Trigger Finger (Stenosing Tenosynovitis) Jules Houk

Case Study
Colleen is a 56-year old woman who works as a full-time hairdresser and is experiencing a
trigger finger in her index finger at the A1 pulley. When she extends and flexes her R index
finger, she experiences pain and a catch, accompanied with a click. The condition has been
worsening over the past few months and she has been experiencing pain and stiffness at the MCP
joint. The pain and dysfunction has a significant impact on Colleen’s ability to cut hair, and she
often finds herself avoiding use of her index finger when using scissors and other tools that
require grasp or pinch. Colleen enjoys playing cards and cooking. She finds opening jars and
gripping the knife to chop vegetables especially difficult. Colleen’s main goal in therapy is to
minimize pain and incorporate her index finger into work, ADLs, and leisure activities. PMH
includes Type II diabetes and rheumatoid arthritis.
Description of Trigger Finger
Trigger finger is caused by a thickening and stiffness of a tendon sheath (most commonly A1
pulley) which inhibits the gliding of the flexor tendon. This can elicit a feeling of a catch in the
range of motion, an audible click, pain in both flexion and extension, and even immobility of the
joint1. The affected pulley is inflamed and thickened, causing difficulties in movement for the
flexor tendon. Next, a small nodule may form on the flexor tendon, further impacting movement
and causing the feeling of a catch in the ROM1. In the most severe cases, total immobility of the
joint occurs1. Nonsurgical treatments include rest, orthoses, OT exercise program, NSAIDs, and
corticosteroid injections1. If none of the above are effective, tenolysis surgery may be necessary7.

Standard Ideal Alignment Line of segment

Posture
The normal posture of the hand
consists of straight alignment of the
wrist with the forearm. The forearm is
in neutral, with no pronation or
supination12. Additionally, the hand is
not in ulnar or radial deviation12.
Skeletal Skeletal imbalance
imbalance
The initial stage of trigger finger may
not exhibit any skeletal changes. With
progression, the proximal, middle, and
distal phalanges of the affected finger
may be limited in their movement and
unable to fully extend and flex. The
most severe cases may result in
contracture in the midrange of flexion1.
Normal resting posture consists of
slight flexion of the MP joints and
extension of the CMC and IP
joints. This looks like an open web
space and tented fingers.
Radiographic view
The affected finger will likely
present with the proximal, middle,
and distal phalanges in a flexed
position compared to other fingers.
There are not usually any visible
changes to the joints with imaging.
Trigger Finger (Stenosing Tenosynovitis)
The digit’s actions are made possible
by a pulley system of ligaments, which
ensure the tendons avoid bowstringing
and allow movement. The A2 and A4
ligaments are most important to avoid
bowstringing, and A1 is most
commonly involved in trigger finger13.
12
Figure One
Muscle Structures
imbalance
Flexor digitorum profundus m. – the
deepest of the finger flexors, with
origin on the ulna and interosseous
membrane and insertions distal
phalanges of digits 2-510. This is an
extrinsic muscle that contributes to
wrist stability11. The tendons run in the
flexor tendon sheath along with flexor
digitorum superficialis and is often
thickened over time with trigger finger.
This thickening leads to loss of
elasticity of the tendon and possible
shortening.
Flexor digitorum superficialis m. –
superficial to FDP, FDS has its origin
on the radius and humerus and
insertion on the lateral aspect of the
middle phalanges of digits 2-510. Near
the insertion these tendons run with the
FDP in the flexor sheath, which are
often inflamed in the affected digit.
This inflammation most often affects
the A1 pulley.
Jules Houk
Figure Two17
Progression
Initially, there is unlikely to be
adaptive shortening of muscles
because, although it may be more
difficult or uncomfortable, the
client likely has full ROM in the
affected finger. As trigger finger
progresses, the client may lose
AROM and only be able to
passively move at the joint and
eventually may lead to a
contracture of the finger joints,
which results in significant
shortening of the flexors3.
Adaptive shortening
In the later stages of the disease,
flexor digitorum profundus and
flexor digitorum superficialis will
shorten as the resting position of
the finger will be significantly
flexed. These tendons are in the
flexor sheath and are at risk for
developing a nodule with
Trigger Finger (Stenosing Tenosynovitis) Jules Houk

Extensor digitorum m. – originates continued friction, which will

on the lateral epicondyle and the further limit movement through the
muscle belly runs along the posterior A1 pulley12.
forearm before inserting on the middle
and distal phalanges of digits 2-510. It is As these muscles shorten, extensor
a major support of the dorsal aspect of digitorum will lengthen. If the
the wrist and produces extension of trigger finger is present in the
digits 2-511. index finger, extensor indicis will
lengthen as well.
Extensor indicis m. – a narrow muscle
that originates on the distal ulna and
inserts on the index finger10. Its action
is to extend the index finger and to a
lesser degree, the wrist.

Compensation
When performing grasping motions, Colleen avoids involvement of her index finger of her right
hand and holds it in a midrange of flexion. Although impossible in works tasks of cutting hair,
Colleen does use her nondominant hand more than her dominant to avoid pain in her index finger
in actions like reaching, grasping, and pinching.
Occupations
Colleen’s most significantly impacted occupation is her ability to use tools like scissors and
combs at work. When using scissors, she avoids use of her index finger, but finds that she is
often less precise and fatigues more quickly using her other fingers. Additionally, Colleen
struggles with the coordination of bimanual tasks like blow drying hair and has significantly
impaired control without use of her R index finger. By the end of the day, Colleen is
experiencing significant pain in her trigger finger. At home, Colleen struggles to open jars, safely
grasp a knife to chop vegetables, and hold the handle of mugs.
Assessments
Postural screen Impairment based Performance based Self-report
Quinnell Grading A dynamometer The Functional DASH measures
system assesses the measures power Dexterity Test (FDT) level of disability of
severity of trigger gross grasp is used in people with the upper extremity.
finger based on strength in pounds various disorders of the It includes questions
posture and or kilograms and upper limb. The client about symptoms,
movement. 0 indicates can be used in must use one hand to physical function,
normal movement, 1 people with trigger turn over all 16 pegs on and social
uneven movement, 2 finger when a peg board. This functioning. This is
actively correctable compared to the measures the ability to scored from 0-100
joint locking, 3 unaffected hand supinate and use a with 0 representing
passively correctable and normative three-jaw chuck grip the greatest level of
Trigger Finger (Stenosing Tenosynovitis) Jules Houk

joint locking, 4 fixed values15. pattern15. disability15.

deformity15.
Goniometry Numerical Pain
measures active Rating Scale asks
Normal resting and passive ROM the patient to self-
posture of the hand of joints12. report pain on a scale
includes the wrist in Measurement of from one to ten. This
slight extension with wrist, CMC, MCP, is useful to track
no pronation or and IP joints are recovery and
supination of the useful information improvement15.
forearm12. There in assessment of
should be slight trigger finger.
flexion of the MP
joints and extension of Semmes
the CMC and IP Weinstein
joints. This looks like Monofilament
an open web space Test measures the
and tented fingers. sensation of skin
Trigger finger may with different
present with thicknesses of
abnormalities with monofilaments.
MP, CMC, and IP This can assess for
joints of the affected any loss of
finger. sensation in the
affected digit.

Intervention Plan

Type of Deficits/imbalance Description

intervention addressed

Therapeutic Addresses limited tendon Complete five repetitions of passive or

procedure gliding at site of impacted
(tendon glide): annular ligament. Movement
Passive or improves synovial fluid
active straight movement and helps maintain
fist flexion optimal tendon excursion17.
This targets tendon excursion at
the PIP and MCP joint.
active straight fist flexion. This should be
included in the HEP three times per
day12. Select active or passive depending
on the stage of the client. If client is
unable to move through the full ROM
actively, do passive instead. If there is
popping with active ROM, switch to
passive12.

Therapeutic Addresses limited tendon glide Complete five repetitions of passive or

Trigger Finger (Stenosing Tenosynovitis)
procedure at site of impacted annular
(tendon glide): ligament. Movement improves
Passive or synovial fluid movement and
active full fist helps maintain optimal tendon
flexion excursion17. This targets
excursion of flexor digitorum
profundus and flexor digitorum
superficialis tendons as it is a
gross movement of all the
digits.
Therapeutic Addresses limited tendon glide
procedure at site of impacted annular
(tendon glide): ligament. Movement improves
Passive or synovial fluid movement and
active hook fist helps maintain optimal tendon
flexion excursion17. This exercise
isolates the PIP and DIP joints
from the MCP.
Figure Three18
Type of Deficits/Imbalances Description
Intervention Addressed
Jules Houk
active full fist flexion. This should also
be included in the HEP plan, with three
sets completed each day12. If client is
unable to move through the full ROM
actively, do passive instead. If there is
popping with active ROM, switch to
passive12.
Complete five repetitions of passive or
active hook fist flexion. This should be
included in the HEP plan, with three sets
completed each day12. This exercise can
be completed while wearing the MP
orthotic. If client is unable to move
through the full ROM actively, do
passive instead. If there is popping with
active ROM, switch to passive12.
Trigger Finger (Stenosing Tenosynovitis) Jules Houk

Therapeutic Reduces tendon gliding
procedure and therefore friction on
(orthoses): MP the affected annular
orthotic in 0-15 ligament12. This also
degrees of provides a gentle stretch
extension to the finger flexors,
which may be shortened
depending on stage of
disease.
Orthotic blocks the MP joint of the affected
finger, keeping it between 0 and 15 degrees
of extension. This prevents flexion of the
finger at the MP joint and therefore reduces
the friction on the flexor tendons. The MP
orthosis should be worn during the day for 6-
10 weeks for maximum efficacy12. Remove
for therapy and HEP. If joint locking persists
after 10 weeks, continue to wear the orthoses
only at night. There are prefabricated and
custom-made options.

Figure Four14
Figure Five15
Therapeutic Strengthening for extensor Wrap a rubber band around the tips of all
procedure digitorum and extensor five digits. Stretch the fingers into extension
(strengthen): indicis, which weakens as then return to start for one rep. Complete five
Finger spread the extensors lengthen. to ten repetitions three times per day.
with rubber band

Figure Six19
Therapeutic Strengthening for extensor Bring affected finger and thumb together in
procedure digitorum and extensor opposition. Then, extend all digits to end
(strengthen): indicis, which weakens as range for one repetition. Complete five to ten
“OK” symbol to the extensors lengthen. repetitions three times per day.
extension
Therapeutic This stretches the tight Lay hand palm side down on a tabletop.
procedure flexor muscles including Grasp digits with other hand and slowly
(muscle stretch): flexor digitorum extend them back to end range of extension
Passive digit profundus and flexor without pain. Hold for ten seconds.Complete
extension digitorum superficialis. five repetitions three times per day.
Occupation This intervention stretches Using a large pair of scissors, have client
Trigger Finger (Stenosing Tenosynovitis)
based tight flexors (flexor
intervention: digitorum profundus and
Scissor-use flexor digitorum
superficialis) through use
of an important work skill
for the client.
Occupation This intervention requires
based forming a fist with the
intervention: affected hand and fully
Comb/ hairbrush releasing the fist, which
grasp and release addresses tendon gliding
in the affected hand. This
movement will stimulate
synovial fluid movement
and improves tendon
excursion17.
Occupation This is an occupation the
based client struggles with and
intervention: addresses flexor strength
Screwing and (and can stretch extensors
unscrewing jars depending on size of the
and bottles bottle). With smaller caps,
this strengthens grip.
References
1. Trigger Finger - Trigger Thumb - OrthoInfo - AAOS. (n.d.). Retrieved May 18, 2020,
from
Jules Houk
open blades until end range of extension is
reached. Hold for a few seconds, then flex
fingers to close the scissors. Repeat for five
to ten repetitions.
Have client pick up a comb or hairbrush
from the table using a gross grasp. Have
client brush her hair or hair on a mannequin
head (or therapist) for a few strokes, then
return the brush or comb to the table, being
sure to fully extend the fingers to release.
Repeat for five to ten repetitions.
Instruct the client to open and close jars and
bottles of various sizes with her affected
hand. For jars that are too difficult, instruct
patient on compensatory method of using
palm of hand with fingers in extension to
open jars.
Trigger Finger (Stenosing Tenosynovitis) Jules Houk

https://orthoinfo.aaos.org/en/diseases--conditions/trigger-finger
2. Makkouk, A. H., Oetgen, M. E., Swigart, C. R., & Dodds, S. D. (2008). Trigger finger:
etiology, evaluation,
and treatment. Current Revised Musculoskeletal Medicine, 1(2), 92–96. doi:
10.1107/s0108768107031758/bs5044sup1.ci
3. Patient, R. M. (n.d.). Trigger Finger: Rehab My Patient. Retrieved May 18, 2020, from
https://www.rehabmypatient.com/hand-fingers-thumb/trigger-finger
4. Gorsche, R., Wiley, J. P., Renger, R., Brant, R., Gemer, T. Y., & Sasyniuk, T. M. (1998).
Prevalence

and Incidence of Stenosing Flexor Tenosynovitis (Trigger Finger) in a Meat-Packing

Plant. Journal of Occupational & Environmental Medicine, 40(6), 556–560. doi:

10.1097/00043764-199806000-00008

5. Trigger Finger: Symptoms, Treatments. (n.d.). Retrieved from

https://my.clevelandclinic.org/health/diseases/7080-trigger-finger--trigger-thumb

6. Ryzewicz, M., & Moriatis Wolf, J. (2006). Trigger Digits: Principles, Management, and

Complications. American Society for Surgery of the Hand, 31, 135–146. doi:

10.1107/s0108768107031758/bs5044sup1.ci

7. Linderbaum, S. (2013, July 14). Trigger Thumb Surgery Options. Retrieved from
https://www.braceability.com/blogs/articles/trigger-thumb-surgery-options
8. Attum, B. (n.d.). Trigger Finger. Retrieved from

https://www.orthobullets.com/hand/6027/trigger-finger

9. Moore, K. L., & Dalley, A. F. (1999). Clinically oriented anatomy. Philadelphia:

Lippincott Williams & Wilkins

10. Dadio, G. G., & Nolan, J. A. (2019). Clinical pathways: an occupational therapy

assessment for range of motion & manual muscle strength. Philadelphia: Wolters Kluwer
Trigger Finger (Stenosing Tenosynovitis) Jules Houk

Health.

11. Cooper, C. (2007). Fundamentals of hand therapy: Clinical reasoning and treatment

guidelines for common diagnoses of the upper extremity. St. Louis: Mosby Elsevier.

12. Flexor Pulley System. (n.d.). Retrieved June 18, 2020, from

https://www.orthobullets.com/hand/6004/flexor-pulley-system

13. Langer, D., Maeir, A., Michailevich, M., & Luria, S. (2017). Evaluating Hand

Function in Clients with Trigger Finger. Occupational Therapy International, 2017, 1-8.

doi:10.1155/2017/9539206

14. Tarbhai, K., Hannah, S., Schroeder, H., Glasgow, C., Fleming, J., Tooth, L., . . . Kwon,

H. (2018, August 01). FIGURE 1: Metacarpophalangeal joint blocking splint to treat a

trigger... Retrieved July 25, 2020, from

https://www.researchgate.net/figure/Metacarpophalangeal-joint-blocking-splint-to-treat-
a-trigger-finger-The-splint-allows_fig1_51904470

15. Sample. (n.d.). Retrieved July 25, 2020, from

https://www.liveconferences.com/digital_book/sample.asp?b=65

16. Evans, R. B., Hunter, J. M., & Burkhalter, W. E. (1988). Conservative management

of the trigger finger: A new approach. Journal of Hand Therapy, 1(2), 59-68.

doi:10.1016/s0894-1130(88)80049-8

17. Vrancken, C., Farid, Y., & Matasa, R. (2018). Trigger finger in a hereditary multiple

exostoses disease: A unique case report. European Journal of Plastic Surgery, 42(3), 305-

308. doi:10.1007/s00238-018-1481-5

18. Common Hand Procedures. (n.d.). Retrieved August 04, 2020, from
Trigger Finger (Stenosing Tenosynovitis) Jules Houk

http://www.bostonhand.com/common-hand-procedures/exercise-for-tendon-gliding-and-
finger-range-of-motion/
19. Carpal Tunnel Syndrome Exercises - What You Need to Know. (n.d.). Retrieved August

04, 2020, from https://www.drugs.com/cg/carpal-tunnel-syndrome-exercises.html