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Trigger finger (stenosing flexor tenosynovitis)

Trigger finger (stenosing flexor tenosynovitis)
Literature review current through: Jan 2024.
This topic last updated: May 06, 2022.

INTRODUCTION — Trigger finger (also called stenosing flexor tenosynovitis) is caused by a disparity in the size of the flexor tendons and the surrounding retinacular pulley system at the first annular (A1) pulley (figure 1) which overlies the metacarpophalangeal (MCP) joint (figure 2). The flexor tendon catches when it attempts to glide through a relatively stenotic sheath, resulting in an inability to smoothly flex or extend the finger. In severe cases, the finger may become locked in flexion or extension, requiring passive manipulation of the finger to achieve normal motion. The cause of trigger finger is most frequently unclear, although patients often attribute it to overuse or repetitive movements. (See "Overview of the musculoskeletal complications of diabetes mellitus", section on 'Trigger finger (stenosing flexor tenosynovitis)'.)

The pathogenesis, clinical manifestations, diagnosis and treatment of trigger finger are discussed here. The anatomy of the finger flexion and pulley system is reviewed separately. (See "Finger and thumb anatomy", section on 'Finger flexion and pulley system'.)

EPIDEMIOLOGY — Trigger finger is one of the most common causes of hand pain in adults. The reported prevalence is roughly 2 percent in the general population, and is most common among women in the fifth or sixth decade of life [1]. It can occur in one or more fingers in each hand and can be bilateral. The prevalence of trigger finger is also higher among patients with diabetes mellitus, rheumatoid arthritis, or conditions that cause systemic deposition of protein such as amyloidosis [1,2]. Trigger finger is occasionally observed in children; in the pediatric age group, there is a much higher probability of an anatomic variation or an inherited condition [1]. (See "Mucopolysaccharidoses: Complications", section on 'Carpal tunnel syndrome'.)

ETIOPATHOGENESIS — The majority of trigger fingers are idiopathic [3]. Symptoms usually begin spontaneously, without a prior history of trauma or change in activity level. There are some observational reports suggesting an association with occupational or repetitive activities, but this is controversial [1].

The main histopathological change is fibrocartilaginous metaplasia of the ligamentous layer of the tendon sheath at the first annular (A1) pulley with secondary reduction in the cross-sectional area of the fibro-osseous canal [1,4]. Functional impairment in finger flexion and extension is primarily a result of mechanical impingement leading to tendon entrapment.

PRESENTATION — Patients with trigger finger initially describe painless snapping, catching, or locking of one or more fingers during flexion of the affected digit. This often progresses to painful episodes in which the patient has difficulty spontaneously extending the affected digit(s). The pain is localized over the volar aspect of the metacarpophalangeal (MCP) joint and radiates into the palm or the distal finger. The patient may rub over the tendon in the palm or demonstrate the locking phenomenon when describing the condition. Some patients awaken with the finger locked in the palm, with gradual "unlocking" as the day progresses.

In more severe cases, the finger may become locked in flexion requiring passive manipulation of the finger into extension, which can be painful. Reluctance to fully flex and extend the digit because of pain or locking can eventually lead to secondary contracture at the proximal interphalangeal (PIP) joint. It is also not unusual for a patient to have multiple trigger digits.

DIAGNOSIS — The diagnosis of trigger finger is primarily based upon a history of locking or clicking during finger movement, which can be demonstrated on physical examination when the patient is asked to fully open and close the hand. The hands are placed in the palms-up position and the patient is asked to actively flex and extend the fingers, and to try to make the finger lock or catch (picture 1). Alternatively, if active triggering is not present, the examiner places his fingers on the proximal interphalangeal joint (PIP) as the finger is actively flexed and extended, noting the presence of loss of smooth motion or a clicking sensation. The locking does not have to occur with every repetition.

Additional findings may include pain or tenderness at the base of the finger, directly over the tendon as it courses over the metacarpophalangeal (MCP) joint. A tender nodule (thickening of the tendons) may also be present. Pain may be aggravated by stretching the tendon in extension or by resisting flexion isometrically (picture 2). In addition to the nodule or swelling of the tendon, patients may also have a palmar nodule of fascial thickening overlying the tendon sheath associated with a concurrent Dupuytren's contracture.

Radiographs are not necessary in diagnosing patient with suspected trigger finger [5].

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of trigger finger includes other conditions that can lead to locking, pain, loss of motion, and swelling of the metacarpophalangeal (MCP) joints, several of which are presented below.

Dupuytren's contracture — Dupuytren's contracture is characterized by loss of full extension of the affected finger or fingers at the MCP joint. The loss of extension is fixed and chronic, while in a trigger finger it is dynamic and episodic. Unlike trigger finger, Dupuytren's is painless and nodular lesions are typically evident in the palmar fascia. The nodule typically progresses over a period of time to form a fibrous cord that extends from the palm to the digits, which also helps distinguish it from trigger finger. (See "Dupuytren's contracture".)

Diabetic cheiroarthropathy — Diabetic cheiroarthropathy is characterized by a typically painless, limited ability to fully flex or extend the MCP joints and/or interphalangeal joints. It generally affects all fingers symmetrically, whereas trigger finger may affect one or, less often, more fingers. It may progress to fixed flexion contractures of the finger joints. A tight, waxy skin surface over the dorsum of the hand is usually observed, which is not observed in trigger finger. However, patients who have diabetic cheiroarthropathy and limited joint mobility are more likely to also develop trigger finger [6]. (See "Limited joint mobility in diabetes mellitus".)

Metacarpophalangeal joint sprain — Tenderness on either side of the MCP joint associated with loss of full flexion suggests a sprain of the MCP joint, particularly in the setting of recent trauma. Thus, a history of trauma and the absence of triggering can help distinguish this from trigger finger.

Infection within the tendon sheath — Severe pain and tenderness of the flexor tendon in the hand, particularly in the setting of a preceding puncture or bite wound involving the finger or hand suggests infectious tenosynovitis. It is imperative to recognize this syndrome, since an unrecognized closed-space infection can lead to severe limitation of motion due to tendon disruption. It can be distinguished from trigger finger as it often leads to more severe pain, tenderness, erythema, and swelling in long axis over the affected tendon or finger. Infection of the hand requires immediate surgical consultation for possible exploration and drainage. (See "Human bites: Evaluation and management".)

Calcific peritendinitis or periarthritis — Calcific peritendinitis or periarthritis is an inflammatory process associated with juxtaarticular deposits of calcium hydroxyapatite, and has been described in the vicinity of almost every joint in the hand and wrist [7]. Patients may present with significant pain and erythema so severe that it simulates infection, which is not usually seen with trigger finger. Locking or triggering of the finger is also not observed with calcific peritendinitis or periarthritis. Radiographs may demonstrate fluffy calcification in the area of inflammation, but this is not usually apparent until a few days after the onset of symptoms.

Tenosynovitis (non-infectious) — Pain, tenderness, and swelling along the flexor tendon in the hand may be associated with an underlying inflammatory arthritis such as rheumatoid arthritis or reactive arthritis. It can be differentiated from trigger finger in that tenosynovitis often leads to swelling and pain along the long axis of the affected tendon, joints, or finger, resulting in limited or painful extension of the involved digit. Tenosynovitis improves with treatment of the underlying arthritis with medications such as nonsteroidal antiinflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and systemic glucocorticoids. (See "Clinical manifestations of rheumatoid arthritis", section on 'Hands' and "Reactive arthritis", section on 'Musculoskeletal signs and symptoms'.)

TREATMENT — The goals of treatment of trigger finger are to alleviate pain and to allow smoother movement of the finger with flexion and extension. A variety of therapeutic options ranging from conservative to more invasive are presented below.

Overall approach — Our initial approach to therapy is usually to start with conservative interventions which include activity modification, splinting, and/or short-term nonsteroidal antiinflammatory drugs (NSAIDs). A local glucocorticoid injection may be offered to patients whose symptoms have not resolved with conservative management.

Patients who present with severe symptoms or frequent episodes of triggering may benefit from a glucocorticoid injection at the initial presentation. Surgical release is generally reserved for patients who have failed conservative therapy and have not improved with one or two glucocorticoid injections.

Acute symptoms — We suggest initial management with either activity modification or splinting. Patients may continue with normal activity but avoid potentially aggravating movements such as pinching or grasping of the fingers. Several small observational studies have also shown that immobilization of the metacarpophalangeal (MCP) joint with splinting with a metal finger splint (picture 3) or a custom made thermoplastic splint can also help alleviate pain and reduce triggering [8-11]. As an example, a study including 28 patients with trigger finger treated with a custom thermoplastic splint found statistically significant improvements across a variety of outcome measures, including the number of triggering events [8]. In addition, approximately 93 percent of patients felt that their triggering had improved after 6 to 10 weeks of splint wear, and 54 percent of patients felt that their symptoms had completely resolved.

The splint should keep the MCP joint in slight flexion and can be worn based on trigger pattern and patient preferences (eg, daytime use, nighttime use, or use with activity). The suggested duration of splinting is generally three to six weeks. For milder cases, primary care clinicians may suggest taping the affected finger with the adjacent normal fingers (buddy taping) to limit flexion of the finger.

We also suggest a concurrent trial of NSAIDs for pain relief, unless contraindicated by gastrointestinal, renal, or heart disease. NSAIDs should be taken for a maximum duration of two to four weeks. (See "Initial treatment of rheumatoid arthritis in adults", section on 'NSAIDs'.)

Persistent symptoms — For patients whose symptoms do not improve with activity modification, splinting, and/or judicious use of NSAIDs, additional therapeutic options include glucocorticoid injections and surgery.

Glucocorticoid injection — A local glucocorticoid injection is suggested for patients whose symptoms have not resolved after four to six weeks of conservative therapy (eg, splinting) (picture 4). We use an intermediate-acting glucocorticoid for injection such as methylprednisolone or triamcinolone mixed with a local anesthetic such as lidocaine. As mentioned above, a glucocorticoid injection may be offered sooner to patients who present with severe locking and incomplete finger flexion or extension. The injection may be repeated in six weeks if symptoms have not improved by at least 50 percent, with a maximum of three injections. There are no data to guide the optimal formulation, dose, timing, or a limit on glucocorticoid injections, and practices vary. However, the vast majority of patients experience significant improvement with a single injection. Persistent relief beyond 12 months is expected in approximately 50 percent of patients [12]. Glucocorticoid injections for trigger finger in patients with diabetes are generally less successful [13].

The efficacy of glucocorticoid injections for trigger finger in adults has been demonstrated in numerous observational studies, with relatively lasting effects [12,14,15]. As an example, a study including 366 patients with trigger finger found that at least 45 percent of patients experienced relief lasting up to 10 years after a single glucocorticoid injection [15]. In addition, a systematic review including two randomized trials of poor methodological quality found that glucocorticoid injection was more effective for symptom relief than lidocaine injection alone after four weeks [16-18]. Another trial randomly assigned 50 patients with trigger finger to receive either local glucocorticoid or placebo injection and found that patients who received a glucocorticoid injection had a significantly greater improvement in pain and reduction in triggering, which persisted during the 12-month follow-up period [19].

Pediatric patients with trigger thumb represent a special circumstance. Injections are not recommended in this population. Splinting and observation leads to resolution in slightly more than 60 percent of children. Surgery is an alternative when the deformity persists [20,21].

Adverse effects from glucocorticoid injections for trigger finger are rare, but include atrophy of the subcutaneous fat and hypopigmentation.

Surgery — Surgery is suggested when pain and locking persist despite conservative therapy and one or two local glucocorticoid injections. Ultrasound-guided percutaneous and open surgical release of the first annular (A1) pulley ligament are both effective, with a recurrence rate of only about 3 percent, but controversy exists as to whether they are equally effective [22-27]. As an example, a large meta-analysis including seven randomized trials compared percutaneous release, open surgery, or glucocorticoid injections in patients with trigger finger, and found no differences in the failure rate and complication frequency between the two different surgical approaches [24]. In addition, patients treated with percutaneous releases were less likely to have treatment failure compared with patients treated with glucocorticoid injections.

Complications from surgery include infection, digital nerve injury, flexor tendon bowstringing (or protrusion of the flexor tendon into the palm with finger flexion), and tendon scarring [28]. Postoperatively, patients are able to resume many activities of daily living, such as dressing, eating, and doing sedentary work, within a few days. Most patients take a week or two to resume more demanding activities, but occasionally they can take longer.

Outcomes of surgery may not be as successful in diabetics. As an example, a study evaluating the outcome of trigger finger treatment in diabetic patients found that 13 percent of diabetic patients who underwent surgery had an unsuccessful outcome compared with 6 percent of non-diabetic patients [29]. Diabetic patients may also have higher rates of complications like infections and surgical revisions [30,31].

Most patients who meet indications for surgery have poor prognoses without surgery, except for the few patients who undergo spontaneous improvement over time with the help of conservative management and pain control. The patients with the best prognosis include those without diabetes and/or a contracture of the proximal interphalangeal (PIP) joint before surgery.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Tenosynovitis (The Basics)" and "Patient education: Hand pain (The Basics)" and "Patient education: Common finger injuries (The Basics)")

SUMMARY AND RECOMMENDATIONS

Definition – Trigger finger is caused by a disparity in the size of the flexor tendons and the surrounding retinacular pulley system, at the first annular (A1) pulley (figure 1) which overlies the metacarpophalangeal (MCP) joint (figure 2). The flexor tendon catches when it attempts to glide through a relatively stenotic sheath, resulting in an inability to smoothly flex or extend the finger. (See 'Introduction' above.)

Clinical presentation – Patients initially describe painless snapping, catching, or locking of one or more fingers during flexion of the affected digit. This often progresses to painful episodes in which the patient has difficulty spontaneously extending the affected digits. (See 'Presentation' above.)

Diagnosis – The diagnosis of trigger finger is primarily based upon a history of locking or clicking during finger movement, which can be demonstrated on physical examination when the patient is asked to fully open and close the hand (picture 5 and picture 1). The locking does not have to occur with every repetition. (See 'Diagnosis' above.)

Differential diagnosis – The differential diagnosis includes other conditions that can lead to locking, pain, loss of motion, and swelling of the MCP joints such as Dupuytren's contracture, diabetic cheiroarthropathy, MCP joint sprain, infection within the tendon sheath, calcific peritendinitis or periarthritis, or non-infectious tenosynovitis. (See 'Differential diagnosis' above.)

Treatment

Acute symptoms – For all patients with trigger finger, we suggest initial management with conservative therapy which includes activity modification or splinting as well as a concurrent trial of nonsteroidal antiinflammatory drugs (NSAIDs) (Grade 2C). (See 'Acute symptoms' above.)

Persistent symptoms – For patients with trigger finger whose symptoms do not improve after four to six weeks of conservative therapy, we suggest a local glucocorticoid injection rather than surgical therapy (Grade 2B). We use an intermediate-acting glucocorticoid injection such as methylprednisolone or triamcinolone mixed with a local anesthetic. A glucocorticoid injection may be offered sooner to patients who present with severe locking and incomplete finger flexion or extension. The injection may be repeated in six weeks if symptoms have not improved by at least 50 percent. (See 'Glucocorticoid injection' above.)

For patients with persistent pain and locking persist despite conservative therapy and at least one or two local glucocorticoid injections, surgical therapy may help relieve symptoms. Ultrasound-guided percutaneous and open surgical release of the A1 pulley ligament are both effective. (See 'Surgery' above.)

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  22. Mishra SR, Gaur AK, Choudhary MM, Ramesh J. Percutaneous A1 pulley release by the tip of a 20-g hypodermic needle before open surgical procedure in trigger finger management. Tech Hand Up Extrem Surg 2013; 17:112.
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