What are the treatment options for trigger finger?

Trigger Finger Treatment

Begin with conservative management including activity modification, splinting, and topical NSAIDs, escalating to corticosteroid injection for inadequate response, and reserve surgical release for patients with persistent marked pain or disability after failed conservative treatment. 1

Initial Conservative Approach

First-line treatment should include activity modification and patient education about avoiding repetitive gripping or forceful finger flexion that exacerbates symptoms. 1 This foundational step applies to all patients regardless of severity.

Non-Pharmacological Interventions

• Splinting the affected finger in extension, particularly at night, can reduce triggering episodes and allow tendon sheath inflammation to resolve. 1, 2
• Heat application using paraffin wax or hot packs before exercise provides symptomatic relief and improves finger mobility. 1
• Range of motion and strengthening exercises maintain finger function and prevent stiffness. 1

Pharmacological Management

Start with topical NSAIDs for mild to moderate pain, especially when only a few fingers are affected, as they provide effective relief with minimal systemic side effects. 1, 3

• If topical NSAIDs are insufficient, use oral paracetamol up to 4g daily as the first-line systemic analgesic due to its favorable safety profile. 1
• Reserve oral NSAIDs for patients who fail paracetamol, using the lowest effective dose for the shortest duration. 1, 3
• For patients with gastrointestinal risk factors, combine non-selective NSAIDs with gastroprotective agents or use selective COX-2 inhibitors. 1, 3
• Avoid COX-2 inhibitors entirely in patients with cardiovascular risk, and use non-selective NSAIDs with extreme caution in this population. 1, 3

Important caveat: A 2021 Cochrane review found that NSAID injections offered no benefit over glucocorticoid injections and may result in higher rates of persistent moderate to severe symptoms (28% vs 14%). 4 This evidence strongly argues against using injectable NSAIDs for trigger finger.

Corticosteroid Injection

For patients with moderate to severe symptoms or inadequate response to conservative measures, corticosteroid injection into the tendon sheath is highly effective for painful flares. 1, 2 This represents the appropriate escalation point before considering surgery.

• A single injection of triamcinolone (typically 20mg) provides significant symptom relief in many patients. 4
• Corticosteroid injection is particularly effective for trapeziometacarpal joint involvement when present. 1
• The diagnosis is clinical, based on finger locking during active flexion movement, making injection straightforward once other pathology is excluded. 5

Surgical Release

Surgical A1 pulley release should be considered when conservative treatments including corticosteroid injection have failed and the patient has marked pain and/or disability limiting activities of daily living. 1, 6

Surgical Indications

• Failure of at least 3 months of conservative management including splinting, NSAIDs, and corticosteroid injection. 5, 6
• Patients presenting initially with fixed flexion deformity or complete inability to flex the finger may warrant earlier surgical intervention due to pain intensity and functional disability. 5
• Persistent triggering despite adequate conservative treatment. 6

Surgical Options

• Open A1 pulley release is the standard surgical approach with high success rates. 6
• Percutaneous A1 pulley release is an alternative technique for appropriate candidates. 6
• Excision of a slip of flexor digitorum superficialis is reserved for patients with persistent triggering despite A1 release or those with persistent flexion contracture. 6

Treatment Algorithm Summary

1. All patients: Activity modification, education, heat application, and range of motion exercises 1
2. Mild to moderate symptoms: Add topical NSAIDs 1, 3
3. Inadequate response: Add oral paracetamol up to 4g daily 1
4. Still inadequate: Consider oral NSAIDs (risk-stratified) 1, 3
5. Moderate to severe or failed oral therapy: Corticosteroid injection 1, 2
6. Failed injection or marked disability: Surgical A1 pulley release 1, 6

Common Pitfalls to Avoid

• Do not use injectable NSAIDs instead of corticosteroids, as evidence shows they are inferior and may worsen outcomes. 4
• Do not proceed directly to surgery without exhausting conservative measures for at least 3 months, unless the patient presents with fixed deformity or complete loss of function. 5, 6
• Do not prescribe oral NSAIDs as first-line therapy when topical options and paracetamol have not been tried. 3
• Do not forget to assess cardiovascular and gastrointestinal risk factors before initiating oral NSAID therapy. 3
• The condition is caused by inflammation and narrowing of the A1 pulley, not simply tendon pathology, making pulley-directed treatment essential. 2

Adjunctive Physical Therapy Modalities

• Extracorporeal shock wave therapy (ESWT) shows promise in reducing pain and trigger severity while improving functional level and quality of life, though more research is needed to establish optimal protocols. 7
• Ultrasound therapy may help prevent symptom recurrence after initial treatment. 7