Trigger Finger Rehabilitation Protocol

This protocol outlines a physical therapy rehabilitation program for trigger finger (stenosing tenosynovitis) of the wrist and hand. It is intended to guide treatment and should be individualized based on patient presentation, pain levels, and progress. The protocol assumes the patient has already been diagnosed by a physician and any necessary medical interventions (e.g., corticosteroid injection) have been performed, or are planned in conjunction with this rehabilitation program.

Pathophysiology

Trigger finger, also known as stenosing tenosynovitis, is a condition that affects the tendons in the hand. Specifically, it involves thickening of the A1 pulley, a ligamentous band at the base of the affected finger or thumb, which restricts the smooth gliding of the flexor tendons. This restriction causes the tendon to catch or "trigger" as it attempts to pass through the narrowed pulley. Repeated irritation can lead to inflammation, fibrosis, and nodule formation within the tendon, exacerbating the problem. Common causes include repetitive hand movements, forceful gripping, and underlying conditions such as diabetes and rheumatoid arthritis.

Special Tests

• Palpation: Palpate the A1 pulley region at the metacarpophalangeal (MCP) joint for tenderness and nodule presence.
• Active Range of Motion (AROM): Assess for the presence of triggering or catching during active flexion and extension of the affected digit. Note the degree of motion at which triggering occurs.
• Passive Range of Motion (PROM): Assess for pain-free PROM of the affected digit. PROM often reveals less triggering than AROM.
• Grip Strength: Measure grip strength using a dynamometer to establish a baseline.
• Finkelstein's Test: While primarily for De Quervain's tenosynovitis, can help rule out other diagnoses involving the wrist and thumb tendons.

Phase I: Protection and Pain Reduction (Approximately 1-3 Weeks)

Goals: Reduce pain and inflammation, protect the affected tendon, and prevent further irritation.

• Activity Modification: Identify and modify activities that exacerbate symptoms. This may involve avoiding repetitive gripping, using adaptive tools, or modifying work ergonomics. Educate the patient on proper hand and wrist mechanics.
• Splinting: Fabrication or provision of a custom or pre-fabricated splint to immobilize the MCP joint in slight extension (typically 0-15 degrees). The splint is worn during the day and/or night to prevent triggering and promote tendon healing. May use a custom-molded oval-8 finger splint.
• Modalities:
  • Ice: Apply ice packs to the affected area for 15-20 minutes, several times a day, to reduce pain and inflammation.
  • Ultrasound: Therapeutic ultrasound may be used to promote tissue healing and reduce inflammation. Continuous or pulsed settings can be used based on the therapist's judgment.
  • Iontophoresis: Corticosteroid medication can be delivered transdermally using iontophoresis to reduce inflammation. Consult with physician orders.
• Gentle Range of Motion (ROM) Exercises:
  • Passive ROM (PROM): Gently move the affected finger through its full range of motion, avoiding forceful movements that could trigger pain. Perform 5-10 repetitions several times a day.
  • Active Assisted ROM (AAROM): Use the unaffected hand to assist with flexion and extension of the affected finger.
• Edema Management: Elevate the hand and perform gentle retrograde massage to reduce swelling. Compression glove may be used.
• Tendon Gliding Exercises: Carefully perform tendon gliding exercises (e.g., hook fist, straight fist, full fist) within a pain-free range to promote tendon excursion and prevent adhesions. Emphasize slow, controlled movements.

Phase II: Loading and Strengthening (Approximately 3-6 Weeks)

Goals: Improve tendon excursion, gradually increase strength and function, and reduce pain with activity.

• Splint Weaning: Gradually decrease splint use based on symptom severity. Start with removing the splint for short periods during the day and progress to wearing it only during activities that tend to provoke symptoms or during sleep.
• Active Range of Motion (AROM) Exercises:
  • Increase repetitions of AROM exercises.
  • Focus on achieving full and pain-free AROM in all planes of motion.
• Strengthening Exercises:
  • Light Resistance Exercises: Begin with light resistance exercises using therapy putty, elastic bands, or light weights. Examples include finger squeezes, finger abduction/adduction, and wrist curls.
  • Gradual Progression: Gradually increase the resistance and repetitions as tolerated.
  • Pain Monitoring: Monitor for pain during and after exercises. If pain increases, reduce the intensity of the exercises.
• Scar Management (if applicable): If surgical release was performed, initiate scar massage and mobilization techniques to prevent adhesions and improve tissue flexibility.
• Proprioceptive Exercises: Implement proprioceptive exercises to improve hand awareness and coordination. Examples include manipulation of small objects, placing pegs in a pegboard, or using a hand exerciser with varying resistance.

Phase III: Return to Function (Approximately 6-8+ Weeks)

Goals: Return to previous level of function, prevent recurrence, and maintain strength and flexibility.

• Activity-Specific Training: Gradually reintroduce activities that were previously limited due to trigger finger symptoms. Modify activities as needed to avoid excessive strain on the affected tendon.
• Progressive Strengthening: Continue with strengthening exercises, gradually increasing the resistance and repetitions as tolerated.
• Endurance Training: Incorporate endurance exercises to improve the ability to perform repetitive tasks for extended periods of time.
• Ergonomic Education: Provide education on proper ergonomics and body mechanics to prevent recurrence. This may include modifying work station setup, using assistive devices, or changing work habits.
• Maintenance Program: Instruct the patient on a home exercise program to maintain strength, flexibility, and tendon excursion. Emphasize the importance of ongoing self-management to prevent recurrence.
• Return-to-Work/Sport/Activity Plan: Develop a gradual return-to-work/sport/activity plan in collaboration with the patient, physician, and employer (if applicable).

Progression Criteria: Progression to each phase depends on pain levels, range of motion, strength, and functional abilities. The patient should be able to perform activities without significant pain or triggering before advancing to the next phase. If symptoms worsen at any point, regress to the previous phase and modify the treatment plan accordingly.

Disclaimer: This protocol is a general guideline and should be modified based on the individual patient's needs and response to treatment. Consultation with a qualified healthcare professional is essential for proper diagnosis and management of trigger finger.