brand logo

Am Fam Physician. 2021;104(6):577-578

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are nonsteroidal anti-inflammatory drug (NSAID) injections as safe and effective as steroid injections for the treatment of trigger finger?

Evidence-Based Answer

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.)

Practice Pointers

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.

Already a member/subscriber?  Log In

Subscribe

From $145
  • Immediate, unlimited access to all AFP content
  • More than 130 CME credits/year
  • AAFP app access
  • Print delivery available
Subscribe

Issue Access

$59.95
  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available

Article Only

$25.95
  • Immediate, unlimited access to just this article
  • CME credits
  • AAFP app access
  • Print delivery available
Purchase Access:  Learn More

Continue Reading

More in AFP

More in Pubmed

Copyright © 2021 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.