What is the priority for a 54-year-old male with nontraumatic left index finger and flexor tendon pain, full range of motion (ROM), and normal X-ray results?

Management of Nontraumatic Flexor Tendon Pain in the Hand

The priority for a 54-year-old male with nontraumatic left index finger and flexor tendon pain is to implement relative rest, NSAIDs, and physical therapy as first-line management while ruling out other pathologies with appropriate imaging if symptoms persist. 1, 2

Initial Assessment and Diagnosis

The presentation of pain along the flexor tendon with palpation, full range of motion with pain, and absence of erythema or warmth is consistent with flexor tendinopathy. This condition typically presents with:

• Localized pain that is reproducible on palpation
• Pain with activity that may subside after a warm-up period
• Normal radiographic findings
• Absence of inflammatory signs such as erythema and warmth 1

The normal X-ray helps rule out bony abnormalities but is expected in tendinopathy, as plain radiographs are usually unable to demonstrate soft-tissue changes of tendinopathy 1.

First-Line Management

1. Relative Rest

   • Reduce activities that cause repetitive loading of the damaged tendon
   • Avoid complete immobilization, which can lead to stiffness 1

2. Pain Management

   • NSAIDs are recommended as first-line medication for pain and inflammation
   • Options include oral NSAIDs (ibuprofen, naproxen) or topical NSAIDs for localized pain
   • Acetaminophen (up to 4g/day) if NSAIDs are contraindicated 2

3. Physical Therapy

   • Should be initiated early alongside medication
   • Focus on gentle, progressive stretching exercises
   • Eccentric strengthening exercises
   • Graded activity to increase functional use 2

4. Supportive Measures

   • Consider a protective brace to unload the affected area
   • Activity modification to avoid aggravating activities 2

Monitoring and Follow-up

• Reassess after 4-6 weeks of conservative management
• If symptoms persist beyond this period, consider further imaging:
  • Plain radiographs (if not already obtained) to rule out other pathologies 2
  • MRI without contrast if symptoms persist despite 6-8 weeks of conservative management to evaluate for tendon tears or other soft tissue injuries 2

Common Pitfalls and Caveats

1. Misdiagnosis: Flexor tendinopathy can be confused with other conditions:

   • Trigger finger
   • Flexor tenosynovitis (which would typically present with more inflammatory signs)
   • Ulnar or median neuropathy
   • Fractures (ruled out by normal X-ray in this case)

2. Inadequate Treatment Duration: Even with optimal management, resolution typically requires 3-6 months 2

3. Overuse of Corticosteroid Injections: Should be considered only if minimal improvement after 8-12 weeks of consistent therapy, as they may inhibit healing and reduce tensile strength 2

4. Failure to Recognize Red Flags: Persistent symptoms despite appropriate management may indicate more serious pathology requiring specialist referral

When to Consider Referral

Consider orthopedic referral if:

• Pain persists despite 3-6 months of well-managed conservative treatment
• Significant functional limitations impact quality of life
• Suspicion of more serious pathology 2

By following this structured approach, most cases of flexor tendinopathy will resolve with conservative management, as over 90% of tendinopathy cases have good outcomes with appropriate conservative care 2.