Am Fam Physician. 2009 Sep 1;80(5):454-455.
A 40-year-old man presents with trigger finger that is being treated with pain medication and splinting. He would like to try steroid injections for symptom relief because the current treatment plan is not helping as much as he would prefer.
Are corticosteroid injections an effective treatment option for digital flexor tenosynovitis (trigger finger) in adults?
Based on limited evidence, corticosteroid injection combined with lidocaine (Xylocaine) was more effective than lidocaine alone for the treatment of trigger finger in adults.1 Compared with those who received lidocaine alone, 38 percent more of the patients who received corticosteroid injection with lidocaine showed complete resolution of symptoms, or sufficient improvement to discontinue treatment, within four weeks (number needed to treat = 3).
Trigger finger occurs when thickening or nodule formation prevents a flexor tendon from gliding within its sheath, catching at the site of the first annular pulley. Patients with this condition may present with palmer pain and difficulty with finger flexion and extension, with a locking, popping sensation as the tendon slides through the tight area. Trigger finger occurs more commonly in persons with repetitive use injuries, diabetes mellitus, rheumatoid arthritis, carpal tunnel syndrome, Dupuytren disease, amyloidosis, hypothyroidism, mucopolysaccharide storage disorders, and congestive heart failure. Diagnosis is made through history and examination. Treatment options include relative rest, pain medications, splinting, steroid injection, and operative therapy.
In this Cochrane review1, there were no articles that directly compared steroid injection with surgical treatment. However, two referenced articles, which were excluded from the review, reported cure rates of 89 to 97 percent for surgery2 and 60 to 90 percent for steroid injection.3 A separate article compared splinting with steroid injection and found cure rates of 70 and 82 percent, respectively.4 There were no reports of serious complications with injection therapy.
Although direct comparisons of the different treatment modalities for trigger finger are needed, there is a role for steroid injection, especially in the patient who is not responding to conservative measures of pain medications and splinting. Guidelines from the American College of Occupational and Environmental Medicine recommend surgical referral only after patient education and treatments (including splinting and injection) have failed.5 Steroid injection is inexpensive, easily performed, and less invasive than surgery. Information on injection technique for the treatment of trigger finger can be found in a previous article from American Family Physician.6
Background: Trigger finger is a disease of the tendons of the hand leading to triggering (locking) of affected fingers, dysfunction, and pain. Available treatments include local injection with corticosteroids, surgery, or splinting.
Objectives: To summarize the evidence on the effectiveness and safety of corticosteroid injections for trigger finger in adults using the following endpoints: treatment success, frequency of triggering or locking, functional status of the affected fingers, and severity of pain of the fingers.
Search Strategy: The databases CENTRAL, DARE, Medline (1966 to November 2007), EMBASE (1956 to November 2007), CINAHL (1982 to November 2007), AMED (1985 to November 2007), and PEDro (a physiotherapy evidence database) were searched.
Selection Criteria: The authors selected randomized and controlled clinical trials evaluating effectiveness and safety of corticosteroid injections for trigger finger in adults.
Data Collection and Analysis: The databases were searched for titles of eligible studies. After screening abstracts of these studies, full text articles of studies that fulfilled the selection criteria were obtained. Data were extracted using a predefined electronic form. The methodologic quality of included trials was assessed by using items from the checklist developed by Jadad and the Delphi list. The authors planned to extract data regarding information on the primary outcome measures: treatment success, frequency of triggering or locking, functional impairment of fingers, and severity of the trigger finger; and the secondary outcome measures: proportion of patients with side effects, types of side effects, and patient satisfaction with injection.
Main Results: Two randomized controlled studies were found that involved 63 participants: 34 were allocated to corticosteroids and lidocaine (Xylocaine), and 29 were allocated to lidocaine alone. Corticosteroid injection with lidocaine was more effective than lidocaine alone on treatment success at four weeks (relative risk = 3.15; 95% confidence interval, 1.34 to 7.40). The number needed to treat to benefit was 3. No adverse events or side effects were reported.
Authors' Conclusions: The effectiveness of local corticosteroid injections was studied in only two small randomized controlled trials of poor methodologic quality. Both studies showed better short-term effects of corticosteroid injection combined with lidocaine compared with lidocaine alone on the treatment success outcome. In one study, the effects of corticosteroid injections lasted up to four months. No adverse effects were observed. The available evidence for the effectiveness of intratendon sheath corticosteroid injection for trigger finger can be graded as a silver level evidence for superiority of corticosteroid injections combined with lidocaine over injections with lidocaine alone.
These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in the Cochrane Library. Their content has, as far as possible, been checked with the authors of the original reviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minor editing changes have been made to the text (http://www.cochrane.org).
REFERENCESshow all references
1. Peters-Veluthamaningal C, van der Windt DA, Winters JC, Meyboom-de Jong B. Corticosteroid injection for trigger finger in adults. Cochrane Database Syst Rev. 2009;(1):CD005617....
2. Turowski GA, Zdankiewicz PD, Thomson JG. The results of surgical treatment of trigger finger. J Hand Surg Am. 1997;22(1):145–149.
3. Moore JS. Flexor tendon entrapment of the digits (trigger finger and trigger thumb). J Occup Environ Med. 2000;42(5):526–545.
4. Patel MR, Bassini L. Trigger fingers and thumb: when to splint, inject, or operate. J Hand Surg Am. 1992;17(1):110–113.
5. Forearm, wrist, and hand complaints. Elk Grove Village, Ill.: American College of Occupational and Environmental Medicine; 2004:34.
6. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Physician. 2003;67(4):745–750.
The Cochrane Abstract is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Dr. Chambers presents a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a critique of the review. The practice recommendations in this activity are available at http://www.cochrane.org/reviews/en/ab005617.html.
The series coordinator for AFP is Clarissa Kripke, MD, Department of Family and Community Medicine, University of California, San Francisco.
Copyright © 2009 by the American Academy of Family Physicians.
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