What is the best way to manage trigger finger?

Management of Trigger Finger

Manual trigger point therapy, corticosteroid injections, and splinting are the most effective first-line treatments for trigger finger, with surgical release reserved for refractory cases. 1

Diagnosis and Initial Assessment

• Trigger finger (stenosing flexor tenosynovitis) presents with:
  • Pain at the A1 pulley (base of finger)
  • Clicking or catching during finger flexion/extension
  • Possible locking of the affected digit in flexion
  • Morning stiffness and tenderness over the A1 pulley
• Diagnosis is primarily clinical; imaging is rarely needed unless other pathologies are suspected

Treatment Algorithm

First-Line Treatments

1. Conservative Non-Surgical Management:

   • Splinting: Particularly effective for thumb base (trapeziometacarpal joint) with strong evidence of benefit 1

     • Use night splinting in extension position for 6-8 weeks
     • Consider custom-made thermoplastic splints that immobilize the MCP joint in slight extension

   • Manual trigger point therapy: Provides significant pain reduction (approximately twice the minimally important difference) 2, 1

     • Apply direct pressure to the affected A1 pulley area
     • Perform gentle stretching exercises of the affected finger

   • Corticosteroid injections: Highly effective for short-term relief

     • Single injection of triamcinolone (20mg) at the A1 pulley 3, 4
     • Success rates of 60-70% with a single injection
     • May require repeat injection after 4-6 weeks if symptoms persist

2. Activity Modification:

   • Avoid repetitive gripping activities
   • Apply joint protection techniques to minimize stress on affected fingers 1
   • Use ergonomic tools to reduce strain during daily activities

Second-Line Treatments

1. Physical Therapies:

   • External shock wave therapy (ESWT): Effective for reducing pain and improving function 5
   • Ultrasound therapy (UST): Useful for preventing recurrence of symptoms 5

2. Pharmacological Options:

   • Topical NSAIDs: First-line pharmacological option with good efficacy and safety profile 1
   • Oral NSAIDs: Consider only if topical treatments are ineffective 1, 4
     • Use lowest effective dose for shortest duration
     • Monitor for gastrointestinal and cardiovascular side effects

Third-Line Treatment (Surgical)

1. Surgical Release: Consider if symptoms persist after 3-6 months of conservative treatment 3
   • Open A1 pulley release: Standard surgical approach with high success rates (>90%)
   • Percutaneous release: Less invasive alternative with comparable outcomes to open surgery
   • Endoscopic release: Minimally invasive option with potentially faster recovery

Special Considerations

• Diabetic patients: Higher incidence and more resistant to conservative treatment
• Multiple digit involvement: May indicate systemic condition requiring more aggressive management
• Pediatric trigger finger: Different management approach, typically requiring surgical release 6

Potential Complications

• Corticosteroid injections: Skin atrophy, fat necrosis, infection (rare)
• Surgery: Nerve injury (digital nerve), infection, bowstringing, persistent pain, scar tenderness 3

Follow-up Recommendations

• Evaluate response to initial therapy within 4-6 weeks 1
• If no improvement after two corticosteroid injections, consider surgical referral
• Post-surgical follow-up at 2 weeks for wound check and initiation of range of motion exercises

The evidence strongly supports a stepped care approach beginning with conservative measures (splinting, manual therapy, and corticosteroid injections) before proceeding to surgical intervention for refractory cases. This approach optimizes outcomes while minimizing potential complications and unnecessary procedures.