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Corticosteroid injections are a good first treatment for stenosing tenosynovitis
Tamara D. Rozental, MD, answers 4 Questions about diagnosing and treating trigger digits.
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Often in a busy clinic, a patient will ask me — almost as an afterthought — about a finger that “gets stuck” or triggers. Stenosing tenosynovitis of a finger(s) represents a common problem in the orthopedic patient population. These patients would prefer to be treated at that visit if possible and not have to go to another physician. For a current, straightforward approach to this problem, I asked Tamara D. Rozental, MD, 4 Questions and share her insight and experience with this common problem.
Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: What is the definition and pathophysiology of trigger finger and who usually develops it?
Tamara D. Rozental, MD: Stenosing tenosynovitis or trigger finger is a common problem in the orthopedic patient population. Most cases are idiopathic, but secondary triggers can occur in patients with diabetes, rheumatoid arthritis, gout and renal disease. Healthy middle-aged women are most commonly involved and the thumb and ring finger are the most frequently affected digits.
Tendon entrapment is due to impingement of the flexor tendon as it passes through a pulley over the metacarpophalangeal joint. The inflammatory changes involve the retinacular sheath and pre-tendinous tissue rather than the tenosynovium itself. Pathologic changes at the level of the A1 pulley include hypertrophy, degeneration and lymphocytic infiltration. Patients can present with pain over the A1 pulley, pain along the flexor tendon, pain with passive stretch and/or locking. The disease can be classified according to the severity of symptoms, ranging from pain and mild crepitus to a locked digit.
Jackson: Should cortisone injections be in the first line of treatment?
Rozental: Activity modification, NSAID medication and splinting are useful in the treatment of mild synovitis. Once symptoms progress, however, they do not provide long-standing relief. Corticosteroid injections are simple to perform in the office setting and have reported success rates ranging from 60% to 90%. In addition, complications such as tendon rupture or infection are rare. As such, corticosteroid injections are an effective first-line treatment for patients presenting with stenosing tenosynovitis.
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Jackson: What factors are predictors of reoccurrence and indications for repeat cortisone injections?
Rozental: There is contradicting evidence regarding predictors of recurrence following corticosteroid injections for trigger digits. Factors previously associated with poor outcome include duration of symptoms greater than 6 months, involvement of multiple digits, and diabetes. Our recent prospective study among 124 trigger digits identified insulin-dependent diabetes mellitus (IDDM), multiple symptomatic digits, younger age and the presence of other tendinopathies of the upper extremities as independent predictors of symptom recurrence. Among these, IDDM was the strongest predictor for poor outcome following injection.
Duration of symptoms and non-insulin dependent diabetes (NIDDM) did not adversely affect outcomes.
In our practice, repeat injections are offered to patients whose symptoms improved but did not completely resolve following injection, as well as patients whose symptoms recurred after a long, disease-free interval. If symptoms return after a second injection, we typically recommend surgical release.
Jackson: When and in whom is surgical release indicated?
Rozental: Surgical release is typically reserved for patients who fail treatment with corticosteroid injections. These include patients who experience no resolution of symptoms, those who present with an early recurrence (within a few weeks after injection) and those who fail multiple injections. Given the high recurrence rate, we also offer surgical release to patients with IDDM presenting with first-time trigger digits. To avoid potential damage to the neurovascular bundles and flexor tendons, we typically perform open A1 pulley releases in the operating room.
For more information:Reference:
- Tamara D. Rozental, MD, can be reached at the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Stoneman 10, Boston, MA 02215; 617-667-2464; e-mail: trozenta@bidmc.harvard.edu.
- Rozental TD, Zurakowski D, Blazar PE. Trigger finger: prognostic indicators of recurrence following corticosteroid injection. J Bone Joint Surg (Am). 2008;90(8):1665-1672.