It’s been a while since my last article. Between the weekly-changing COVID restrictions in my area and major house renovations, I have been delinquent with my life mission of helping others manage and heal their pain and injuries, on their own. But today, I’m back on track. Today, I’ll talk about a peculiar condition known as Trigger Finger.
But first, a little background:
For those who ever engaged in do-it-yourself home renovations such as landscaping, fence building, paver-laying and bathroom and kitchen remodeling you know how much stress it can put on your body. This is my story of how I developed trigger finger for the first time in my life, and serves as a “lessons learned” opportunity for others so that they can be spared the inconveniences of this condition..
For the last 10 years, I would categorize my daily physical activity as “moderate.” I would go the gym and lift free weights (reps over max); do various cardio fitness classes such as the Les Mills classes and Bootcamp; and run 3 miles about 3x/week. My average time in the gym I would say was 60-90 minutes, with about half of that actual exercising. At home, I would be working on my website and producing videos. This did require prolonged sitting, but I would get up every 30 minutes or so to walk around to relieve pressure to my lumbar spine.
Starting the second week of this past July, I started the aforementioned home renovation projects. I basically went straight from moderate activity to short bursts of sustained intense activity, daily for over four weeks. Since I didn’t have any major musculoskeletal impediments other than a chronic right AC (acromioclavicular) joint sprain, I moved freely as though I was in my 20s, which wasn’t such a good idea. The combination of the intense movement patterns my body wasn’t used to, plus my age, took a significant toll after four weeks.
Here are some of the heavy labor activities that I engaged in:
- Carrying heavy lumber from Home Depot and loading into a pickup truck, about 10 trips
- Carrying 50 and 80 pound bags of concrete mix and sand, for my paver project, about 5 trips.
- Used a 2-person auger (about 120 pounds; gasoline powered) to drill several 3’ deep post holes
- Shoveled piles and piles of dirt (pickup truck loads—about 10x)
- Hauled away bulk trash to the dumpster
- Carried 100 clay 12”x12” paver squares (bricks) from a truck to my yard and positioned them carefully
- Used hand tools that required hard gripping and/or twisting including various types of saws, wrenches and screwdrivers
- Used vibrational tools including a miter saw, reciprocating saw, drill, and nail gun
By the third week, I was starting to feel pain at my right AC joint, my left wrist, and both hands especially my right, dominant hand. Thankfully, despite frequent bending at the waist my lower back wasn’t affected. I attributed the AC join pain to aggravation of the old strain (I rate it a Grade 2 or 3 sprain – partial tearing, but intact). What happened is the heavy lifting placed a repetitious load on that unstable joint, causing the acromion and distal clavicle to aggravate surrounding soft tissues, particularly the supraspinatous tendon, and the insertion points of the ligament. My doctor suggested my pain was impingement syndrome—compression of the supraspinatous tendon where it passes below the acromion– which could be occurring, but I’m certain most of the pain is emanating from the joint itself because I can reproduce the pain simply by pressing it with my fingertip. I’ll tell you how I’m treating this in the next article.
I believe my left wrist pain is a Grade 2 strain of the flexor ulnaris tendon where it inserts into the distal ulnar’s styloid process; caused when I lost control of the auger. The auger is a very powerful machine that requires two people to operate (see picture above). Not being familiar with using one, I wasn’t prepared for the powerful torque it generated, and lost control of it, hurting my wrist.
The third problem that I’m dealing with is trigger finger. This is the first time I’ve had it and let me tell you, it’s not very pleasant.
Trigger finger is so named because as you attempt to straighten out your finger after closing your hand, the finger “catches” mid-way, and pain is felt in one or several joint capsules usually on the palmar side. Then, as you power through the restriction the pain increases and a popping/snapping sensation occurs right before it straightens out, just like how a gun trigger offers gradual resistance then suddenly releases at a point. See the short video below of my actual trigger finger taken this morning that explains this.
Trigger finger is a stenosing tenosynovitis disorder. Stenosing means narrowing of a passageway in the body; tenosynovitis refers to inflammation of the tendon and synovium. The synovium is a specialized layer of tissue surrounding the tendon in areas where it rubs against other structures in the body. Synovium secretes synovial fluid, a biological lubricant that helps reduce friction where the tendon moves. Synovium also lines the synovial joints of the body which include the hips, knees, shoulders, elbows, spine and joints of the hands and feet.
There are three, main populations of trigger finger sufferers: young children (up to 8 years old); trigger finger as a comorbidity to a primary disease; and adults experiencing trauma/ stress to the hands, typically in the 40s-50s. It tends to affect women more, and the most common finger is the thumb although it can occur in any finger, and in multiple fingers at the same time.
In children, trigger finger is believed to be due to uneven growth rates of the hand flexor tendons and the ligaments, where the tendon growth outpaces the growth of the ligaments that hold them against the finger bones.
Trigger finger is observed to often occur alongside certain other diseases such as carpal tunnel syndrome, diabetes, hypothyroidism, gout, rheumatoid arthritis, and amyloidosis; each probably having different etiologies involving the dysfunction causing the primary disease. Diabetics seem to be affected by trigger finger at a higher rate than the regular population, and it is uncertain why. With diabetes mellitus, there are high levels of glucose in the blood, and usually high insulin levels. Insulin is considered an anabolic hormone associated with tissue growth, so this may be a possible explanation for the increased incidence of trigger finger in diabetics, if the growth leads to tendon hypertrophy (enlargement).
For the third group, which the rest of this article will address, trigger finger is caused by hypertrophy and inflammation of the finger flexor tendons at the synovial sheath, typically from repetitious hand movements, especially those involving power gripping and vibration, making them chafe against the ligaments that hold them down to the finger bones (phalanges). (Remember, ligaments connect two bones, while tendons connect a muscle to a bone; both are components of all moveable joints). Imagine these ligaments as slips of Scotch tape forming a tunnel over the bone. As the hypertrophied (enlarged) section of the tendon enters the narrow tunnel during extension (straightening out of the finger), it gets stuck in that tunnel momentarily; much like how a big person trying to climb out of a small bathroom window can get stuck before being able to make it through. Then, as the tendon makes it past that entrance, it causes the popping sensation.
Orthopedic specialists identify the tendon-ligament structures involved in hand movement as pulleys. Remember from basic physics, a pulley is one of the simple machines (the others being a lever, plane and gear). This is an appropriate name because the tendons and ligaments accomplish work just like the cables and pulleys used in cranes.
Image courtesy of OrthoBullets.com
The A1 pulley is at the metacarpo-phalangeal joint, commonly called the knuckles. It’s where the proximal phalanx connects to the respective metacarpal bone. This is where trigger finger usually occurs. Those who have it here feel the pain and popping/snapping on the palmar side of the knuckle.
The A2 pulley encircles the proximal phalanx, or first finger bone, from the knuckle.
The A3 pulley is at the PIP, or proximal interphalangeal joint—the first joint from the knuckle connecting the proximal and intermediate phalanges (first and second bones of the finger). This is also a common area of trigger finger.
The A4 pulley encircles the intermediate phalanx (second bone of the finger from the knuckle).
The A5 pulley is at the DIP, or distal interphalangeal joint, the furthest joint of the finger connecting the intermediate and distal phalanges (second and third bones of the finger, from the knuckle). Although triggering can happen here, it is less common.
Since the thumb is comprised of only two phalanges, it has an A1 and A2 pulley only. Trigger finger affecting the thumb almost always occurs at the A1 pulley. Unlike the other fingers, your thumb can move in multiple planes, much like the shoulder joint. It has a unique pulley called the oblique pulley that allows it to touch the pinky, a movement called thumb opposition.
Image courtesy of OrthoBullets.com
In my case, I have trigger finger in the middle and ring fingers of my right hand, mostly in the A1 and A2 pulley, and less in the A3, with the middle finger being more problematic. Pain is most pronounced in the middle of the night and upon waking, then gets better rather quickly in my case, in the first waking hour of the day. This is because as you sleep, there is less movement of the joints and less synovium produced, causing them to be stiffer.
I have the classic symptom where there is locking of those fingers when I move them from the natural, half-open relaxed hand to fully extending the fingers. As I force them past the locked angle, they snap at the A1 and A2 pulleys, then straighten out. It’s momentarily painful, but tolerable. But for some people, it’s a lot worse. All those weeks of sustained power gripping and twisting caused the flexor tendons and synovium to rub excessively against the ligaments holding them in place, causing microtears and initiating the inflammatory response.
TREATMENT FOR TRIGGER FINGER
The medical standard of care for trigger finger is corticosteroid injection below the affected ligament. This quickly knocks down the inflammation, and in some cases, symptomatic improvement happens within seconds. However, some patients report pain following the injection, and slower or no results.
Splinting is sometimes attempted. The idea is that if you immobilize the tendon, inflammation will stop and the tendon will shrink and heal, bringing things back to normal. However, this is not always the case. Sometimes inflammation takes a life of its own, and prolongs long after the injurious event ceases.
If neither corticosteroid injection nor finger splinting fail to correct the problem, surgery is an option. Direct, open surgery and percutaneous (minimal incision, special surgical tools) surgery are the two options, with direct surgery usually having better results. This is where the ligament is cut to provide more room for the tendon to move. This is possible because the adjacent ligament serves as a backup; for example, the A2 can back up A1 if A1 needs to be cut/ split apart. However, as you can imagine such destruction of a functional component means some strength and stability are sacrificed. I’m sure those having this kind of surgery lose some power in their grip.
MY TREATMENT STRATEGY
As I write this article, my trigger fingers have improved about 75%, from their worst presentation. It could be that my connective tissues are in pretty good shape; my healing capacity is strong; my injury was not very severe; or my treatment regimen is helping accelerate healing. Some sufferers don’t see such a quick pace of resolution.
Here is what I’m doing: as I mentioned, the symptoms are most pronounced in the middle of the night (when I get up to use the bathroom) and upon waking. In the middle of the night, I simply don’t move my fingers, and go back to sleep.
In the morning, I run cold water over my hand for 2 minutes, and gently move my fingers. I get the snapping, but it dissipates shortly after. I still feel some stiffness and soreness in my knuckles throughout the day, but no snapping.
I get localized cryotherapy done on my fingers. Cryotherapy is extremely cold air, as in sub-zero, for 3 minutes. The cold not only slows inflammation, it is said to cause a shock to the sensory nerves, which causes the central nervous system to respond by increasing blood flow, fibroblast activity, and nutrients to the area.
Note: the image above is a localized cryotherapy session on my hand, for a previous complaint. The red dot is not red light therapy; it is a laser thermometer the technician uses to measure my skin temperature so that it doesn’t too low (his hand is visible in the picture). Localized cryotherapy can reach temperatures of -30 degrees F.
Lastly, I apply red light therapy. I’m an advocate of this therapeutic technology and have written articles about it. Red light therapy is actually an electromagnetic waveform (600-880 nanometer wavelengths) that appears red to the human eye. It’s not the red you get from shining a light through a red lens; it’s a specific waveform in the electromagnetic spectrum generated from an LED (light-emitting diode). The device I use uses three LEDs, one of which emits a waveform closer to infrared and therefore does not appear to be red as it is invisible. The electromagnetic energy is at a frequency that gets absorbed by cell mitochondria and other structures, which can result in changed oxidative states that lead to cell signaling that initiates reparative processes, such as increased ATP production and increased membrane permeability. This lessens inflammation and stimulates healing.
I anticipate my trigger fingers to fully recover, to pre-injury status. I will continue to do these therapies, as I feel they are partly responsible for my good results.
BOTTOM LINE
Prevention is the best cure: if you know you are going to be using your hands a lot, such as starting on a do-it-yourself project involving power tools and hard gripping, know that this can cause trigger finger. Do what you can to minimize the stress to your hands—take frequent breaks; don’t overdo it/ don’t hold a power grip for more than a few seconds; and rest and stretch your hands often. Don’t rush it. Trigger finger creeps up on you, and by the time you notice it, it is too late. The presentations are different from person to person, depending on age, health, fitness and so on. I am lucky as my condition is resolving; others are not so lucky and wind up getting surgery and permanent percent loss of hand function. So make sure you keep prevention in mind. If you do get it, try the treatment methods for trigger finger described here that have worked for me.
