What is the recommended treatment for a patient with trigger finger?

Trigger Finger Treatment

For adults with trigger finger, corticosteroid injection is the first-line treatment after conservative measures fail, as it provides superior outcomes compared to NSAIDs and avoids immediate surgery. 1, 2

Initial Conservative Management

• Begin with activity modification and splinting for 6-8 weeks, particularly for mild to moderate symptoms, as this allows the inflammatory process to resolve without invasive intervention 1, 2
• Splinting should maintain the metacarpophalangeal (MCP) joint in slight flexion while allowing interphalangeal joint motion to prevent stiffness 3
• NSAIDs (oral or topical) provide minimal benefit for trigger finger and should not be relied upon as primary treatment—evidence shows no significant improvement in resolution, symptoms, or function compared to placebo 4

Why NSAIDs Don't Work

A Cochrane review of 231 patients demonstrated that NSAID injections offered no advantage over placebo for trigger finger, with only 34% symptom resolution at 24 weeks and higher rates of persistent moderate-to-severe symptoms 4. This contradicts their effectiveness in other inflammatory conditions and reflects the mechanical nature of trigger finger pathology 3.

Corticosteroid Injection Protocol

If conservative measures fail after 6-8 weeks, proceed directly to corticosteroid injection rather than continuing ineffective NSAIDs 1, 2

• Inject 20 mg triamcinolone or equivalent into the A1 pulley region (not into the tendon itself to avoid rupture) 4, 3
• Success rates range from 60-90% depending on severity and comorbidities 1, 2
• Diabetic patients respond less favorably to injection and may require earlier surgical consideration 3
• A second injection can be attempted if the first provides partial relief, but more than two injections increases risk without additional benefit 2, 3

Critical Injection Technique

Inject at the level of the A1 pulley (proximal to the MCP joint crease), not distally where you risk intratendinous injection and potential rupture 3. The patient should feel immediate relief of mechanical catching if properly placed 1.

Surgical Intervention

Proceed to surgical A1 pulley release if symptoms persist after 2 corticosteroid injections or if there is fixed flexion contracture 2, 3

• Open A1 pulley release is the gold standard with >95% success rate and allows direct visualization to avoid neurovascular injury 2, 3
• Percutaneous release is an alternative for experienced surgeons but carries higher risk of incomplete release and digital nerve injury 3
• If triggering persists after A1 release, excision of one slip of flexor digitorum superficialis (FDS) is required 2

Surgical Complications to Avoid

• Incomplete A1 pulley release leads to persistent triggering—ensure complete division under direct visualization 3
• Digital nerve injury occurs with percutaneous techniques when anatomy is not directly visualized 3
• Bowstringing is rare if only the A1 pulley is released (not A2 or A3) 3

Special Populations

Rheumatoid Arthritis Patients

Perform tenosynovectomy instead of simple A1 pulley release, as the underlying pathology is proliferative synovitis rather than mechanical stenosis 3

Diabetic Patients

• Lower threshold for surgical intervention as corticosteroid injections have reduced efficacy (approximately 50% vs 70-90% in non-diabetics) 3
• Multiple digits are often affected simultaneously, requiring staged or simultaneous releases 3

Pediatric Trigger Thumb

Surgical A1 pulley release is definitive treatment as spontaneous resolution beyond age 1 year is uncommon 2

Pediatric Trigger Finger (Non-Thumb)

Requires A1 pulley release plus FDS slip excision or complete FDS excision if triggering persists, as the pathoanatomy differs from adults 2

Physical Therapy Adjuncts

• Extracorporeal shockwave therapy (ESWT) may reduce pain and improve function in patients who refuse injection or surgery, though evidence is limited to small studies 5
• Ultrasound therapy has minimal evidence for primary treatment but may prevent symptom recurrence after other interventions 5
• These modalities should not delay definitive treatment (injection or surgery) in patients with moderate-to-severe symptoms 5

Common Pitfalls

• Do not waste time with prolonged NSAID trials—they are ineffective for trigger finger and delay appropriate treatment 4
• Do not inject corticosteroid into the tendon substance—this causes tendon rupture; inject into the sheath at the A1 pulley level 3
• Do not perform more than 2 corticosteroid injections—diminishing returns and increased risk of tendon weakening 2, 3
• Do not release pulleys beyond A1—this causes bowstringing and loss of mechanical advantage 3
• Do not assume pediatric trigger finger will resolve spontaneously after age 1 year—surgical release is required 2