This document outlines the physiotherapy management of trigger finger. It begins with an introduction defining trigger finger and epidemiology. It then discusses the pathophysiology, etiology, clinical presentation, diagnosis, and outcome measures. It describes the conservative management including medical, physiotherapy, activity modification, splinting and modalities. Surgical management and post-surgical management are also covered. It concludes that while corticosteroid injection and surgery are evidence-based treatments, more research is needed on physiotherapy management.

1. PHYSIOTHERAPY MANAGEMENT OF TRIGGER FINGER
PRESENTED
BY
OLUWADAMILARE JOSHUA AKINWANDE (PT)
IN
PHYSIOTHERAPY DEPARTMENT
AT
STATE HOSPITAL, ABEOKUTA

2. OUTLINES
• INTRODUCTION
• EPIDEMIOLOGY
• PATHOPHYSIOLOGY
• ETIOLOGY
• CLINICAL PRESENTATION
• DIFFERENTIAL DIAGNOSIS
• EXAMINATION AND DIAGNOSIS
• OUTCOME MEASURES
• MANAGEMENTS
• CONCLUSION
• REFERENCES

3. INTRODUCTION
Trigger finger is a condition where abnormal gliding of the flexor tendons within
their flexor sheath results in snagging or locking of the affected digit in flexion or
occasionally extension (British Society for Surgery of the Hand Evidence for
Surgical Treatment [BEST], 2016).
Trigger finger is also referred to as:
• Trigger digit
• Stenosing tenosynovitis
• Stenosing flexor tenosynovitis.

4. EPIDEMIOLOGY
Trigger finger occurs up to six times more frequently in women than men and the
onset is usually in the middle fifth to sixth decades of life. The lifetime risk of
developing trigger finger is between 2% and 3% but increases to up to 10% in
diabetics (Makkouk, Oetgen, Swigart & Dodds, 2008).

5. PATHOPHYSIOLOGY
Histologically, the A1 pulley may demonstrate fibrocartilagenous metaplasia and
hypertrophy, increased glycosaminoglycan, degenerative changes and proliferation
of fibrous tissue (Sampson et al 1991). These changes can result in the wall of the
A1 pulley becoming three times thicker than normal (Ryzewicz and Wolf 2006). The
thickening of the A1 pulley is most probably responsible for jamming of the flexor
tendons in the entrance to the flexor sheath of the digit (Ryzewicz and Wolf 2006).
Often, trigger finger is referred to as “stenosing tenosynovitis.” However, histologic
studies have revealed that inflammatory changes are not seen in the tenosynovium
consequently making this name a false representation of the actual pathophysiology
of trigger finger (Makkouk et al, 2008).

7. ETIOLOGY
Potential causes of trigger finger have been proposed. Examples of such causes
include:
• Occupational-related causes
• Any activity that requires prolonged forceful finger flexion. For example, carrying
a briefcase etc. (Andreu, Oton, Silvia-Fernandez & Sanz, 2011).
However, the precise etiology remains unclear. It is important to consider that the
cause of the pathological condition is mostly multifactorial in nature (Makkouk et
al, 2008).

8. CLINICAL PRESENTATION
It has a range of clinical presentations. At the onset, patient may present with
painless clicking during movement of the affected finger. This can progress to
painful catching ,commonly, at the metacarpophalangeal or proximal
interphalangeal joints. There can also be stiffness (particularly in the morning) of the
finger and tenderness over the A1 pulley (Makkouk et al, 2008).
There can be slight thickening at the base of the finger and a pain that may radiate to
the palm or the distal part of the finger (Colbourn, Heath, Manary & Pacifico,
2008).
Functional limitations can include limited grip strength and decreased ability to hold
narrow-handle objects which can cause snapping of the involved finger (Valdes,
2012).

10. DIFFERENTIAL DIAGNOSIS
• Dupuytren’s contracture

11. EXAMINATION AND DIAGNOSIS
The examination of a patient presenting with the signs and symptoms of a trigger
finger encompasses:
• Comprehensive history taking which should be cognizant of recent trauma, job-
related repetitive movement, locking or snapping while flexing or extending the
affected finger and relevant past medical history (Makkouk et al, 2008)
• Observing for swelling and locking of the affected finger
• Palpating the A1 pulley region to check for tenderness
• Range of motion assessment to check for loss of motion particularly in extension.
The diagnosis of trigger finger is usually made on the basis of the clinical signs and
symptoms revealed during physical examination (Huisstede, Hoogvliet, Coert &
Fridén, 2014).

12. OUTCOME MEASURES
• Numeric Pain Rating Scale
• DASH Outcome Measure
• Stages of Stenosing Tenosynovitis (SST) Scale where
1= Normal
2= A painful palpable nodule
3= Triggering
4= The proximal interphalangeal (PIP) joint locks into flexion and is unlocked with
active PIP joint extension
5= The PIP joint locks and is unlocked with passive PIP joint extension
6= The PIP joint remains locked in a flexed position.

13. MANAGEMENT
The management of trigger finger is of two categories which are:
• Conservative/Non-operative management which comprises medical management
and physiotherapy management
• Operative management which is basically surgical management.

14. MEDICAL MANAGEMENT
Corticosteroid such as methylprednisolone in form of injection is used in the
management of trigger finger. Some studies have shown that the combination of
corticosteroid injections with lidocaine has more significant effectiveness than
lidocaine alone ((Peters-Veluthamaningal, van der Windt, Winters & Meyboom-de
Jong 2009). However, the long-term efficacy of steroid injection is yet to be
clarified (BEST, 2016).

15. PHYSIOTHERAPY MANAGEMENT
Physiotherapy management of trigger finger can be carried out via:
• Activity modification
• Splinting
• Modalities
• Exercise therapy

16. Activity Modification: This entails the avoidance of activities that result in
triggering or the aggravation of patient’s symptoms. It is presumed that activity
modification may allow the pathologic process to settle (BEST, 2016).

17. Splinting: Many authors believe that splinting can help to alter the biomechanics of
flexor tendons while promoting maximal differential tendon glide. Nevertheless,
authors disagree on which joints to include in the splint and the degree of joint
positioning (Colbourn et al, 2008). It should be noted that splinting yields low
success rates in patients with severe or chronic symptoms (Makkouk et al, 2008).
The two commonly used splints are namely: metacarpophalangeal(MCP) blocking
splint and the distal interphalangeal (DIP) blocking splint.

19. Modalities:
• Heat Therapy: Heat increases blood flow and extensibility of collagen tissues
assisting in resolution of edema, decreasing joint stiffness and pain (Salim,
Abdullah, Sapuan & Haflah, 2012) . Therapeutic heat modalities include wax bath,
therapeutic ultrasound, hot water pack, infra-red radiation and hot pack etc.
• Cryotherapy: This can help to relieve pain and reduce inflammation. Cryotherapy
modalities include cold pack and ice cube massage.
• Contrast Bath: This may help to decrease pain and swelling.
• Massage: It improves tendon function by increasing circulation and tendon
nutrition. It may also help to remodel hypertrophic tendons therefore reducing
tissue bulk at the pulleys (Evans, Hunter & Burkhalter, 1988). Some authors have
advocated that the entire tendon sheath and the adjacent area should be massaged.

20. Exercise Therapy: This can be carried out in form of tendon glide and joint blocking
exercises. In addition, stretching as a form of flexibility exercise after the
application of heat can provide more extensibility with plastic deformation.
The examples of tendon glide exercises are active straight fist exercise, active hook
fist exercise, active full fist exercise, passive full fist exercise and table top exercise.
The examples of joint blocking exercises include PIP flexion exercise and DIP
flexion exercise.

24. A study was carried out by some researchers (Salim et al., 2012) to know the
effectiveness of Physiotherapy in the management of mild trigger finger (described
as painful and triggering). The therapy regimen consisted of ten sessions during
which wax therapy, ultrasound, muscle stretching exercises and massage were
collectively made use of to treat the condition. The authors quoted an overall
success rate, defined as absence of pain and triggering, of 68.6% at 3 months. At 6
months, according to the authors, there was no recurrence of symptoms in the
patients (BEST, 2016). However, the results of this study are compromised by the
lack of details regarding the treatments and the fact that multiple modalities are
used rather than just one (BEST, 2016).

25. SURGICAL MANAGEMENT
This is usually indicated when conservative management has failed to improve
symptoms, when the symptoms are very severe and recurrent despite rigorous
conservative management or the patient opted for operative management.
It involves the surgical division or partial resection of A1 pulley so as to reduce the
symptoms of trigger finger (BEST, 2016). There are two major techniques through
which the surgical management can be achieved namely :
• Percutaneous release
• Open release (BEST, 2016).

26. POST-SURGICAL MANAGEMENT
The essence of this management is to return patient to full function by increasing
range of motion, preventing edema and scar adhesions after undergoing surgery
(BEST, 2016). This management (about 10-14 days after surgery, when the sutures
are removed) can be carried out by educating patient to :
• Elevate the hand above the heart level so as to prevent edema
• Move the finger to prevent scar adhesions
• Avoid heavy lifting or forceful activities until 2-4 weeks post-surgery
• Undergo physiotherapy if necessary/needed (BEST, 2016).

27. CONCLUSION
According to a study (Huisstede et al, 2014) aimed at achieving consensus on a
multidisciplinary treatment guideline for trigger finger, splinting was regarded as an
evidenced-based treatment of managing trigger finger conservatively.
According to a systematic review study (BEST, 2016) carried out to determine
evidence-based management of adult trigger finger, there is a paucity of quality
evidence in the English literature currently supporting physiotherapy management
as an effective means of treating trigger finger conservatively.
The two aforementioned studies have revealed corticosteroid injection and surgical
techniques as evidence-based managements of trigger finger.

28. REFERENCES
• Andreu, J. L., Oton, T., Silvia-Fernandez, L., & Sanz, J. (2011). Hand pain other than
carpal tunnel syndrome (CTS): The role of occupational factors. Best Practice and
Research Clinical Rheumatology, 25, 31–42.
• British Society for Surgery of the Hand Evidence for Surgical Treatment. (2016).
Evidence based management of adult trigger digits. Retrieved from
https://www.bssh.ac.uk
• Colbourn, J., Heath, N., Manary, S., & Pacifico, D. (2008). Effectiveness of splinting
for the treatment of trigger finger. J Hand Ther, 21, 336–43.
• Evans, B., Hunter, J., & Burkhalter, W. (1988). Conservative management of the
trigger finger: A new approach. J Hand Therapy, 2, 59-68.
• Huisstede, B. M. A., Hoogvliet, P., Coert, J. H., Fridén, J. (2014). Multidisciplinary
consensus guideline for managing trigger finger: Results from the European
Handguide Study. Phys Ther, 94, 1421–1433.

29. • Makkouk, A. L., Oetgen, M. E., Swigart, C. R., & Dodds, S. D. (2008). Trigger finger:
Etiology, evaluation and treatment. Curr Rev Musculoskelet Med, 2, 92–6.
• Peters-Veluthamaningal, C., van der Windt, D. A., Winters, J. C., & Meyboom-de Jong,
B. (2009). Corticosteroid injection for trigger finger in adults. Cochrane Database Syst
Rev, (1), CD005617.
• Ryzewicz, M., & Wolf, J. (2006). Trigger digits: Principles, management and
complications. J Hand Surg Am, 31, 135–46.
• Salim, N., Abdullah, S., Sapuan, J., & Haflah, N. H. (2012). Outcome of corticosteroid
injection versus physiotherapy in the treatment of mild trigger fingers. J Hand Surg
Eur, 37, 27-34.
• Valdes, K. (2012). A retrospective review to determine the long-term efficacy of
orthotic devices for trigger finger. J Hand Ther, 25, 89-96.