful in guiding ergonomic designs for manual pipettes.
De Quervain's tenosynovitis
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La ténosynovite de De Quervain résulte d’une inadéquation entre les tendons du long abducteur et du court extenseur du pouce et le tunnel ostéofibreux dans le premier compartiment dorsal du poignet. Elle survient habituellement chez les femmes entre 40 et 50 ans et est souvent rencontrée lors de la surutilisation du tendon en sport, notamment au volley-ball, mais est aussi observée chez les travailleurs manuels et les femmes au foyer. Les modifications histopathologiques de la gaine des tendons nous suggèrent que la ténosynovite de De Quervain est le résultat d’un mécanisme intrinsèque et dégénératif plutôt que extrinsèque et inflammatoire. La caractéristique clinique principale est la douleur sur le versant radial du poignet, accentuée par les mouvements du pouce et par une inclinaison ulnaire passive, associée à une flexion maximale du pouce (test de Finkelstein). Parmi les examens complémentaires, l’échographie est un moyen rapide et efficace pour confirmer le diagnostic clinique et permettre le suivi des lésions. Elle précise la présence d’un septum intertendineux et guide les infiltrations de corticoïdes. Elle permet d’augmenter les indications du traitement conservateur aux dépens de la chirurgie basée sur la présence d’un septum. Le traitement conservateur consiste en effet en des infiltrations de corticoïdes dans le premier compartiment des extenseurs, l’évitement des efforts répétés du premier rayon et le port d’une attelle de repos. L’indication chirurgicale est considérée lorsque les douleurs sont persistantes malgré un traitement médical bien conduit. La technique chirurgicale classique consiste simplement en une section de la poulie, mais peut présenter des complications postopératoires. Ces complications peuvent être évitées par des nouvelles techniques plus conservatrices.
De Quervain's tenosynovitis is an inadequacy between the abductor pollicis longus and extensor pollicis brevis tendons and the osteo-fibrous tunnel in the first extensor compartment of the wrist. It usually arises in women between 40 and 50 years old and is often related to tendon overuse in sports, especially volley-ball, but is also seen in manual workers and housekeepers. The changes in histopathological appearances in the tendon sheath make us believe that De Quervain's disease is a result of intrinsic degenerative mechanisms rather than extrinsic, inflammatory ones. The main clinical feature is pain around the radial styloid process, exacerbed by movements of the thumb and by passive ulnar deviation of the wrist with the thumb flexed maximally (Finkelstein's test). Among the different tests, ultrasound seems to be a fast and efficient way to confirm the suspected diagnosis and to provide follow-up of lesions. It can confirm the presence of an intertendinous septum and provide guidance at the time of steroid injection. It can increase the rate of conservative management by demonstrating the presence of septum. The medical management consists indeed on corticoids infiltrations of the first extensor compartment, the avoidance of repetitive and stress movement of the first ray with the use of a rest splint. The surgical approach is considered with the recurrence of the painful symptoms in spite of a well-done medical management. The classical surgical technique consists in a simple section of the pulley, but can have postoperative complications. These complications can be avoided by new conservative procedures.
Performing arts medicine - Instrumentalist musicians: Part III - Case histories
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Many clinicians erroneously refer to Eichhoff's recommendation to place the thumb within the hand and subsequently bring the hand into ulnar abduction as the Finkelstein test. Interestingly, recent biomechanical analysis has shown that the Finkelstein test has a bias toward the extensor pollicis brevis tendon over the abductor pollicis longus, and it was suggested that de Quervain's syndrome may in fact be a pathology of the extensor pollicis brevis tendon and subsheath (Kutsumi et al., 2005). Surgical releases of the subsheath have resulted in complete relief of symptoms (Louis, 1987).
In parts I and II of this article series, the basic principles of examining musicians in a healthcare setting were reviewed [Dommerholt, J. Performing arts medicine – instrumentalist musicians: part I: general considerations. J. Bodyw. Mov. Ther., in press-a; Dommerholt, J. Performing arts medicine – instrumentalist musicians: part II: the examination. J. Bodyw. Mov. Ther., in press-b]. Part III describes three case reports of musicians with hand pain, interfering with their ability to play their instruments. The musicians consulted with a performing arts physiotherapist. Neither musician had a correct medical diagnosis if at all, when they first contacted the physiotherapist. Each musician required an individualized approach not only to establish the correct diagnosis, but also to develop a specific treatment program. The treatment programs included ergonomic interventions, manual therapy, trigger point therapy, and patient education. All musicians returned to playing their instruments without any residual pain or dysfunction.

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Supported by the National Institute of Arthritis and Muscular and Skin Diseases, National Institutes of Health grant AR44391.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Original articlesTendonFinkelstein’s test: A biomechanical analysis

Purpose

Methods

Results

Conclusions

Section snippets

Materials and methods

Excursion

Resistance

Discussion

J Hand Surg

J Hand Surg

DeQuervain’s disease

Stenosing tendovaginitis at the radial styloid process

J Bone Joint Surg

Original articles
Tendon
Finkelstein’s test: A biomechanical analysis