Salim N. J Hand Surg (Eur). 2011. doi: 10.1177/1753193411415343
Researchers in Malaysia have found corticosteroid injection may be more effective treatment of mild trigger fingers than physiotherapy, but physiotherapy may be better in preventing recurrence.
Defining mild trigger fingers as those displaying mild crepitus, uneven finger movements and actively correctable triggering, the study was performed from June 2009 to August 2010 and involved 74 patients — 39 who underwent steroid injection and 35 who underwent physiotherapy.
The researchers performed evaluations at 6 weeks, 3 months and 6 months after treatment, with 3-month success rates — defined as an absence of pain and triggering — of 97.4% in the steroid injection group and 68.6% in the physiotherapy group. The steroid group also reported to have lower pain scores, higher satisfaction rates, stronger grip strength and an earlier recovery to near normal function.
At the 6-month mark, patients who were successfully treated were questioned about recurrence, defined as the presence of pain and triggering. It was found that the patients who received the steroid injections displayed a significant recurrence rate of pain, but not triggering — with the physiotherapy group experiencing no recurrence of pain or triggering.
The authors hypothesized this may be because the patients were able to institute self-treatment of physiotherapy when they noticed symptoms developing.
“We conclude that corticosteroid injection has a better outcome compared to physiotherapy in the treatment of mild trigger fingers, but physiotherapy may have a role in prevention of recurrence,” the authors wrote.
The finding that corticosteroids provide greater relief than physiotherapy in treatment of trigger fingers, or stenosing tenosynovitis, is not surprising. What is surprising is that physiotherapy has as a high a success rate as 68.6%. What is also surprising is the 97.4% success rate after injection which is much greater than the previous literature would suggest.
There are several issues that arise. Is this a prospective, randomized study where co-morbidity biases are eliminated. Also, although they have defined success as "significant reduction" in pain and triggering, what is "significant" and did the patients have return of a full range of motion. A fixed flexion deformity is a well known occurrence, both in stenosing and non-stenosing tenosynovitis. Was this eliminated? Also, although this is a 6-month study, the authors report the results at 3 months. It is well known that initial success in treating stenosing tenosynovitis may not be long lasting.
A further issue in this time of increasing medical expenditures is the cost of the treatment. One of the virtues of the injection, despite the discomfort, is the fact that it is a one-time visit that must be less costly than therapy.
Although it is admirable to consider alternative treatment for this common problem, physiotherapy is not only less successful but undoubtedly more of an inconvenience and more costly. I would still urge treating physicians to offer a corticosteroid injection as the procedure of choice for patients with stenosing (and non-stenosing) tenosynovitis.
— Barry P. Simmons, MD
Brigham & Women’s Hospital