Are nonsteroidal anti-inflammatory drug (NSAID) injections as safe and effective as steroid injections for the treatment of trigger finger?
In patients with trigger finger, there is no significant difference in outcomes at 12 to 24 weeks— including resolution of symptoms, recurrence, total active motion, residual pain, patient satisfaction, or adverse events—when comparing treatment with NSAID injections vs. corticosteroid injections.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)
Trigger finger occurs when the motion of the flexor tendon of a digit through the first annular pulley becomes abnormal due to inflammation or swelling. With an estimated general prevalence of 2.6%, trigger finger is more common in women and people in their 40s and 50s. Individuals with arthritis or diabetes mellitus appear to be at increased risk. Conservative treatment options include physical therapy, topical or oral NSAIDs, splinting, and activity modification. Symptoms may also resolve without treatment.2 However, watchful waiting and other conservative measures may not be acceptable for some patients. Invasive treatment with injection or surgery is often reserved for cases that are more severe or do not respond to conservative measures.
Two prior Cochrane reviews focused on this subject.3,4 The first demonstrated that corticosteroid injection was superior to lidocaine injection at four weeks' follow-up3; the second review showed that surgery may have superior long-term outcomes to corticosteroid injection but was associated with more short-term pain.4 Both reviews indicated that their conclusions were based on limited, low-quality data.
The authors of this most recent Cochrane review looked for randomized controlled trials comparing topical, oral, or injected NSAIDs with placebo, corticosteroids, or alternate NSAID treatments (i.e., a different drug or different route of administration).1 Only two studies with a total of 231 patients met inclusion criteria, and each used an injection of an NSAID (12.5 mg of diclofenac in one study [n = 110], 15 mg of ketorolac in the second [n = 121]) compared with injection of triamcinolone. Different doses were used in the two studies. One study permitted use of lidocaine in both arms, whereas the other study did not permit lidocaine use. Both studies used the Quinnell grading system for assessment, a five-point ordinal scale from 0 to 4, in which 0 represents normal joint movement; 1, uneven movement; 2, an actively correctable tendon obstruction; 3, passively correctable; and 4, a fixed deformity. Reassessments were performed at three weeks and 12 weeks after injection in one study and at three, six, 12, and 24 weeks in the other. The first author for one study was also the first author of this Cochrane review; however, assessment of the study was performed by other analysts.
At the end of the observation period, there were no statistical differences between the treatments. Both studies revealed a pattern of greater initial improvement after corticosteroid injection with a later disappearance of differences at follow-up. Adverse events following injection were rare and did not occur more often in either group.
Another study not included in this analysis used various doses of triamcinolone (5, 10, or 20 mg) and demonstrated greater short-term (one week to six months) benefit when higher doses of corticosteroids were used, but this difference was no longer present after nine months.5
The two trials in this analysis were small, and the data were inconclusive, leaving many unresolved questions, including the effect of injection technique, dose, or volume of substance injected, as well as whether combining these treatments would be effective.
Consensus guidelines suggest that splinting, corticosteroid injection, and surgery are all indicated for the treatment of trigger finger based on timing, symptom severity, and previous therapy.6 It remains unclear whether there are any differences between observation and injection in long-term outcomes. Although there is some evidence that NSAID injection may be an option for patients with trigger finger, shared decision-making regarding treatment options is warranted.
The practice recommendations in this activity are available at http://www.cochrane.org/CD012789.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or the Uniformed Services University of the Health Sciences.