Lunsford, D., Valdes, K., & Hengy, S. (2017). Conservative management of trigger finger: A systematic review. Journal of Hand Therapy, 32(2), 212-221. https://doi.org/10.1016/j.jht.2017.10.016
The main purpose of the literature review was to determine the efficacy of conservative management of trigger finger (TF) through the use of an orthosis in addition to therapy. The review identified characteristics of orthotic management and evaluated patient-reported outcomes to assess satisfaction. Review of the studies primarily focused on the number and specific joints immobilized, wearing schedule, and complications.
In the Weeds
Seven articles met the inclusion criteria from the literature search: one RCT, four prospective cohort studies, one retrospective cohort study, and one pilot study. Collectively, there were 297 subjects in the studies with a mean age of 63 years old, ranging from 23-80. 63% of the collective participants were female. The distribution of fingers involved included: 34 index, 114 long, 93 ring, 20 small, and 46 thumbs.
Outcome measures used in the studies included: incidence of triggering, Quinnell scale of stages of stenosing tenosynovitis (SST), Modified Quinnell, secondary outcomes of pain and grip, COPM, Quick DASH, pain ratings using Visual Analog Scale or Numeric Pain Rating Scale, and patient success/satisfaction report.
There is some discrepancies in literature regarding the type of orthosis used. Six studies immobilized the MCP joint (metacarpal block orthosis), one study immobilized the PIP joint, one study used both a DIP blocking and MCP joint blocking orthoses, and one study immobilized the DIP joint. A comparison of 2 orthotic designs, MP block orthosis and a DIP block orthosis, identified the MP block as a more effective option.
Another inconsistency in the literature included the number of digits immobilized. Overall it was identified that patients who had multiple digits immobilized had poorer results than those with just a single finger. Although trigger thumbs were excluded in most studies, two studies provided conflicting generalizations. One stated that thumbs had poorest outcomes, whereas the other stated results could be generalized for multiple trigger finger digits as well as thumb involvement.
The wearing schedules provided averaged 6 weeks (day and night), with a range of 3 to 12 weeks. One study had their subjects wear the orthosis only at night for 6 weeks, after identifying patients as non-compliant with full time wear. Exercise programs and orthosis wearing schedule was inconsistent between studies.
Review of conservative treatment of TF with use of orthosis at all times identified an 81% patients success rate with average return to work in 6 weeks. The study with solely night time wear of the orthosis found a 53% success rate. Long term outcomes at one year varied with an identified recurrence of symptoms in 12% of the orthosis group within one year and 13% requiring steroid injection or surgical intervention.
Overall, orthosis use is an effective conservative treatment due to the large effect sizes of the pain rating and the scores of the SST. The studies that evaluated patient reported success rate results ranged between 47% and 93%. From the review’s findings, it is recommended to use the SST scale over the Quinnell due to the level of detail to better classify triggering.
Bringing it home
Orthotic intervention is an appropriate conservative option for individuals who experience TF who are classified in stages 2-6 of SST scale. Based on the findings of the review, full time wear of an orthosis immobilizing the MCP or PIP joint for six weeks is recommended. If triggering symptoms remain after 6 weeks, orthosis wear can be continued for up to 12 weeks.
Inclusion criteria for the literature review was broad and included RCTs, prospective, and retrospective cohort studies due to limited high level evidence. Research in the study did not compare the effectiveness of finger-based orthotic device to a hand based device. Based on these limitations, it is recommended that the therapist uses clinical judgement, patient preference, and evaluation of functional tasks as a way to determine the best orthosis and wear schedule to meet the needs of the patient.
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