What is the treatment for flexor tenosynovitis?

Treatment of Flexor Tenosynovitis

Digital flexor tenotomy is the recommended treatment for flexor tenosynovitis when conservative treatment fails, particularly in patients with hammertoes and pre-ulcerative signs or ulcers on the distal toe. 1

Initial Conservative Management

• Begin with relative rest and reduced activity to prevent further damage and promote healing 1
• Apply cryotherapy (melting ice water through a wet towel for 10-minute periods) for acute pain relief 1
• Implement eccentric strengthening exercises to reverse degenerative changes and treat tendinopathy 1
• Use NSAIDs for short-term pain relief, though they don't affect long-term outcomes 1
• Consider corticosteroid injections, which are effective in nearly 90% of cases and free from serious adverse reactions 2
• For trigger finger specifically, local corticosteroid injections resolve symptoms in 61% of cases after a single injection 2

Advanced Treatment Options

Surgical Intervention

• When conservative treatment fails, digital flexor tenotomy should be considered, especially for patients with:

  • Hammertoes with pre-ulcerative signs 1
  • Distal toe ulcers that don't respond to conservative treatment 1
  • Flexible toe deformities with neuropathic plantar or apex ulcers on digits 2-5 1

• Digital flexor tenotomy benefits:

  • Healing rates of 97% in a mean of 29.5 days 1
  • Low recurrence rates (0-20%) over follow-up periods of 11-36 months 1
  • Prevention of ulcer occurrence in patients with impending ulcers 1
  • Can be performed in an outpatient setting with no need for subsequent immobilization 1

Special Considerations

• For diabetic patients with neuropathic toe ulcers:

  • Digital flexor tenotomy is particularly effective and should be considered as first-line treatment 1
  • The procedure normalizes foot structure to prevent ulceration 1
  • Few complications have been reported, making benefits likely to outweigh harm 1

• For rheumatoid arthritis patients:

  • Tenosynovectomy may be required instead of simple A-1 pulley release 3
  • MRI can help identify flexor tenosynovitis as it may be an early marker for rheumatoid arthritis 1

Diagnostic Approach

• Ultrasound is superior to clinical examination for detecting joint inflammation and tenosynovitis 1
• MRI can identify flexor tenosynovitis and is useful for confirming diagnosis 1, 4
• Hand flexor tenosynovitis on imaging may be a specific marker for rheumatoid arthritis classification 1

Potential Complications

• Surgical complications are rare but may include:
  • Transfer lesions in some cases 1
  • Digital nerve injury 3
  • Continued triggering 3
  • Post-operative infection (though uncommon) 1

Treatment Algorithm

1. Start with conservative management (rest, NSAIDs, splinting)
2. If no improvement, proceed to corticosteroid injection
3. For persistent cases or those with hammertoes/toe deformities, consider digital flexor tenotomy
4. For diabetic patients with neuropathic ulcers, consider earlier surgical intervention
5. For rheumatoid arthritis patients, consider tenosynovectomy rather than simple release

Digital flexor tenotomy is a cost-effective procedure that requires minimal resources and is feasible to implement in most healthcare settings 1. The procedure has high patient satisfaction rates and is particularly valuable for patients with recurrent or non-responsive flexor tenosynovitis 1.