Stenosing Tenosynovitis: Trigger finger treatment without surgery
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.
Stenosing Tenosynovitis: Trigger finger treatment without surgery
If you are reading this article, you may have recently been diagnosed with or have been suffering from a “trigger finger,” or Stenosing Tenosynovitis. Typically you wake up in the morning and one or two of your fingers are flexed or in a “trigger” position. During the course of the day, that tightly flexed finger may open up and you go about your daily business with just a painful finger. The problem is, your finger repeats this daily cycle over and over and while you are waiting for that finger to open up, it makes the use of that hand difficult until it does. For some people, maybe like yourself, that finger does not open all the way and the pain continues throughout the day. Maybe that finger does not open at all.
As you know, many things can cause trigger finger and in your trips to your doctor, you started eliminating these possible causes. By this time you may have been screened for diabetes and a rheumatoid problem as these are leading causes for this finger problem. For many people, however, trigger finger, or Stenosing Tenosynovitis is a problem of overuse injury and is seen in people who use their hands and fingers a lot in their work. For instance, someone like yourself who may be a musician, a truck driver, someone whose job requires gripping an instrument or tool all day, like a landscaper or construction laborer.
Treating your trigger finger with splints and sleeves
Many people put themselves on a self-treatment program. This includes the sleeves and splints at night and NSAIDs or anti-inflammatories during the day when necessary.
You may have already done a lot of research online and you have found that splits and finger sleeves at bedtime can help you wake up with straight fingers. The key to the splints and sleeves is to prevent your hand from making a fist in the middle of the night. You have also found while this will help, it is not a long-term solution, you still have pain and it is getting bothersome. If you are a musician or someone who requires finger dexterity, it is of course impacting your ability to make a living and splints and sleeves are not realistic answers for you.
Treatments: The A1 pulley and the flexor tendon. This is where the Tenosynovitis is and ligament injury
Let’s introduce the main culprit in all this. The A1 pulley and the flexor tendon. This is where the Tenosynovitis is.
As it has probably been explained to you already, the flexor tendon attaches the muscles of the forearm to the bones of the fingers. To do this, the flexor tendons pass through a groove or tunnel in the palm of the hand into the fingers. Your problem is recognized as “Stenosing Tenosynovitis” an inflammation of the tendon (Tendinitis) and the tendon sheath inside of this groove or tunnel.
The “Pulley” is a ring-like soft tissue structure along the tendon sheath that holds the flexor tendons to the finger bones. The pulley works just like a pulley should, it provides a point or base that the tendon can glide along as the finger moves. The pulley at the base of the finger is the A1 pulley and the main culprit in trigger finger. If the pulley is not working correctly, the tendon gets stuck.
The ligaments of the A1 Pulley – Is Trigger Finger a Ligament Sprain?
In this one minute video, Ross Hauser, MD explains the concept of ligament damage and finger instability
The A1 pulley is composed of the annular ligaments at the metacarpophalangeal joint, which is the mid palm joint in the hand where the finger bones meet the palm bones. The annular ligaments connect the bones of the palm the metacarpal bones to the phalanges or the finger bones. The radial collateral ligaments (RCL), prevent fingers from overextending to the left and right. The Volar plate, a somewhat unique structure to the fingers is a thick ligament band that prevents the fingers from being “jammed” or overextended backwards.
Just like any joint, these ligaments in the fingers can be damaged. Ligament damage is classified as “sprains:” from a simple Grade I sprain which makes making a fist somewhat painful; to a Grade II sprain which would be a partial rupture of the A1 pulley; to a Grade III or complete rupture which would cause your finger to be locked in a bent position and the possible visible tenting or protrusion of the tendon in the palm.
These are the types of trigger finger problems we see. Damage to the ligaments of the A1 pulley causing finger instability and eventual osteoarthritis or in some cases the development of trigger finger symptoms. Understanding you have ligament damage that is causing tendon inflammation can help understand why some treatments may work better than others.
Trigger finger treatments
Before you move onto cortisone injections, physical therapy may be recommended
As your condition worsens and after a few weeks or months of trying to deal with your trigger finger problem, you made a visit to your health care provider. As this is an inflammation problem of the A1 pulley in your hand, you will probably be managed with anti-inflammatories to reduce the thickening or inflammation of the tendon that passes through the hand’s A1 pulley. Physical therapy and finger stretching exercises may be started as a necessary treatment to either help your situation or confirm the need for surgery. As many of you are already aware, surgery recommendations cannot usually be made until after you have failed physical therapy and cortisone injections. Not every doctor is in a rush to offer cortisone for this problem. As we will see below cortisone presents its own challenges and problems in some.
Extracorporeal shock wave therapy
For some therapists, Extracorporeal shock wave therapy is a tool that they use to help their patients with trigger finger. Extracorporeal shock wave therapy delivers “shock waves,” to damaged or injured tendons with the hopes that the tendon will start a new healing process.
A March 2020 study in the Open Access Journal of Sports Medicine (1) looked at the effectiveness of Extracorporeal shock wave therapy for trigger fingers in 19 patients. Here are the simple learning points:
- Each patient was treated with extracorporeal shock wave therapy in three sessions with a 1-week interval.
- There were statistically significant differences with regard to reduction of the pain severity, severity of triggering, and functional impact of triggering before intervention, immediately after intervention, and in 6 and 18 weeks after intervention. However, the effect of extracorporeal shock wave therapy on reducing the severity of triggering immediately after intervention did not yield a statistically significant difference compared to before intervention.
For many, the main benefit of extracorporeal shock wave therapy is that it is not a cortisone injection.
Limited results from Extracorporeal shock wave therapy but it can be an option to cortisone
In this study published in The Journal of Hand Surgery, European Volume (2) researchers examined and compared the effectiveness of extracorporeal shock wave therapy and corticosteroid injection for the management of trigger finger. In this prospective randomized clinical trial, 40 patients with actively correctable trigger fingers were randomly assigned to extracorporeal shock wave therapy or cortisone injection groups. Both groups demonstrated statistically significant improvements. The researchers concluded that extracorporeal shock wave therapy could be a non-invasive option for treating trigger finger, especially for those patients who wish to avoid steroid injections.
For many, the main benefit of extracorporeal shock wave therapy is that it is not a cortisone injection.
Ultrasound for Trigger Finger
A June 2020 study in the journal Orthopedic Reviews (3) noted that of the more well known and offered treatments for Trigger Finger, including “NSAIDs, hand splints, corticosteroid injections, physical therapies, and percutaneous or open surgery,” there is still no evidence that any of these treatments work any better than each other.
We would like to point out that many people do get benefit from these treatments. These are not the people we see at our center. We see people with lingering and chronic symptoms.
In this study, the researchers focused on the comparative effectiveness between external shock wave therapy and ultrasound therapy for trigger finger. In examining the clinical outcomes of previously reported research, these investigators found extracorporeal shock wave therapy can be an effective and safe therapy for the conservative management of trigger finger. It seems to reduce pain and trigger severity and to improve functional level and quality of life. Ultrasound therapy has proven to be useful to prevent the recurrence of trigger finger symptoms.
Treating your trigger finger with a cortisone injection
The idea behind Extracorporeal shock wave therapy and physical therapy is that these treatments can represent an alternative to cortisone injections. Now some people will do very well with steroid / cortisone injection for their trigger finger. A June 2020 study from the Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore (4) suggested that in 52 out of 66 digits (fingers) in patients diagnosed with trigger finger, 79% had resolution of the trigger at one month. One average it took about 9 days for the cortisone to have a beneficial impact.
So while many people do very well with a single or repeated cortisone injections for their trigger finger problems, many will not. It is when the cortisone fails that people seek out a hand surgeon or another treatment option.
Do cortisone injections increase the risk of infection in trigger finger surgery? If you have surgery within 90 days of receiving a cortisone injection, yes it does.
While cortisone injections remain a main and sometimes first treatment option for trigger finger. Surgeons stress caution in administering cortisone in patients who are probably heading for surgery anyway.
Here is an April 2020 study in The Journal of Hand Surgery, (5) that examines the risk for infection in trigger finger release surgery after preoperative corticosteroid injection.
- In this cohort of 2,480 fingers in 1,857 patients undergoing trigger release surgery, 53 (2.1%) developed an infection (41 superficial [1.7%] and 12 deep [0.5%]).
- Before surgery, 1,137 fingers had no corticosteroid injection. These patients developed 1 deep (0.1%) and 17 superficial (1.5%) infections.
- In contrast, 1,343 fingers had been given a corticosteroid injection before surgery. These patients developed 11 deep (0.8%) and 24 superficial (1.8%) infections.
- Average time from corticosteroid injection to trigger release surgery was shorter for fingers that developed a deep infection (63 days) compared with those that developed no infection (183 days).
- The risk for developing a deep infection in patients who were operated on within 90 days of an injection (8 infections in 395 fingers) was increased compared with patients who were operated on greater than 90 days after an injection (3 infections in 948 fingers).
Conclusions: Preoperative corticosteroid injections are associated with a small but statistically significantly increased rate of deep infection after trigger finger release surgery. The risk for postoperative deep infection seems to be time dependent and greater when injections are performed within 90 days of surgery, especially in the 31- to 90-day postinjection period.
Percutaneous Release of the Trigger Finger
A recommended surgery for trigger finger is the Percutaneous Release. Many surgeons do not like this surgery as they prefer an open surgery. In the Percutaneous Release procedure, a needle is used to go into the A1 pulley and shave down the tendon. In open surgery, an incision is made to open up the hand so the surgeon can explore if there are more problems present. Like ligament damage.
A February 2019 study in the journal Cureus (6) suggested that the main drawback to Percutaneous Release is that the trigger finger returns. Here is a summary of this study:
- In this study, patients with trigger fingers who underwent percutaneous release operations were evaluated for short and long-term outcomes.
- The thirty-nine patients (avergae age 54) of this study were evaluated for digital nerve injury (hypoesthesia), recurrence, painful scar, and tendon rupture.
Results in the 39 patients:
- Hypoesthesia (numbness) was most frequently seen at the first and fourth fingers.
- At the end of the first year, one patient developed tendon rupture (fourth finger).
- Recurrences were seen at the end of the first (in 5 patients) and third (in 9 patients) years. Recurrence was mostly seen in the fourth finger, followed by the third finger. Painful scars were observed in two patients.
Conclusion: Percutaneous release is a blindly performed intervention and the emergence of unexpected complications should not be forgotten.
In other words, this can be a very effective treatment for some, not for everyone and there are complications.
Fixing the abnormal rubbing of the tendons and inflammation of the tendon and the tendon sheath by addressing ligament damage.
In the treatments above, doctors sought to treat the problems of tenosynovitis with anti-inflammatories which address the symptom, not the cause, and with surgery, which addresses the symptom, not the cause unless it is discovered in exploratory surgery that ligament reconstruction surrounding the A1 pulley is needed. In this section, we will address non-surgical options that address injection therapy to rebuild damaged ligaments and reduce tendon inflammation while strengthening the tendon attachments to the muscles.
At Caring Medical, our option is to fix the finger joints by rebuilding and repairing damaged tissue with regenerative injections. We can accomplish this with Prolotherapy and Platelet Rich Plasma Injections used together.
- Prolotherapy is an injection technique that uses a simple sugar, dextrose, and in some cases, it is combined with Platelet Rich Plasma Therapy (blood platelets) to address damage and micro-tearing of the ligaments and tendons of the finger joints. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction.
The localized inflammation causes healing cells to arrive at the injured area and lay down new tissue, repairing ligaments, and rebuilding soft tissue. As the ligaments tighten and the soft tissues heal, the finger joints function more normally rather than subluxing and moving out of place, the pain and swelling go away the trigger finger symptoms have been addressed.
- Nature’s way is for chondrocytes (healing and rebuilding cells in our body) to repair the damage. Our therapies can assist in this process and accelerate healing.
- During this healing, the body produces its own specialized inflammatory process that acts as a protective barrier to protect the new cartilage that is being built.
- Once the repair is complete, our body shuts down the inflammation. The inflammation is no longer needed.
Treatment explanation with Danielle R. Steilen-Matias, MMS, PA-C. Release and repair without surgery
This video is a summary of how we treat trigger finger and trigger thumb. A summary transcript with explanatory notes is below:
- Trigger finger is a condition that often causes locking of any finger of the hand. Most commonly trigger finger affects the ring finger and the thumb. It is also called Stenosing Tenosynovitis but obviously, it is much easier to call it trigger finger.
- What happens in this condition is the tendons that allow us to move our hands and fingers get stuck or trapped within the protective sheath or the tunnel that they have to travel through in order for us to be able to move our fingers freely.
- A lot of times trigger finger might develop just from simple overuse.
- Typically a patient with trigger finger would get a recommendation for a steroid shot to decrease the inflammation of the tendon and the tendon sheath.
- The goal of the steroid shot is to and allow the tendons and fingers to get unstuck and to move freely – while that sounds like a good idea the reality is an increased risk of tendon rupture which is why people are limited to the number of steroid shot that they could get each year.
- A lot of people with trigger finger may undergo a steroid shot only to find that these are short-term treatments and their symptoms come back a short time later. A second steroid shot may be recommended and the same results occur… possible short-term relief, then a returning and perhaps worsening problem.
Treatments at Caring Medical
- We may offer a Hydrodissection procedure along with Prolotherapy.
- In hydrodissection, we are looking to treat the tendon entrapment. It is a quick, straightforward process, often with instant results for the patient. (Not all patients respond in this way). First, the practitioner uses ultrasound to identify the tendons or nerves being entrapped. Next, a natural solution, non-steroid is injected around the tendon and nerve to begin a repair to damage and mechanically release it from the surrounding tissue, fascia, or adjacent structures.
- In trigger finger, this involves is using a NON-steroid injection into the inflamed tendon sheath. This is to help draw out swelling and “unstick,” any adhesions that might be impeding the natural movement of the fingers. It allows that tendon to move more freely through that tunnel. Prolotherapy may be warranted in these cases because many patients do not simply have trigger finger as a problem in isolation. They may be suffering from finger osteoarthritis or loose wobbly fingers and thumbs. In some patients, if you follow the path of the problem tendon you will find co-existing problems of finger instability and wear and tear damage.
- By giving the hydrodissection procedure, we can free up and release the tendon trapped in the tunnel, and then look at Prolotherapy to strengthen any injury in these fingers those procedures work really well together to get the trigger finger to resolve.
Treatment video: The treatment begins at 1:08. In this video, the problems of the fingers and thumbs are addressed. Ross Hauser, MD provides narration during the treatment
At 1:08 of the video: Treatment of the thumb
At 1:42 of the video the injections across the hands of the metacarpophalangeal joint (A1 pulley area).
In 2010 we published research in the Journal of Prolotherapy (7) on the effectiveness of Prolotherapy in various finger problems:
- Forty patients, who had been in pain an average of 55 months (4.6 years), were treated quarterly with Prolotherapy. Patients were contacted an average of 18 months following their last Prolotherapy session and asked questions regarding their levels of pain and stiffness before and after their last Prolotherapy treatment.
- In these 40 patients,
- 98% had improvements in their pain.
- Eighty-two percent had 50% or more pain relief.
- Prolotherapy caused a statistically significant decline in patients’ pain and stiffness.
- Prolotherapy helped all but one patient on pain medications reduce the amount of medications taken. All 40 patients have recommended Prolotherapy to someone.
The use of Platelet Rich Plasma therapy for trigger finger
Like Prolotherapy, Platelet Rich Plasma injections are regenerative in nature, providing stability, tissue repair, and pain relief. The PRP injections are often given with Prolotherapy injections to provide a whole joint treatment.
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into the areas impacting your trigger fingers and thumb.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.
- In much of the research surrounding PRP treatments you will see, single injections given and then monitored for months. This is not the way we perform these treatments. In our 27+ years of clinical experience, we have noted that degenerative damage requires a more comprehensive approach. Even so, improvements in single-shot treatments have been noted in the medical literature.
We have used Platelet Rich Plasma for many disorders and again, we want to stress this aspect, it is not a treatment that we consider “stand alone.” We combine this treatment with Prolotherapy in an effort to maximize the benefit and long-term repair of the problems that is causing the patient’s trigger finger.
Researchers are anxious to demonstrate the same effectiveness that many clinicians have reported empirical (the observation of improved symptoms in their patients). In November 2020 in the medical journal Trials (8) announced such research.
Here is what they wrote:
“The initial treatment (of trigger finger) is generally a local corticosteroid injection around the first annular (A1) pulley. However, it is not unusual that surgical release of the A1 pulley is required. Moreover, adverse events after local corticosteroid injection or operative treatment may occur. Platelet-rich plasma (PRP) has been shown to be safe and to reduce symptoms in different tendon pathologies, such as De Quervain’s disease.”
The researchers point out that the effects of PRP on trigger finger have not been studied or published and the aim of this new study is to compare and examine PRP to corticosteroid injection in treating trigger finger. The secondary outcome is to assess the safety and efficacy of PRP in comparison to placebo. “The results of the trial will indicate if PRP is appropriate for the treatment of trigger finger.”
If you have questions about your finger problems, get help and information from our Caring Medical Staff
1 Vahdatpour B, Momeni F, Tahmasebi A, Taheri P. The Effect of Extracorporeal Shock Wave Therapy in the Treatment of Patients with Trigger Finger. Open Access J Sports Med. 2020;11:85-91. Published 2020 Mar 9. doi:10.2147/OAJSM.S232727 [Google Scholar]
2 Yildirim P, Gultekin A, Yildirim A, Karahan AY, Tok F. Extracorporeal shock wave therapy versus corticosteroid injection in the treatment of trigger finger: a randomized controlled study. J Hand Surg Eur Vol. 2016;41(9):977-983. doi:10.1177/1753193415622733 [Google Scholar]
3 Ferrara PE, Codazza S, Maccauro G, Zirio G, Ferriero G, Ronconi G. Physical therapies for the conservative treatment of the trigger finger: a narrative review. Orthopedic Reviews. 2020 Jun 29;12(Suppl 1). [Google Scholar]
4 Yak RS, Lundin AC, Tay PH, Chong AK, Sebastin SJ. Time to Resolution of Triggering after Steroid Injection for First Presentation Trigger Digits. J Hand Surg Asian Pac Vol. 2020;25(2):214-218. doi:10.1142/S2424835520500253 [Google Scholar]
5 Matzon JL, Lebowitz C, Graham JG, Lucenti L, Lutsky KF, Beredjiklian PK. Risk of Infection in Trigger Finger Release Surgery Following Corticosteroid Injection. J Hand Surg Am. 2020;45(4):310-316. doi:10.1016/j.jhsa.2020.01.007 [Google Scholar]
6 Aksoy A, Sir E. Complications of Percutaneous Release of the Trigger Finger. Cureus. 2019;11(2):e4132. Published 2019 Feb 25. doi:10.7759/cureus.4132 [Google Scholar]
7 Hauser R, Baird NM, Cukla JJ. A retrospective observational study on Hackett-Hemwall dextrose prolotherapy for unresolved hand and finger pain at an outpatient charity clinic in rural Illinois. Journal of Prolotherapy. 2010;2(4):480-6. [Google Scholar]
8 Aspinen S, Nordback PH, Anttila T, Stjernberg-Salmela S, Ryhänen J, Kosola J. Platelet-rich plasma versus corticosteroid injection for treatment of trigger finger: study protocol for a prospective randomized triple-blind placebo-controlled trial. Trials. 2020 Dec;21(1):1-9. [Google Scholar]