Physical Medicine and Rehabilitation for Trigger Finger Clinical Presentation

  • Author: Patrick M Foye, MD; Chief Editor: Rene Cailliet, MD   more...
 
Updated: Nov 2, 2010
 

History

A classic complaint is difficulty in achieving full extension of a single digit, which eventually releases or snaps open with pain at the distal palm and into the digit.

In individuals with diabetes or rheumatoid arthritis, multiple digits may be involved in trigger finger.

Some patients have difficulty with finger flexion rather than extension, although the former is less common.

Other patients may have a painful nodule in the distal palm without any catching or triggering.

Some patients report stiffness in the fingers, especially after they have been asleep or following other periods of inactivity.

Some patients may have a history of repetitive trauma to the affected area.

Some patients have occupational duties requiring repetitive use of the involved tendons.[6]

Patients may have a history of diabetes or rheumatoid arthritis.

Some patients report swelling of the affected digit, particularly at the digit's base or proximal aspect.

For further reading, please see the following related Medscape topics:

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Physical

At the level of the distal palmar crease, a tender nodule can be palpated, usually overlying the metacarpophalangeal (MCP) joint.

The affected digit may lock in a flexed (see image below) or (less commonly) extended position. When the patient attempts to move the digit more forcefully beyond the restriction, the digit may snap or trigger beyond the restriction. The triggering movement is very painful for the patient.

A trigger finger often results in difficulty flexiA trigger finger often results in difficulty flexing or (in this case) extending the metacarpophalangeal joint of the involved digit.

In severe cases, the patient is unable to move the digit beyond the restriction, so no triggering occurs.

With a trigger thumb, the tenderness to palpation is found at the palmar aspect of the first MCP joints rather than over the distal palmar crease.

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Causes

Congenital cases of trigger thumb are generally caused by a nodule of the flexor pollicis longus tendon.

In adults, some cases may be associated with repetitive trauma.

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Contributor Information and Disclosures
Author

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Coauthor(s)

Todd P Stitik, MD  Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine

Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Dev Sinha, MD  Research Associate/Physiatrist Observership, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM  President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, and Texas Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Michael T Andary, MD, MS  Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD  Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center

Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association

Disclosure: Nothing to disclose.

References

  1. Trigger finger. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:249-53.

  2. Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:756-82.

  3. Breen TF. Wrist and hand. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:99-138.

  4. Brinker MR, Miller MD. The adult hand. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:196-220.

  5. McGee DJ. Forearm, wrist and hand. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:168-215.

  6. Moore JS. Flexor tendon entrapment of the digits (trigger finger and trigger thumb). J Occup Environ Med. May 2000;42(5):526-45. [Medline].

  7. Moriya K, Uchiyama T, Kouda H, Kawaji Y. Acromegaly as a cause of trigger finger. Scand J Plast Reconstr Surg Hand Surg. 2009;43(4):236-238.

  8. Kumar P, Chakrabarti I. Idiopathic carpal tunnel syndrome and trigger finger: is there an association?. J Hand Surg Eur Vol. Feb 2009;34(1):58-9. [Medline].

  9. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am. Jan 2006;31(1):135-46. [Medline].

  10. Fitzgerald BT, Hofmeister EP, Fan RA, et al. Delayed flexor digitorum superficialis and profundus ruptures in a trigger finger after a steroid injection: a case report. J Hand Surg [Am]. May 2005;30(3):479-82. [Medline].

  11. Jianmongkol S, Kosuwon W, Thammaroj T. Intra-tendon sheath injection for trigger finger: the randomized controlled trial. Hand Surg. 2007;12(2):79-82. [Medline].

  12. Anderson B, Kaye S. Treatment of flexor tenosynovitis of the hand ('trigger finger') with corticosteroids. A prospective study of the response to local injection. Arch Intern Med. Jan 1991;151(1):153-6. [Medline].

  13. Nimigan AS, Ross DC, Gan BS. Steroid injections in the management of trigger fingers. Am J Phys Med Rehabil. Jan 2006;85(1):36-43. [Medline].

  14. Fleisch SB, Spindler KP, Lee DH. Corticosteroid injections in the treatment of trigger finger: a level I and II systematic review. J Am Acad Orthop Surg. Mar 2007;15(3):166-71. [Medline].

  15. Geiringer SR. Tendon sheath and insertion injections. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:44-8.

  16. [Best Evidence] Peters-Veluthamaningal C, Winters JC, Groenier KH, et al. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomized placebo controlled trial. Ann Rheum Dis. Jan 7 2008;[Medline].

  17. [Best Evidence] Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study. J Bone Joint Surg Am. Dec 2007;89(12):2604-11. [Medline].

  18. Kerrigan CL, Stanwix MG. Using evidence to minimize the cost of trigger finger care. J Hand Surg Am. Jul-Aug 2009;34(6):997-1005.

  19. Nonsteroidal anti-inflammatory drugs (NSAIDs). In: Green SM, ed. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Pub; 2000:11-2.

  20. Akhtar S, Bradley MJ, Quinton DN, et al. Management and referral for trigger finger/thumb. BMJ. Jul 2 2005;331(7507):30-3. [Medline].

  21. Taras JS, Raphael JS, Pan WT, et al. Corticosteroid injections for trigger digits: is intrasheath injection necessary?. J Hand Surg [Am]. Jul 1998;23(4):717-22. [Medline].

  22. Colbourn J, Heath N, Manary S, Pacifico D. Effectiveness of splinting for the treatment of trigger finger. J Hand Ther. Oct-Dec 2008;21(4):336-43. [Medline].

 
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Flexor tendons pass within the tendon sheath and beneath the A-1 pulley at approximately the metacarpal head, beyond which they travel into the digit.
An inflamed nodule can restrict the tendon from passing smoothly beneath the A-1 pulley. If the nodule is distal to the A-1 pulley (as shown in this sketch), then the digit may get stuck in an extended position. Conversely, if the nodule is proximal to the A-1 pulley, then the patient's digit is more likely to become stuck in the flexed position.
A trigger finger often results in difficulty flexing or (in this case) extending the metacarpophalangeal joint of the involved digit.
 
 
 
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