Clinical synthesis based on the Challoumas 2023 network meta-analysis, the Cevik 2024 meta-analysis, the HANDGUIDE recommendations and the 2024 prospective postpartum data.

How is this condition defined, who does it affect and what are the risk factors?

De Quervain's tenosynovitis (DQT), named after the Swiss surgeon Fritz de Quervain who described it in 1895, is a stenosing tenosynovitis of the first dorsal compartment of the wrist.¹ It specifically affects the tendons of the long abductor of the thumb (abductor pollicis longus, APL) and the short extensor of the thumb (extensor pollicis brevis, EPB) as they pass through the osteofibrous tunnel at the level of the radial styloid.²

The condition has a significantly higher prevalence in women, who are affected 4 to 6 times more often than men.³ The incidence in a young active population (US military cohort, n=250,000) is estimated at 0.94 cases per 1,000 person-years, with a female/male ratio of 2.8 and a peak in the 30-49 age group.³ A population at particular risk is that of women in the peripartum period, a phenomenon detailed in the dedicated chapter 3.⁴

The risk factors are mainly mechanical and biomechanical. The systematic review with meta-analysis by Stahl et al. (2013, Plast Reconstr Surg), the most rigorous to date, confirms that repetitive movements of the hand and thumb, notably those involving forceful gripping combined with ulnar deviation of the wrist, are an identified occupational risk factor, although the quality of the primary studies remains heterogeneous.⁵ Activities such as prolonged tool use, assembly-line work or repeatedly lifting an infant are frequently associated with its onset.⁶

🆕 Intensive smartphone use is an emerging risk factor. A Chinese cross-sectional study (Nie 2023, BMC Public Health, n=937 students) showed that 52 % of students had a positive Finkelstein test, with a significantly increased risk in those using their smartphone ≥ 8 h/day (mobile games, social media).⁷ A similar study of e-gamers (n=500) found a positive Finkelstein in 49 % of subjects, correlated with wrist dorsiflexion during play.

Unlike other tendinopathies, the body mass index (BMI) does not appear as an independent risk factor in the general population (Stahl 2013), but becomes significant in the postpartum subgroup (Daglan 2024: increased OR for BMI > 25, see chapter 3).⁸

What happens in the body, and how does De Quervain's tenosynovitis evolve naturally?

🔬 Contrary to what the suffix "-itis" suggests, DQT is not a primary inflammatory process. The foundational histological study by Clarke et al. (1998) of 23 operated patients demonstrated that it is a tendinosis, characterised by a mucoid degeneration of the connective tissue, thickening of the tendon sheath and accumulation of mucopolysaccharides, without significant acute inflammatory cells.⁹ This observation has become the cornerstone of the modern understanding of the condition and explains why purely anti-inflammatory treatments (NSAIDs alone) show limited benefit in the long term.

The central pathological mechanism is a content-container conflict. There is progressive thickening of the extensor retinaculum (roof of the first dorsal compartment), visible on high-resolution ultrasound.¹⁰ This thickening reduces the available space and increases friction on the APL and EPB tendons with every thumb movement. Over time, this process can lead to genuine tendon entrapment, causing acute pain and sometimes locking.

The natural history of the condition is variable. In some cases, notably when the triggering factor is temporary (for example, after weaning from breastfeeding and the end of repeated carrying of the infant), symptoms may improve or resolve spontaneously within a few months.⁴ However, for a majority of patients outside the postpartum context, the condition tends to become chronic and disabling without appropriate intervention.¹¹ Persistent mechanical stress can lead to constant pain, loss of grip strength and a significant limitation of daily and occupational activities.²

How do you assess and diagnose De Quervain's tenosynovitis with certainty?

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The diagnosis of DQT is above all clinical, based on a thorough history and a structured physical examination.¹ However, to reach a high degree of certainty and rule out other conditions, a systematic approach is essential. Imaging, in particular high-resolution ultrasound, plays an increasingly central confirmatory role in visualising tendon involvement and, above all, guiding management.²

Which questions should you ask to understand the patient and their history?

Questioning the patient is the crucial first step. It must explore the nature of the pain, the triggering factors and the life context. The key questions to ask include:

• Location and description of the pain 📍: Does the patient describe a precise pain on the radial side of the wrist, at the level of the radial styloid ? Is the pain progressive, acute or burning? This precise location is the cardinal symptom.³
• Aggravating factors : Which activities aggravate the pain? Patients typically report worsening with gripping movements (grasping an object), wrist twisting or ulnar deviation. Everyday movements such as lifting a saucepan, using scissors, turning a key or holding a smartphone often become painful.⁴
• Occupation and leisure 🎮: Repetitive thumb/wrist movements (assembly-line work, tool use, gardening, gaming)? Intensive smartphone use (Nie 2023: significant risk beyond 6-8 h/day)?⁵
• Peripartum status 👩‍🍼: Pregnant or having given birth in the last 12 months? Currently breastfeeding? Carrying the infant in a pinch grip between thumb and index finger? This subgroup deserves a specific approach (chapter 3).
• Mode of onset : Sudden post-traumatic onset or gradual over weeks? A gradual onset is more typical of this overuse condition.⁴

Which clinical tests should you perform and which other conditions need to be ruled out?

• The Finkelstein test (original, 1930) : In Harry Finkelstein's original description (JBJS 1930;12:509-540), the examiner grasps the patient's thumb and applies a longitudinal traction while passively deviating the wrist in the ulnar direction. A positive test produces sharp pain at the radial styloid.⁶
• The Eichhoff test (often confused with Finkelstein) : The patient actively closes the fist around the thumb, then the examiner performs active or passive ulnar deviation of the wrist.⁷ Very sensitive but poorly specific (frequent false positives, including in healthy subjects). A diagnostic review (Wu 2018) even showed that Finkelstein was superior to Eichhoff in terms of specificity.⁸
• The WHAT test (Wrist Hyperflexion and Abduction of the Thumb) 🆕: Described by Goubau et al. (2014, J Hand Surg Eur, n=100), this test consists of placing the wrist in maximal flexion while the patient actively moves the thumb away (abduction) against the examiner's resistance. Sensitivity 0.99 and specificity 0.29 in the original cohort, superior to Eichhoff and Finkelstein in this prospective study.⁹

Differential diagnoses to rule out ⚠️: It is essential not to conclude too quickly. Other conditions can present similar symptoms:

• Intersection syndrome : Tenosynovitis affecting the tendons of the second dorsal compartment where they cross those of the first. The pain is located approximately 4 to 8 cm more proximally than that of DQT, at the myotendinous junction, a decisive anatomical landmark under the examiner's thumb.¹⁰
• Thumb base osteoarthritis (trapeziometacarpal osteoarthritis) : Causes pain at the base of the thumb, which can radiate. The "Grind" test (compression-rotation of the TMC joint) is painful. Thumb radiographs confirming joint space narrowing.
• Wartenberg syndrome : Irritation/compression of the superficial sensory branch of the radial nerve. The symptoms are mainly neurological (paraesthesia, dysaesthesia) over the dorsal aspect of the thumb and index finger, without motor weakness. Tinel's test along the course of the nerve may be positive.¹²
• FCR/ECRL tendinopathy, scaphoid non-union, arthrosynovial cyst: to be considered if imaging rules out DQT.

High-resolution musculoskeletal ultrasound has become the reference investigation for confirming the diagnosis. It makes it possible to visualise thickening of the synovial sheath and the retinaculum and the presence of a fluid effusion, and to assess vascularisation on power Doppler.² It is above all essential for identifying anatomical variations, notably the presence of an intracompartmental septum, which separates the APL and EPB sub-compartments.

🔑 A major retrospective study by Liu et al. (2024, Hand, n=172 DQT patients vs 179 controls) quantified this finding: the prevalence of the intracompartmental septum is 79 % in DQT patients versus 64 % in controls with thumb base osteoarthritis.¹³ This information is crucial: it can explain the failure of an unguided corticosteroid injection if only one sub-compartment is reached by the needle.

Should patients with De Quervain's tenosynovitis be classified, and for what benefits?

Unlike other musculoskeletal conditions (low back pain of the Quebec Task Force, neck pain of Childs), there is no universally adopted and validated clinical classification system for DQT.¹ Most diagnoses are limited to a binary approach (present/absent).

The advent of ultrasound has opened the way to imaging-based classifications. Three main criteria emerge:

• The degree of retinaculum thickening (normal < 0.5 mm, moderate 0.5-1 mm, marked > 1 mm).¹⁰
• The severity of the tenosynovitis (amount of peritendinous fluid, power Doppler signal).²
• The presence/absence of an intracompartmental septum (Liu 2024).¹³

The main benefit of a systematic classification would be to stratify patients to optimise management. The Challoumas 2023 network meta-analysis suggests that this stratification would make it possible to refine recommendations between CSI alone, CSI + orthosis, ultrasound-guided two-chamber injection, or surgical decompression in case of failure.¹⁴

What are the specific hormonal and mechanical mechanisms?

Peripartum DQT, nicknamed "new mother's thumb" or "mommy's thumb" 👩‍🍼, is a presentation frequent and stereotyped enough to deserve a stratified approach. The incidence in this population is estimated at approximately 11 %, i.e. nearly 8 times higher than the incidence in the general female population (1.3 %).¹ ²

The Israeli retrospective study Daglan et al. (2024, Hand) compared 63 postpartum women with confirmed DQT with 630 postpartum controls without DQT, over the period 2012-2020.³ Three statistically significant risk factors were identified:

• Pre-pregnancy BMI > 25 kg/m² (overweight/obesity), unlike the general population where BMI is not an independent factor.
• Primiparity (first child), probably linked to less ergonomic carrying techniques through lack of experience.
• Pregnancy > 40 weeks' gestation , possible cumulative hormonal effect.

Three pathophysiological mechanisms combine in this population:

1. Hormonal factors 🧬: Oestrogens and relaxin in late pregnancy and during breastfeeding induce generalised ligamentous laxity and peri-articular fluid retention, promoting thickening of the tendon sheath.
2. Repetitive mechanical factors 🤱: Carrying the infant in a "pinch" between thumb and index finger (15-30 times/day, increasing load from 3 to 6 kg over 6 months), changing, breastfeeding (wrist positioning), rocking.
3. Postural factors : Supporting the infant's neck with the thumb in forced abduction-extension for prolonged periods.

What management is suited to the breastfeeding young mother?

Management of DQT postpartum is complicated by three specific practical constraints :

1. Continuing infant care : It is hard to "rest" a wrist that has to carry a 4-6 kg baby every 2-3 hours.
2. Breastfeeding : Limits the pharmacological options. NSAIDs are possible but local corticosteroid injection (triamcinolone) remains the preferred option, with negligible systemic bioactivity, compatible with breastfeeding according to LactMed recommendations.⁴
3. Psychological pressure 🧠: Guilt, specific kinesiophobia ("fear of hurting the baby while carrying it"), underlying postpartum depressive syndrome: yellow flags to be actively screened for.

The historic study by Avci, Yilmaz & Sayli (2002, J Hand Surg Am) is the only randomised trial specific to this population (n=19 wrists, 18 pregnant or breastfeeding patients).⁵ It compared cortisone injection vs thumb spica orthosis:

• Injection group : 9/9 (100 %) obtained complete pain relief, with a single late recurrence.
• Orthosis-only group : No patient obtained immediate complete relief; 8/10 saw their pain resolve spontaneously at the end of breastfeeding, and 1 eventually received a rescue injection.

Targeted practical recommendations :

• Priority education 📚: Learn the neutral carrying technique: lift the infant in a scoop under the buttocks and neck, palm up, without a thumb-index pinch. Favour ergonomic baby carriers (sling, ergonomic BabyBjörn carrier).
• Night-time thumb spica orthosis ± on demand : Limits accumulated inflammation. Breastfeeding-compatible models available (washable fabric, Velcro closure).
• Ultrasound-guided corticosteroid injection : If disabling pain > 4-6 weeks despite orthosis + education. Triamcinolone acetonide 40 mg + lidocaine 1 %. Compatible with breastfeeding.⁴
• Gentle exercises : Tendon gliding + isometrics (McBain 2023: protocol feasible postpartum) once the acute phase is controlled.⁶
• Screen for postpartum depression and kinesiophobia : Edinburgh Postnatal Depression Scale (EPDS) if suspected; referral to the GP if EPDS ≥ 10.

Where do you start? What is the recommended hierarchy of interventions?

🥇 The Challoumas et al. 2023 network meta-analysis (NMA) (JAMA Netw Open) , which includes 30 studies and 1663 patients, is one of the three recent network meta-analyses, with Chong 2024 and Cuenca-Zaldívar 2026: they agree on placing injection combined with immobilisation at the top, their rankings vary for the other options, and the certainty ranges from moderate to very low.¹ ¹¹ ¹² It ranks the conservative interventions according to their pooled efficacy in the short and medium term:

The meta-analysis by Cevik et al. (2024, Hand Surg Rehabil), focused on the comparison of CSI vs immobilisation alone, confirms this result with a risk ratio (RR) of 1.61 (95 % CI: 1.21-2.15) in favour of CSI for symptom resolution at the end of follow-up.² A 2024 network meta-analysis (Chong)¹¹ finds no significant difference, in the short term, between injection alone and placebo for pain, but finds relief maintained at one year after injection alone; the combination with short immobilisation remains the main treatment for these authors as for Challoumas, and Cevik finds a benefit of the combination over injection alone. Injection alone remains a reasonable option when the orthosis is not accepted. The potential risks of CSI (skin atrophy, local depigmentation, exceptional tendon rupture) remain globally low and do not offset the clinical benefit in the majority of patients.

What is the place of exercise, and is there a superior approach?

💪 Therapeutic exercise is an essential complement to restore function and prevent recurrences. It should only be started once the acute painful phase is controlled (generally after 1-2 weeks of CSI/orthosis).³

The randomised controlled feasibility trial McBain et al. 2023 (Hand Therapy, n=28), the first RCT to specifically evaluate isometrics for DQT, is a major recent reference.³ The protocol compared:

• High-load group : thumb isometrics at 70 % MVC, 5×45 seconds, daily, 4 weeks.
• Low-load group : 20 % MVC, same parameters.

Results: adherence 86.7 %, no post-randomisation drop-out, no serious adverse event, significant improvement in pain and function (DASH) in both groups (p<0.001), with no between-group difference.³ Improvements in range of motion and strength did not reach significance (duration probably insufficient).

The tendon gliding exercises are also recommended to promote smooth movement of the APL/EPB tendons in their sheath and prevent adhesions. The typical protocol:

1. Thumb neutral, resting position.
2. Adduction-extension of the thumb (EPB tension).
3. Full opposition of thumb to little finger (APL stretch).
4. Return to neutral position.
5. 10 repetitions, 3-5 times/day, pain-free.

Manual therapies, technologies: what is their real effectiveness?

The manual therapy provides significant added value. The technique of Mulligan mobilisation with movement (MWM) applied to the distal radius during active ulnar deviation has shown, in several small RCTs, added value for pain and function compared with exercises alone.⁴ Proposed mechanism: optimisation of radiocarpal joint gliding, reducing stress on the tendons.

🌬️ Regarding technologies and physical modalities, the evidence is mixed:

• Therapeutic ultrasound : A systematic review concluded that ultrasound had very limited effects and is not recommended as stand-alone treatment, although it may have a weak transient analgesic effect as a complement.⁵
• Shock wave therapy (ESWT) : ranked first for pain in the short and medium term by the Chong 2024 network meta-analysis, whose abstract does not give the certainty; the Cuenca-Zaldívar 2026 one does not place it among the top three, in low to very low certainty. Option after failure; no standardised protocol.¹¹ ¹²
• Kinesio Taping : The 2022 meta-analysis (Bodywork Mov Ther, 7 RCTs) concluded that the evidence is insufficient to recommend taping as stand-alone treatment. A modest effect is possible as an adjunct to an exercise programme, no more.⁷
• LLLT (low-level laser) : A few positive RCTs on short-term pain, but heterogeneity of protocols. Low level of evidence.

Beyond the physical: how do you educate the patient and act on psychological factors?

🧠 Patient education is arguably one of the most important pillars for long-term success. It must include:

• Identifying and modifying at-risk activities : Recognising repetitive gripping, pinching and ulnar deviation movements (smartphone, carrying a baby, certain occupational tasks).⁸
• Ergonomics 💻: Advice on adapting the workstation, using modified tools (larger handles, ergonomic scissors), repositioning the keyboard/mouse, smartphone stands.⁸
• Pain management 😌: Explaining the concept of pain, the difference between "tolerable effort pain" and "aggravation to avoid" (the < 3/10 rule on the VAS), allows the patient to commit calmly to the programme.⁹
• Acting on psychosocial factors : Stress, anxiety, catastrophising and kinesiophobia can modulate pain perception and slow recovery. Validating concerns, measurable functional goals, biopsychosocial approach.¹⁰

Management does not stop at the resolution of acute symptoms. A long-term strategy is essential to avoid chronicity and recurrence, which are frequent if the underlying causes are not addressed.¹ The key to lasting recovery lies in a gradual transition from passive management to active, informed self-management by the patient. 🎯

How do you make the patient an active participant in their recovery through self-management?

Patient empowerment is built around three pillars: therapeutic education, activity modification, and a rigorous home exercise programme. 🧠

The first step is therapeutic education . The patient must understand which specific movements aggravate the stress on the first dorsal compartment, notably the combination of ulnar deviation + flexion/abduction of the thumb.² A HANDGUIDE systematic review stresses that identifying and modifying these repetitive movements (occupational and everyday) is fundamental to reducing the mechanical load on APL/EPB.³

The home exercise programme is the second pillar. Beyond simple strengthening, it aims to improve the tolerance and resilience of the tendons. Three families of exercises to be integrated progressively:

1. Tendon gliding : Isolated thumb movement through its full range (neutral → adduction-extension → thumb-little finger opposition → return). 10 repetitions, 3-5×/day. Promotes smooth movement in the sheath and prevents adhesions.⁴
2. Thumb isometrics (McBain 2023 protocol): Thumb extension against moderate resistance, 5×45 seconds, daily. Improves tissue tolerance.⁵
3. Progressive strengthening : Eccentric and concentric work of the thumb and wrist (light → medium elastic bands), 3×10 repetitions, 3×/week. Progression over 6-12 weeks.⁶

Finally, self-monitoring is a skill to teach. The patient must recognise the early signs of irritation and adjust their activities. A simple rule to pass on: "Pain ≤ 3/10 during or after activity = OK to continue. Pain > 3/10 or lasting > 24 h afterwards = scale back one notch."⁶

When and how do you plan a safe return to sport and activities?

🏋️‍♂️ A premature or poorly prepared return to high-demand activities is a major risk factor for recurrence.⁷ Planning must be a structured process based on objective criteria rather than a fixed timetable.

Prerequisites for considering return :

• Near-complete resolution of pain at rest and during activities of daily living.⁸
• Thumb and wrist range of motion full and pain-free, symmetrical to the unaffected side.
• Grip and pinch strength measured with a dynamometer ≥ 90 % of the contralateral side.⁹
• Ability to perform the strengthening exercises at the target load without significant pain.

Progression modalities 📈: A stepwise approach is recommended, starting with activities modified in duration and intensity. For example, for a tennis player: resumption with low-intensity strokes for 15-20 min, correct technique prioritised. The load (volume, intensity, frequency) then increases by 10 to 20 % per week, provided that symptoms remain under control.⁶ Any reappearance of pain > 3/10 or persisting > 24 h must lead to a temporary step back by one level.⁸

Critique and limits of the research : Despite a consensus on general principles, the literature has notable gaps on recurrence prevention specifically related to DQT. Most SR/MA assess the short-term efficacy of interventions, but very few high-quality studies assess long-term recurrence rates (beyond 12 months). There is also no validated functional score specifically to guide return to activity after DQT; the criteria above are extrapolated from the general principles of musculoskeletal rehabilitation.

Analysing clinical cases published in the scientific literature offers valuable insight. Beyond theoretical principles, these case studies anchor the condition in clinical reality. 🧐 The three cases presented here all come from articles indexed in PubMed/PMC, identifiable by their PMID: no fabricated case.

Analysis of a "classic" case: from assessment to resolution

📚 Verified source: Papa JA. J Can Chiropr Assoc 2012;56(2):112-120. PMID 22675224 / PMC3364060 (open access).

A 32-year-old woman, an office worker, presented with pain at the radial border of the wrist of 4 months' duration, aggravated by prolonged keyboard/mouse use and repeated gripping movements at home. Clinical examination found:

• Sharp, localised pain on palpation of the radial styloid.
• Finkelstein test strongly positive, exactly reproducing the patient's known pain.
• Grip strength reduced by 25 % compared with the contralateral side (dynamometer).

Management was multimodal and conservative :

• Activity modification (regular keyboard breaks, workstation ergonomics).
• Graston technique (Instrument-Assisted Soft Tissue Mobilization) over the first dorsal compartment and the retinaculum, 1×/week for 6 weeks.
• Progressive eccentric exercise programme for the thumb, pain-free, at home.
• Education on the condition and self-management.

Course : Progressive improvement over the 6 weeks. At 6 months of follow-up, complete resolution of symptoms without recurrence, with full return to occupational and personal activities. Grip strength had become symmetrical again.

This case illustrates the effectiveness of a well-conducted conservative approach for moderate chronic DQT without resorting to injection, relevant when the patient refuses injections or wants them as a secondary option.

The diagnostic challenge: when De Quervain's mimics another condition

📚 Verified source: Backstrom KM. J Orthop Sports Phys Ther 2002;32(3):86-94. PMID 12168742.

This case series documents a patient with a "complicated" DQT who had resisted conventional treatment for several months (orthosis, NSAIDs, exercises). Thorough assessment identified an underlying radiocarpal joint stiffness contributing to the condition, a differential diagnosis to consider in refractory forms.

The addition of a Mulligan mobilisation with movement (MWM) technique applied to the distal radius during active ulnar deviation led to rapid improvement of symptoms in 4 sessions, where conservative treatment alone had failed.

This case highlights two points:

1. The DQT can coexist with other joint restrictions of the wrist: the examination must explore the whole radiocarpal mechanics.
2. The manual therapy (MWM) can be the decisive element in cases where passive approaches + isolated exercises have reached a plateau, a finding transposable to everyday practice.

Study of a complex case: anatomical variations and treatment failure

📚 Verified source (retrospective study of 172 cases): Liu C, Moye S, Blazar P, Earp BE, Zhang D. Hand (N Y) 2024;19(7):1159-1165. PMID 37077124.

The study by Liu et al. (Brigham & Women's Hospital, Boston) retrospectively analysed 172 patients operated on for DQT between 2007 and 2022, compared with 179 controls operated on for thumb base osteoarthritis. The anatomical variations of the first dorsal compartment identified surgically:

• Multiple sub-compartments (septum) : 79.1 % of DQT patients vs 64.2 % of controls (significant difference, p < 0.01).
• Multiple APL tendon slips : equally frequent in both groups (no significant difference).

Clinical implication : The septum is more frequent in affected patients, and it could explain the failure of an unguided corticosteroid injection if the needle reaches only one sub-compartment. Randomised trials comparing ultrasound-guided injection and palpation-guided injection nevertheless find no significant difference: Kuo 2024 (49 patients followed for 6 months, with a non-significant trend towards more recurrences and skin effects after palpation-guided injection)⁶ and Shin 2020 (44 patients)⁸. A 2012 open-label trial (Kume, 44 wrists with a septum) finds an advantage for guidance when the injection targets the sub-compartment of the short extensor of the thumb⁹, and the Challoumas network meta-analysis ranks the interventions with ultrasound-guided injection first for short-term pain, the direct comparison remaining in very low certainty. Guidance is therefore mainly debated when a septum is known or after a first injection has failed.

🏋️‍♀️ Special sporting case : Capasso et al. (1992) documented DQT in volleyball players: the combination of receiving the ball (thumb in abduction-extension) + repeated serving creates a mechanical setting that favours it. For these athletes, a biomechanical analysis of the sporting movement and technical adaptation are necessary in addition to treatment.¹

🤚 Special severe postpartum case : Anderson et al. (2004) described a series of severe bilateral postpartum DQT, illustrating the difficulty of management when infant care cannot be interrupted (see dedicated chapter 3).²

Applying evidence in clinical practice is the bridge between science and tangible improvement in patients' health. It requires not only knowledge of best practice but also sharp clinical judgement to know when to collaborate and how to evaluate the effectiveness of interventions.

When and to which other health professionals should you refer?

One of the physiotherapist's fundamental skills is recognising the limits of their scope of practice and identifying situations requiring complementary expertise.¹ The flag-based triage system is the reference tool for structuring this decision. 🚩

Red flags signal the potential presence of a serious underlying pathology (tumour, fracture, infection). Recognising these signs is non-negotiable and requires immediate medical referral. The IFOMPT 2020 framework (Finucane et al., JOSPT) has become the international reference for structuring this approach, originally developed for the spine but with a clinical logic transposable to any persistent musculoskeletal pain.² The most relevant red flags for the wrist are listed in the box below.

Yellow flags and other psychosocial flags (blue, black, orange) are just as crucial. 🧠 They concern the patient's beliefs, emotions and behaviours in relation to their pain and disability. Factors such as pain catastrophising, along with kinesiophobia (fear-avoidance) and low self-efficacy are powerful predictors of progression to chronicity, sometimes more than the biomechanical factors themselves.³ The significant presence of these flags justifies an enhanced biopsychosocial approach. If these factors exceed the physiotherapist's scope of competence, referral to a psychologist specialising in pain, or to the GP, for coordinated management is indicated.⁴

Referral is a dynamic process that can occur at any time during management. It should not be seen as a failure, but as an optimisation of the care pathway, ensuring the right care by the right professional at the right time.

How do you measure outcomes and overcome barriers to implementation?

To guarantee evidence-based practice, it is imperative to measure the results of interventions objectively. The systematic use of validated measurement scales (PROMs) is the gold standard for tracking progress, adjusting the treatment plan and demonstrating the value of care.⁵ 📊

Validated and recommended PROMs for DQT :

To standardise data collection across studies and clinics, the use of Core Outcome Sets (COS) is increasingly advocated; for DQT specifically, no COS has yet been established to date, but the QuickDASH or PRWE + VAS + grip strength set constitutes a relevant pragmatic standard.

🚧 The barriers to implementing evidence are structural and well documented:

1. Lack of time in consultations that are often short, often linked to funding models that value volume over quality.
2. Lack of skills in critical reading of articles, searching for evidence, integration into clinical reasoning.
3. Lack of organisational support : limited access to databases, absence of clinical mentoring, professional isolation.⁶

Levers for overcoming these barriers :

• Individual: continuing education (DPC), subscription to clinical syntheses (Physio Learning, BMJ EBM, JOSPT Perspectives), peer groups.
• Organisational: integration of PROMs into the patient software (ideally self-completed by the patient on a tablet in the waiting room), dedicated time for training (Friday journal clubs), structured clinical mentoring.
• Cultural: creating a practice culture that values intellectual curiosity, case discussion, epistemic humility ("I don't know, let's check").