What is the appropriate treatment for trigger finger?

Treatment for Trigger Finger

Begin with conservative management including activity modification and splinting, followed by corticosteroid injection if symptoms persist, and reserve surgical release for cases that fail conservative treatment after 3-6 months. 1

Initial Conservative Management (First-Line Treatment)

Activity modification and education about avoiding repetitive gripping motions and adverse mechanical factors should be initiated immediately for all patients with trigger finger. 1

• Heat application (paraffin wax or hot packs) for 15-20 minutes before exercise sessions can improve finger mobility and reduce stiffness 1, 2
• Implement a structured home exercise program consisting of range-of-motion and strengthening exercises for the affected finger 1
• Splinting may provide benefit, particularly when applied to immobilize the affected finger in extension, though evidence is limited 1

Pharmacological Adjuncts to Conservative Care

• Topical NSAIDs (diclofenac gel, ibuprofen cream) applied 3-4 times daily are effective first-line pharmacological treatments, especially for mild-to-moderate pain 1, 2
• Oral acetaminophen (up to 4g/day) is the preferred oral analgesic due to its efficacy and safety profile 1
• Oral NSAIDs should only be used at the lowest effective dose and shortest duration in patients who fail topical NSAIDs and acetaminophen 1
• For patients with gastrointestinal risk factors, use non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 1
• COX-2 inhibitors are contraindicated in patients with cardiovascular disease or risk factors 1, 2

Emerging Physical Therapy Modalities

• Extracorporeal shock wave therapy (ESWT) appears effective and safe for reducing pain and trigger severity while improving functional level, though optimal treatment protocols remain undefined 3
• Ultrasound therapy may help prevent recurrence of trigger finger symptoms 3

Second-Line Treatment: Corticosteroid Injection

When conservative measures fail after 4-8 weeks, corticosteroid injection into the flexor tendon sheath is effective for painful flares and represents the appropriate next step. 1, 4, 5

• The cure rate with a single corticosteroid injection is approximately 57%, increasing to 86% when a second injection is administered if needed 6
• Corticosteroid injection is less invasive than surgery but has higher recurrence rates (385 per 1000 patients) compared to surgical release (65 per 1000 patients) at 6-12 months follow-up 7
• Failure of corticosteroid injection after one or two attempts is an indication to proceed to surgical intervention 1

Surgical Management for Refractory Cases

Surgery should be considered only when patients have marked pain and/or disability that limits activities of daily living AND conservative treatments (including corticosteroid injection) have failed after 3-6 months. 1, 7

Surgical Options and Outcomes

• Open A1 pulley release is the gold standard surgical approach with near 100% resolution rates 6, 7
• Percutaneous A1 pulley release achieves similar effectiveness to open surgery with 100% remission rates 6
• Both percutaneous and open surgery methods are superior to corticosteroid injection regarding cure rates (RR 0.17,95% CI 0.09 to 0.33 for recurrence with surgery versus injection) 7
• Excision of a slip of the flexor digitorum superficialis is reserved for patients with persistent triggering despite A1 release 4

Important Surgical Considerations

• Open surgery causes more immediate postoperative pain than steroid injection (678 per 1000 versus 184 per 1000 at one week), but provides superior long-term outcomes 7
• The risk of adverse events (infection, tendon injury, neurovascular injury) is low and similar between surgical and injection approaches (RR 1.02,95% CI 0.57 to 1.84) 7
• Endoscopic surgery is an alternative to open surgery, though comparative effectiveness data is limited 7

Critical Pitfalls to Avoid

• Never proceed directly to surgery without exhausting conservative measures first—the evidence-based algorithm mandates stepwise progression through non-pharmacological, pharmacological, and corticosteroid injection before surgery 1
• Do not continue oral NSAIDs indefinitely without reassessing necessity, efficacy, and emerging risk factors every 4-8 weeks 2
• Never overlook cardiovascular and gastrointestinal risk stratification before prescribing oral NSAIDs, particularly in elderly patients 2
• Avoid using COX-2 inhibitors in patients with established cardiovascular disease 2
• Do not dismiss the importance of non-pharmacologic interventions—these form the foundation and should never be omitted even when medications or injections are added 2