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 ultrasound image we demonstrate an unstable finger joint. An unstable finger joint leads to osteoarthritis and the possible development of trigger finger. This image demonstrates that loose and damaged ligaments (ligament sprains) allow the bones to pull away from each other and can stretch tendons, fascia, and other soft tissue.

In this ultrasound image, we demonstrate an unstable finger joint. An unstable finger joint leads to osteoarthritis and the possible development of trigger finger. This image demonstrates that loose and damaged ligaments (ligament sprains) allow the bones to pull away from each other and can stretch tendons, fascia, and other soft tissue.

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:

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.

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:

Results in the 39 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.

Did Carpal tunnel release surgery cause your trigger finger

 Carpal tunnel release and trigger finger

A paper published in the World journal of plastic surgery (3) examined a noted side-effect of Carpal tunnel release. The development of trigger finger. The authors of the study wrote: “Carpal tunnel release is acknowledged as a predisposing factor for the development of the trigger finger. However, the incidence of new-onset trigger finger after Carpal tunnel release surgery has been inconsistently reported. In this study, we aimed to evaluate the prevalence of Carpal tunnel release as a risk factor of the development of the trigger finger.”

Learning points:

The authors concluded: “The rate of developing a post-Carpal tunnel syndrome trigger finger was remarkable in our study.” In other words, a lot of people got it. The authors of this study suggested that patients under going Carpal tunnel release be advised of the potential of developing trigger finger.

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.

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.

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:

Treatments at Caring Medical

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:

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.

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.”

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your finger problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References

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] 4023

This page was last updated February 2, 2021

 

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