Referral Pathways for Trigger Finger
Patients with trigger finger should initially be managed by their primary care provider or referred to an occupational/physical therapist for conservative treatment, with referral to a hand surgeon (orthopedic or plastic surgery) reserved for cases failing conservative management or requiring surgical intervention. 1, 2
Initial Management and Referral to Occupational/Physical Therapy
All patients with trigger finger should be evaluated by their primary care provider or an occupational/physical therapist for assessment of activities of daily living, instruction in joint protection techniques, provision of assistive devices, and education on thermal modalities for pain and stiffness relief. 3
Occupational therapists play a central role in conservative management, providing orthoses (splinting), activity modifications, and physical agent modalities as part of the treatment protocol. 4
Hand therapy specialists can administer comprehensive occupation-based assessments and treatments, though current practice shows limited consensus on standardized treatment protocols. 4
Conservative Treatment Options Before Surgical Referral
Splinting is universally recommended as first-line treatment, with all surveyed occupational therapists reporting use of orthoses for trigger finger management. 4, 2
Corticosteroid injections can be administered by primary care providers or specialists as a non-surgical treatment option before considering surgical referral. 1, 2
Physical therapies including extracorporeal shock wave therapy (ESWT) may be effective for reducing pain and trigger severity, though this requires referral to facilities offering these specialized modalities. 5
Activity modification and NSAIDs can be initiated by primary care providers as part of conservative management. 5, 2
Surgical Referral Criteria
Referral to a hand surgeon is indicated when:
Conservative treatments (splinting, corticosteroid injections, activity modification) have failed to provide adequate symptom relief. 1, 2
Recurrence of triggering occurs after initial conservative management, as open surgery demonstrates significantly lower recurrence rates (6.5% with surgery versus 38.5% with steroid injection alone at 6-12 months). 1
Patients prefer definitive treatment over repeated conservative interventions, particularly given the 83% improvement rate with surgical release. 1
Surgical Options and Specialists
Hand surgeons (orthopedic or plastic surgery subspecialists) perform open A1 pulley release, percutaneous release, or endoscopic approaches. 1, 6, 2
Open surgical release of the A1 pulley is the gold standard with excellent long-term results, showing no recurrences and minimal complications at 14-year follow-up. 6
Percutaneous A1 pulley release is an alternative surgical option that can be performed by trained hand surgeons. 2
Important Caveats
Expect increased pain in the first week post-surgery (68% of surgical patients versus 18% with injection), which should be discussed during pre-referral counseling. 1
Pediatric trigger thumb requires different management with direct referral to hand surgery for open A1 pulley release, as conservative treatment is less effective in children. 2
Rehabilitation following surgery is important for optimal outcomes, often requiring post-operative occupational therapy referral. 7
Avoid delaying surgical referral excessively in cases with persistent symptoms, as prolonged conservative treatment without improvement may lead to secondary complications including flexion contractures. 2