Dupuytren’s Disease: Causes, Symptoms and Treatment

Dupuytren’s disease, also known as Dupuytren’s contracture or palmar fibromatosis, is a pathology affecting the hand characterized by thickening and progressive retraction of the palmar aponeurosis, a fibrous membrane located just under the skin of the palm. This condition, benign in nature but progressively disabling, leads to forced and permanent flexion of one or more fingers toward the palm of the hand, preventing their complete extension. Although it can affect any finger, the most frequently involved fingers are the ring finger and little finger. The pathology is named after French surgeon Baron Guillaume Dupuytren, who first described its surgical intervention in detail in 1831. Understanding this condition thoroughly is essential to intervene promptly, limiting functional damage and preserving the patient’s quality of life.

Table of Contents

• Anatomy and Pathophysiology
• Causes and Risk Factors
• Symptoms and Development Phases
• Diagnosis and Clinical Evaluation
• Medical and Surgical Treatment
• The Fundamental Role of Physiotherapy
• Therapeutic Exercises and Rehabilitation
• Instrumental Physical Therapies
• Prevention and Long-term Management
• Frequently Asked Questions (FAQ)
• Frequently Asked Questions
• Sources and Scientific References

Anatomy and Pathophysiology

To fully understand the dynamics of this pathology, a brief anatomical overview is necessary. The palmar aponeurosis is a fan-shaped fascial structure that protects the underlying tendons, nerves and blood vessels, while ensuring the stability of the palm skin during gripping. In Dupuytren’s disease, a cellular alteration occurs: fibroblasts, the cells responsible for collagen production, transform into myofibroblasts.

These abnormal cells begin to produce an excessive amount of type III collagen (less elastic and more disorganized compared to normal type I collagen), creating nodules and, subsequently, true fibrous cords. These cords, contracting, exert mechanical traction on the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, forcing the finger to bend toward the palm. The disease does not directly involve the flexor tendons, which remain intact, but the overlying fascial structure that traps them.

Causes and Risk Factors

Anatomy and Pathophysiology: Dupuytren’s disease involves abnormal fibroblast transformation in the palmar fascia, causing excessive collagen deposition that creates contracting fibrous cords progressively flexing fingers toward the palm. The exact etiology of Dupuytren’s disease remains unknown today, which is why it is classified as an idiopathic pathology. However, decades of clinical and epidemiological studies have identified a series of determining risk factors in the development and progression of the disease:

• Genetic Factors and Heredity: There is a strong genetic component. The pathology is often called “Viking disease” because it has a significantly higher incidence in populations of Northern European and Celtic origin. Having a first-degree relative affected greatly increases the chances of developing the condition.
• Age and Gender: The disease manifests predominantly in adulthood, with a peak incidence after age 50. Men are affected three to ten times more frequently than women and tend to develop more severe and rapidly progressive forms.
• Diabetes Mellitus: There is an established correlation between diabetes (both type 1 and type 2) and palmar fibromatosis. In diabetic patients, however, the disease tends to manifest in a milder form, although more widespread.
• Lifestyle (Alcohol and Smoking): Excessive alcohol consumption and smoking have been associated with increased risk. Smoking, in particular, causes micro-alterations of the vascular microcirculation, which could favor fibrotic proliferation.
• Epilepsy and Medications: Prolonged use of certain anticonvulsant drugs, such as barbiturates, has been correlated with an increased incidence of the pathology.
• Trauma and Manual Work: Although the role of repeated microtrauma is still debated in the scientific community, symptom exacerbation is observed in subjects who use vibrating tools or perform heavy manual work for decades.

Symptoms and Development Phases

Dupuytren’s disease has a typically slow and progressive course, which can extend over months or years. The symptomatology evolves through distinct phases, each characterized by specific clinical signs:

Initial Phase (Nodular Phase)

The first clinical sign is usually the appearance of a small subcutaneous nodule in the palm of the hand, at the base of the ring finger or little finger. Initially, this nodule may be sensitive to pressure or slightly painful, but the pain tends to disappear over time. The overlying skin may appear wrinkled or present small dimples (pitting), due to traction of the cutaneous ligaments.

Intermediate Phase (Cord Formation)

As the disease progresses, the nodules unite and extend longitudinally, forming hard, palpable fibrous cords under the skin. These cords extend from the palm toward the fingers. In this phase, the patient begins to feel a sensation of tension and a slight limitation in the complete extension of the involved fingers.

Advanced Phase (Flexion Contracture)

The fibrous cords retract, inexorably pulling the fingers toward the palm of the hand. True contracture is established. The metacarpophalangeal joint is usually the first to be involved, followed by the proximal interphalangeal joint. In this phase, normal daily activities (such as washing the face, putting hands in pockets, wearing gloves or shaking hands) become extremely difficult or impossible.

Diagnosis and Clinical Evaluation

The diagnosis of Dupuytren’s disease is essentially clinical and does not require, in most cases, complex instrumental examinations such as X-rays or MRI scans, unless concomitant pathologies are suspected.

The evaluation must be accurate to determine the stage of the disease. The best known and most immediate clinical test is Hueston’s Test (or Table Top Test): the patient is asked to place the palm of the hand and fingers completely flat on a rigid surface, like a table. If the patient cannot make the palm and fingers adhere perfectly to the table due to contracture, the test is considered positive and generally indicates the need to evaluate therapeutic intervention.

It is essential to consult your doctor or physical therapist for correct differential diagnosis. The pathology must be distinguished from other conditions that cause stiffness or nodules in the hand, such as trigger finger (stenosi (restringimento del canale vertebrale o vascolare)ng tenosynovitis), tendon cysts, hand osteoarthritis or post-traumatic cicatricial retractions.

Medical and Surgical Treatment

Although physiotherapy plays a crucial role, it is important to outline the medical and surgical options, since conservative treatment alone cannot reverse fibrotic contracture once established. The choice of treatment depends on the severity of the contracture, the patient’s age and the impact on quality of life.

• Mini-Invasive Treatments: Include needle cordotomy (percutaneous aponeurotomy), in which a needle is used to weaken and break the fibrous cord, and collagenase injections (an enzyme that dissolves collagen), which allow breaking the cord with subsequent manipulation.
• Fasciectomy: This is the traditional and most common surgical intervention. It consists of making an incision in the palm and surgical removal of the diseased fascial tissue (partial or selective fasciectomy) or the entire aponeurosis (total fasciectomy).
• Dermo-fasciectomy: Reserved for the most severe cases or recurrences, it involves removing not only the fascia but also the overlying skin, which is replaced with a skin graft.

The Fundamental Role of Physiotherapy

Physiotherapy represents an indispensable pillar in the management of Dupuytren’s disease, both in the initial phases as a conservative approach and, especially, in the post-operative phase. The success of any medical or surgical intervention for this pathology depends largely on the quality and timeliness of the rehabilitation pathway.

Conservative Physiotherapy (Pre-operative Phase)

In the initial phases, when only nodules or minimal contracture that does not limit functionality are present, the goal of physiotherapy is to maintain maximum possible mobility and monitor the evolution of the disease. Conservative treatment cannot arrest the genetic progression of fibrosis, but can optimize the biomechanics of the hand. Deep transverse friction massage techniques, gentle joint mobilizations and specific stretching are used. Patient education is vital in this phase to avoid repeated trauma that could accelerate the inflammatory and fibrotic process.

Post-operative Rehabilitation

After surgical intervention (fasciectomy or mini-invasive treatment), rehabilitation must begin early, often within the first 3-5 days. The rehabilitation protocol is divided into several phases:

Acute Phase (0-14 days):

• Edema Management: Swelling is the main enemy of hand recovery. Anti-gravity positions (hand elevated above heart level), light compressive bandaging and lymphatic drainage massage are used.
• Wound Care: Maintaining cleanliness to prevent infections.
• Early Mobilization: Initiation of very gentle active and passive movements to prevent tendon adhesions, respecting pain limits and tension on suture points.

Intermediate Phase (2-6 weeks):

• Scar Management: Once sutures are removed, the scar tends to retract. Scar massage techniques, tissue mobilization and application of silicone sheets to soften tissue are applied.
• ROM (Range of Motion) Recovery: Intensification of flexion and extension exercises. It is crucial to recover complete extension without losing the ability to make a fist.
• Use of Orthoses (Splinting): Making a custom splint is often indispensable. Usually a static extension splint is used to be worn at night to maintain the results obtained with surgery and physiotherapy, counteracting the natural tendency of tissues to retract again.

Advanced Phase (Beyond 6 weeks):

• Muscle Strengthening: Introduction of resistance exercises to recover grip strength and pinch strength.
• Functional Recovery: Fine dexterity exercises and simulation of specific work or daily activities for the patient.

Therapeutic Exercises and Rehabilitation

Therapeutic exercises must be performed with consistency, several times a day, but without ever evoking acute pain. A typical program, which must always be personalized by a professional, includes:

• Tendon Gliding: Fundamental exercises to prevent adhesions. They consist of moving the fingers through different positions: open hand, “roof” position (flexion of only the metacarpophalangeal joints), straight fist, complete fist and hook fist.
• Passive Extension Stretching: Placing the hand on a table, gently lift the affected finger upward with the other hand, maintaining tension for 15-20 seconds.
• Active Stretching: Open the hand as much as possible, spreading the fingers in a fan. Maintain the position of maximum tension for a few seconds and then relax.
• Active Flexion Exercises: Squeeze a soft sponge ball or rolled towel, maintaining the contraction for 5 seconds before releasing.
• Dexterity Exercises: Pick up small objects (coins, buttons) from the table, button and unbutton clothes, to re-educate fine coordination.

Instrumental Physical Therapies

In the context of a complete rehabilitation program, instrumental physical therapies can offer valuable support, especially in pain management, inflammation and improvement of tissue elasticity:

• Ultrasound Therapy: Used for its deep thermal and micro-massage effect, useful for softening fibrous cords and post-operative scars.
• Laser Therapy (LLLT or High Power): Effective in controlling local inflammation and stimulating cellular regeneration, particularly useful in the post-acute phase.
• Tecar Therapy (Diathermy): Helps improve local vascularization, reducing edema and favoring the distensibility of retracted fascial tissues.

It should be emphasized that these therapies do not replace manual therapy and therapeutic exercise in any way, but act as adjuvants to optimize recovery times.

Prevention and Long-term Management

Considering the strong genetic basis of Dupuytren’s disease, there is no true primary prevention capable of preventing its appearance. However, it is possible to implement secondary prevention strategies to slow its evolution and manage the condition long-term:

• Lifestyle Modification: Abstaining from smoking and moderating alcohol consumption are fundamental recommendations, not only for general health, but also to preserve the peripheral microcirculation of the hands.
• Control of Concomitant Pathologies: Keeping blood glucose levels under strict control in diabetic patients.
• Ergonomics and Protection: Those who perform heavy manual work or use vibrating tools should adopt anti-vibration gloves and take frequent breaks to perform hand stretching exercises. Avoid prolonged and maximum force grips when possible.
• Constant Monitoring: Self-observation is essential. Periodically performing the “Table Top Test” at home allows early detection of any worsening.
• Early Intervention: At the first sign of functional limitation, it is imperative to consult your doctor or physical therapist. Ignoring the problem inevitably leads to more severe contractures, which will require more complex surgical interventions and longer and more uncertain rehabilitation pathways.

The management of Dupuytren’s disease requires patience and consistency. The disease has a high recurrence rate, even after a perfectly successful surgical intervention. Therefore, maintaining a routine of stretching exercises and occasional use of night splints (if prescribed) can make the difference in preserving hand functionality over the years.

Frequently Asked Questions (FAQ)