Management of Flexor Tendon Tenosynovitis
Distinguish the Type First
The management of flexor tendon tenosynovitis depends critically on whether you are dealing with infectious (pyogenic) versus non-infectious (stenosing/trigger finger) tenosynovitis, as these require fundamentally different approaches.
Infectious Flexor Tenosynovitis (Pyogenic)
Early Presentation (Kanavel Signs Present <48 Hours)
Consider non-surgical management with IV antibiotics, strict immobilization, and elevation as first-line treatment for early infectious flexor tenosynovitis. 1
- Empirical IV antibiotics should be started immediately upon diagnosis 2, 3
- Immobilization with splinting in the position of function 1
- Strict elevation to reduce edema 1
- Close monitoring for clinical response within 24-48 hours 3
Expected timeline: Resolution of infectious symptoms typically occurs within 5 days (range 2-11 days) with conservative management in early cases 1
Indications for Urgent Surgical Intervention
Proceed to surgical drainage with open or closed irrigation if: 2, 3
- No clinical improvement within 24-48 hours of IV antibiotics
- Presentation beyond 48 hours from symptom onset
- Advanced infection at presentation
- Presence of abscess formation
- Patients with medical comorbidities (diabetes, immunosuppression)
Surgical options include: 3
- Open surgical drainage with sheath irrigation
- Closed catheter irrigation (may be continued postoperatively)
- Combined approach based on severity
Critical Pitfall
Even with aggressive prompt treatment, expect residual digital stiffness in most patients. 3 Patients presenting late or with comorbidities face significantly worse outcomes including severe stiffness or amputation 3
Non-Infectious Stenosing Tenosynovitis (Trigger Finger)
First-Line Treatment Algorithm
Corticosteroid injection into the tendon sheath is the primary treatment, with timing of presentation determining success rates. 4, 5
Initial Injection Protocol
- Inject depo-methylprednisolone acetate or triamcinolone acetonide directly into the flexor tendon sheath 4, 5
- Success rate after single injection: 61% achieve complete resolution 4
- Symptoms present ≤3 months: 2.6 times more likely to resolve after one injection compared to symptoms >3 months 5
Second Injection (If First Fails)
- Symptoms present ≤5 months before first injection: 9.4 times more likely to respond to second injection compared to symptoms >5 months 5
- Overall, 27% of patients experience recurrence after prolonged pain-free intervals and respond well to re-injection 4
Third Injection (If Second Fails)
- Safe to administer third injection: 75% remission rate after third dose 5
- No instances of tendon rupture, infection, or soft-tissue atrophy reported with up to three injections 5
Adjunctive Conservative Measures
Prior to or alongside injection: 4
- Rest from aggravating activities
- NSAIDs for symptomatic relief
- Splinting (though many cases are resistant to these measures alone)
Surgical Referral
Reserve surgery for patients who fail 3 injections or have persistent symptoms despite optimal medical management. 5
- Overall medical management success rate: nearly 90% with injection protocol 4
- Surgery involves release of the A1 pulley 5
Special Context: Diabetic Foot with Hammertoe Deformity
Digital Flexor Tenotomy for Prevention
In diabetic patients at risk of foot ulceration (IWGDF risk 1-3) with non-rigid hammertoe and pre-ulcerative lesions:
Perform digital flexor tendon tenotomy as first-line treatment for neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity. 6
- 97% healing rate in mean 29.5 days with digital flexor tenotomy 6
- Significantly superior to offloading devices alone for sustained healing 6
- Can be performed as outpatient procedure with no immobilization required 6
For prevention (pre-ulcerative lesions that fail conservative treatment): 6
- Consider digital flexor tendon tenotomy to prevent first or recurrent foot ulcers
- Alternative: orthotic interventions (toe silicone or semi-rigid devices) for callus reduction
- 0-20% recurrence rate over 11-36 months follow-up 6
Potential complications to discuss: 6
- Transfer lesions or transfer pressure (most common)
- Non-healing of surgical incision in patients with poor arterial supply
- Risk of heel ulceration if significant ankle dorsiflexion achieved post-procedure
Key Clinical Distinctions
Do not confuse these entities: 7
- De Quervain's tenosynovitis involves the first dorsal compartment (APL/EPB tendons) at the radial wrist, not flexor tendons
- Infectious vs. stenosing flexor tenosynovitis require opposite approaches: urgent antibiotics/surgery vs. corticosteroid injection
- The term "tendinitis" is often misapplied; chronic stenosing tenosynovitis represents degenerative tendinopathy (tendinosis), not acute inflammation 7