eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
Trigger Finger: Treatment & Medication
Updated: Apr 18, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
Physical therapy is generally not required for patients with trigger finger. For chronic cases, however, treatment may include a trial of heating modalities followed by sustained nonballistic stretching of the flexor tendon, as well as soft-tissue mobilization of the A1 pulley. Following injection or surgery, a home exercise (stretching) program may be one component of treatment for patients. No therapy programs have been documented to improve trigger finger.
Occupational Therapy
If a trial of therapy is recommended for patients with chronic trigger finger or for individuals who require postsurgical hand therapy, the physician may refer them to a physical or occupational therapist, depending on his/her preference and the therapists' availability. The treatment provided by an occupational therapist is very similar to the above-discussed physical therapy treatment. In addition, the occupational therapist may provide a patient with strategies for completing activities of daily living with limited or no use of the affected hand while it is splinted or is recovering from surgery.
Medical Issues/Complications
- The main potential complications of trigger finger are pain and decreased functional use of the affected hand.
- Potential complications of corticosteroid injection include the following:
- Infection - The use of sterile technique can minimize this problem.
- Bleeding - This can be minimized by applying direct pressure immediately after the procedure. Caution should be exercised before injecting a patient who is taking anticoagulants or an individual with a bleeding disorder.
- Weakening of the tendon - This increases the risk of subsequent tendon rupture, a possibility that is of particular concern if the injection is performed incorrectly (specifically, if the injection is administered into the tendon itself rather than just within the tendon sheath).6,7 The risk may increase with multiple injections; however, at least some clinical researchers (eg, Anderson and Kaye) have found no episodes of tendon rupture after corticosteroid injection for this condition, even with repeated injections.8
- Fat atrophy occurring locally at the injection site - Such atrophy can occur if the corticosteroid is injected into the subcutaneous tissue. This complication can cause a cosmetic depression in the skin, and tenderness can result from the loss of padding provided by the fat.
- Nerve infiltration and subsequent nerve injury - This complication is uncommon; it can be be monitored by assessing sensation throughout the affected digit.
Surgical Intervention
- A congenital nodule on the flexor pollicis longus tendon generally does not respond to injections. Therefore, it usually requires referral for surgical intervention.
- Trigger digits that fail to respond to 2 or perhaps 3 injections may require surgical treatment, including dissection of the nodule on the tendon and surgical release of the A1 pulley, under local anesthesia.
- Surgical release is highly effective, leading to a permanent resolution of the triggering symptoms. Such surgery should be reserved for patients in whom conservative treatment methods fail.9
- When patients with diabetes were compared with persons who did not have diabetes, no statistically significant differences were found in surgical complication rates. This was also true when patients with type 1 diabetes were compared with individuals who had type 2 diabetes.9
Consultations
Surgical consultation for operative treatment may be required. Typically, such procedures are performed by an orthopedic hand surgeon or a plastic surgeon.
Other Treatment
- Corticosteroid injection in the area of tendon sheath thickening is considered to be the first-line treatment of choice for a trigger finger.9,10,11,12
- Typically, such an injection is performed using a 25-gauge needle to inject a mixture of 0.5-1 mL of 40 mg/mL corticosteroid (eg, methylprednisolone) and 0.5 mL of 1% lidocaine (without epinephrine).
- Corticosteroid injections seem to be less effective in treating trigger finger in patients with diabetes mellitus; thus, patients with diabetes are more likely to require surgical treatment.13
- A second corticosteroid injection may be performed 3-4 weeks after the first one. If 2 or perhaps 3 injections fail to provide adequate resolution, consider referring the patient for surgical release. Repetitive injections theoretically increase the likelihood of tendon rupture, although such a risk was not found in Anderson's study of repeated injections for trigger fingers.8
- An increased risk of tendon rupture may potentially exist after corticosteroid injection, particularly if the corticosteroid is erroneously injected into the tendon itself rather than injected only into the tendon sheath.
- Oral nonsteroidal anti-inflammatory drugs (NSAIDs) also may help.14
- Although corticosteroid injection has traditionally been administered into the tendon sheath (but not into the tendon itself),7 studies now seem to indicate that subcutaneous injection may be as effective as the intrasheath approach.15,16 Additionally, in some cases, steroid injection into the subcutaneous tissue seems to result in better clinical outcomes than does injection into the sheath alone.15
See also the following related Medscape topic:
CME Improving NSAID Outcomes: Stratifying Risks and Tailoring Treatment (Slides with Audio)
Medication
For this musculoskeletal condition, medications are used primarily to decrease pain and inflammation in conjunction with the rehabilitation plan. Thus, the most common medication treatments are focal corticosteroid injection and the administration of NSAIDs.
Nonsteroidal anti-inflammatory drugs
Oral NSAIDs can help to decrease pain and inflammation. Various oral NSAIDs can be used, although none of these agents holds a clear distinction as the drug of choice. The choice of NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.
Ibuprofen (Motrin, Advil, Nuprin, Rufen)
DOC for patients with mild to moderate pain. NSAIDs inhibit inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-800 mg PO tid/qid
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; to minimize risks of adverse effects, avoid taking multiple NSAIDs concurrently; caution in anticoagulation abnormalities or during anticoagulant therapy
Corticosteroids
In contrast to the widespread systemic distribution that occurs when an oral anti-inflammatory drug is administered, a local corticosteroid injection can achieve the focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. A variety of corticosteroid preparations are available. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. The clinician has numerous local anesthetic agents from which to choose.
Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol, Adlone)
Corticosteroids are commonly used in local injections administered to bursae or joints. The drugs provide a local anti-inflammatory effect while minimizing some of the GI and other risks of systemic medications.
Adult
40 mg (1 mL), intralesionally, is common for injection at many sites; often mixed with a few mL of a local anesthetic, such as 1% lidocaine
Pediatric
Not established
Local corticosteroid injection is not known to give rise to the same degree of medication interaction that oral or other systemic administration of corticosteroids produces; co-administration with anticoagulants may increase risk of hemorrhage or local bruising
Documented hypersensitivity; skin infection at the site of injection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Never inject corticosteroids through an infected area of skin; diabetic patients may sometimes experience transient elevation of blood glucose level after a local corticosteroid injection
More on Trigger Finger |
| Overview: Trigger Finger |
| Differential Diagnoses & Workup: Trigger Finger |
 Treatment & Medication: Trigger Finger |
| Follow-up: Trigger Finger |
| Multimedia: Trigger Finger |
| References |
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References
Trigger finger. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:249-53.
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.
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.
Brinker MR, Miller MD. The adult hand. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:196-220.
McGee DJ. Forearm, wrist and hand. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:168-215.
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].
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].
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].
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].
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].
Geiringer SR. Tendon sheath and insertion injections. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:44-8.
[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].
[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].
Nonsteroidal anti-inflammatory drugs (NSAIDs). In: Green SM, ed. Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon Pub; 2000:11-2.
Akhtar S, Bradley MJ, Quinton DN, et al. Management and referral for trigger finger/thumb. BMJ. Jul 2 2005;331(7507):30-3. [Medline].
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].
Further Reading
Keywords
trigger finger, digital flexor tenosynovitis, digital tenovaginitis stenosans, flexor tendon stenosing tenosynovitis, locked finger, stick palsy, trigger digit, trigger thumb, volar flexor tenosynovitis, flexor pollicis longus tendon nodule
