Should a flexed trigger finger causing pain be straightened and immobilized?

Management of Painful Trigger Finger

A painful trigger finger in a flexed position should not be forcibly straightened and immobilized, as this approach may worsen symptoms and lead to increased pain and potential complications. 1

Understanding Trigger Finger

Trigger finger is a common tendinopathy characterized by stenosing flexor tenosynovitis, where movement of a finger flexor tendon through the first annular (A1) pulley is impaired by degeneration, inflammation, and swelling. This causes pain and restricted movement of the affected finger 2, 3.

Evidence-Based Management Approach

Initial Management

1. Avoid forced straightening

   • Forcing a flexed trigger finger into extension can increase pain and potentially worsen the condition 1
   • Straightening may lead to increased inflammation and tissue damage

2. Preferred conservative treatments:

   • Activity modification to reduce repetitive finger movements 3
   • Pain management with acetaminophen or NSAIDs at the lowest effective dose 4
   • Eccentric strengthening exercises to promote healing and improve function 4
   • Deep transverse friction massage to reduce pain 4

3. Therapeutic positioning:

   • Encourage optimal postural alignment at rest and during function 1
   • Promote therapeutic resting postures rather than immobilization 1
   • Support the affected finger when at rest, using pillows or furniture to take weight off the digit 1

Splinting Considerations

Splinting for trigger finger requires careful consideration as it may have potential drawbacks:

• Potential problems with splinting include: 1

  • Increasing attention and focus to the affected area, potentially exacerbating symptoms
  • Increasing accessory muscle use
  • Promoting compensatory movement strategies
  • Immobilization leading to muscle deconditioning
  • Learned non-use
  • Increased pain

• When to consider splinting:

  • Only after trying strategies that encourage normal movement patterns and resting postures 1
  • If removable splints are used, they should be monitored regularly 1
  • The patient should be empowered to discontinue use if adverse effects occur 1

Medical Interventions

If conservative measures fail after 4-6 weeks:

1. Corticosteroid injection:

   • Considered the first-line treatment for persistent trigger finger 5, 3
   • More effective than NSAIDs in the acute phase 1
   • May be more effective without local anesthetic (triamcinolone alone causes less injection pain than when combined with lidocaine) 5

2. NSAID injections:

   • May offer little to no benefit over glucocorticoid injections 2
   • Higher rate of persistent moderate to severe symptoms compared to glucocorticoid injections 2

3. Other physical therapies:

   • External shock wave therapy (ESWT) may be effective in reducing pain and improving function 6
   • Ultrasound therapy may help prevent recurrence of symptoms 6

Imaging and Diagnosis

• Radiography is the initial imaging modality to rule out fractures 1, 4
• MRI is most sensitive (78%) and specific (86%) for confirming diagnosis and assessing extent of tendon involvement 4
• Ultrasound is more specific (94%) than sensitive (58%) for detecting tendon thickening 4

Surgical Considerations

If conservative treatment fails after 3-6 months:

• Surgical options include percutaneous or open A1 pulley release 7, 3
• Excision of a slip of the flexor digitorum superficialis is reserved for persistent triggering despite A1 release 7

Key Pitfalls to Avoid

1. Forced straightening - can increase pain and tissue damage
2. Prolonged immobilization - leads to stiffness and muscle deconditioning 1
3. Ignoring pain signals - pain indicates potential tissue damage
4. Delaying appropriate treatment - can lead to persistent symptoms and decreased function
5. Improper splinting - may cause increased focus on the area and worsen symptoms 1

By following these evidence-based guidelines, most patients with trigger finger can expect gradual improvement over 3-6 months, with approximately 80% fully recovering within this timeframe 4.