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Stenosing tenosynovitis, or trigger finger, most commonly occurs at the third or fourth digit and results from a thickening of the flexor tendon sheath. The sheath, which contains the tendons of the flexor digitorum superficialis and flexor digitorum profundus, normally slides easily through a series of fibrous pulleys that improve the muscles’ angle of pull and aid the tendon sheath in maintaining contact with the phalanx and metacarpal.

When thickening of the sheath occurs, active flexion of the joints in the digits can cause an abnormal gliding of the tendon, usually as it passes through the proximal annular pulley (A1 pulley) at the head of the metacarpal. As the tendon gets stuck within the pulley upon flexion, patients report the finger “lets go” or “snaps” upon attempted finger extension. Advanced cases of trigger finger result in the need to passively extend the affected digit, and can further evolve into a flexion contracture if not treated properly.

Trigger finger is two to six times more common in women than men and often involves the dominant hand. Although its cause remains a mystery in most cases, it occurs more frequently in patients with rheumatoid arthritis and diabetes mellitus than in the general population.

Treatment Triggers

Treatment of trigger finger runs the gamut from conservative measures, including cortisone injections and rehabilitation, to surgical intervention. Emily Altman PT, DPT, CHT, of the Hand Therapy Center at the Hospital for Special Surgery in New York, says on the nonsurgical side, “Patients with trigger finger are typically referred to therapy for splinting, education, and a home exercise program; and we rarely see these nonsurgical patients for more than one visit.”

During that single visit, Altman says, “The patient education component includes activity modification with restrictions on repetitive gripping activities [and] avoiding full composite flexion of the involved digit, along with [an] explanation of splint rationale and instruction in a wearing schedule.”

“Splinting protocols and preferences are surgeon-specific,” Altman continues. “Some prefer nighttime use of hand-based splints that hold the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints of the involved digits and, for comfort, the neighboring digit, in extension. Others prefer a smaller splint that blocks full MP joint flexion but allows PIP and DIP joint flexion, to be worn at all times except during hand hygiene and bathing. There are many splint designs, but the bottom line is that full composite flexion of the involved digit is blocked.”

In terms of therapeutic exercise, two types of range of motion are commonly utilized. Altman explains that these are, “‘hook fist,’ where the DIP and PIP joints are actively flexed while the MP joints are held in extension, and ‘duck fist,’ which entails active MP joint flexion with the DIP and PIP joints maintained in extension.” The benefit to these positions is, she says, “MP, PIP, and DIP joint range of motion is maintained, but full composite digit flexion is avoided.”

While many patients following this protocol recover with conservative treatment, some may still require surgery.

Pulling the Trigger

“About 95% of patients requiring surgical intervention experience relief from the procedure,” says L. Andrew Koman, MD, Professor and Chair, department of orthopedic surgery at Wake Forest University School of Medicine in Winston-Salem, N.C.

Koman, who is president of the American Society for Surgery of the Hand, explains that normally the surgical procedure is “very short and involves just a half-inch incision to expose the tendon; after ensuring that the nerves are protected, the tendon sheath and A1 pulley are cut.”

Koman refers most of his postsurgical patients to therapy for one visit and a home program. “Occasionally, they do require further rehabilitation,” he adds.

At Altman’s facility, patients are typically not splinted postoperatively. “We focus on edema reduction, scar management, tendon gliding exercises, and strategies to prevent PIP joint flexion contractures during the healing process,” she says. “If they are having trouble regaining digit range of motion, have a hypersensitive scar, or have excessive edema, more visits may be requested.”

Other considerations to treatment include patients with certain comorbid conditions who must be handled with care, Koman points out: “If a patient with rheumatoid arthritis presents with trigger finger, this is a signal of an impending rupture and this person would be indicated for rapid surgical intervention.”

The surgical procedure is different for these patients. “You do not cut the pulley,” Koman says, as this may cause a biomechanical imbalance at the MCP joint in patients who are already prone to ulnar deviation. Instead, he says, “You perform a synovectomy, and if this is insufficient, a slip of the flexor digitorum superficialis is cut,” to improve gliding motion.

Consequently, PTs should see patients with RA and trigger finger as a red flag. Whether the patient has come to therapy through direct access or via physician referral, these patients should be referred to a hand surgeon for further management. “A rupture can be a disaster because it is so difficult to reconstruct,” Koman cautions.

In stark contrast to Koman’s other patients, who generally receive one visit with a hand therapist for a home program, “rehabilitation is a crucial element for these patients,” he says.

Certifying Recovery

Rehabilitation for trigger finger is typically provided by PTs or OTs who are certified hand therapists. According to the Hand Therapy Certification Commission, there are 4,819 CHTs in U.S., of which 15% are PTs and 85% are OTs. Mary C. Kasch OTR/L, CHT, FAOTA, executive director of the HTCC in Sacramento, Calif., reports this ratio has remained consistent during the past five to 10 years.

Altman, who serves as the membership chair of the Hand Rehabilitation Section of the APTA agrees: “Membership [in the section] has remained relatively stable over the past four years.”

Having been involved in the evolution of hand therapy for several decades, Kasch says the future looks bright for CHTs. She explains, “Hand injuries are not going away, and we need individuals with specialized training to treat the fragile structures of the hand.”

“Also, patients are showing an increased desire for certified professionals. They want the most value for their healthcare dollar,” she adds. “Likewise, hand surgeons
recognize the value of a CHT and request these professionals,” which, she maintains, has a lot to do with CHTs representing the credential well in medicine.

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Jennifer Bresnick, PT, DPT, is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.

© Copyright 2009 Gannett Healthcare Group