General Guideline Principles for Flexor Tendon
Entrapment (Tenosynovitis and Trigger Digit)
for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit).

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit) of Hand, Wrist and Forearm Injuries

Flexor tendon entrapment of the digits is a condition that causes the thumb or fingers to snap or lock (with or without pain). The majority of cases are caused by thickening of the digit’s A1 pulley, but other pathogeneses are possible.

Diagnostic Studies of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit)

There are no special tests that are usually administered. X-rays are rarely useful. The threshold for testing for confounding conditions like diabetes, hypothyroidism, and connective tissue disorders should be low in order to avoid other morbidities..

Medications of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit)

For the majority of patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Although the majority of evidence suggests that acetaminophen (or its analogue paracetamol) is marginally less effective than NSAIDs, it may be a viable option for patients who are not candidates for NSAIDs.

There is evidence that NSAIDs are as effective at relieving pain as opioids (including tramadol). less harmful.

1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

   Non-Steroidal Anti-inflammatory Drugs (NSAIDs) is recommended for the treatment of flexor tendon entrapment, whether acute, subacute, or chronic

   Indications – NSAIDs are recommended for the treatment of acute, subacute, or chronic flexor tendon entrapment. Over-the-counter (OTC) medications may be adequate and should be tried first.

   Frequency/Duration: For many patients, using it as needed may be appropriate. Suggestions for

   Discontinuation: Symptom relief, ineffectiveness, or the emergence of adverse effects necessitates discontinuation.

    

2. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

   NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is recommended Misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors should be used concurrently in patients at high risk of gastrointestinal bleeding.

   Indications: Cytoprotective medications should be considered for patients with a high-risk factor profile who also have indications for NSAIDs, especially if longer-term treatment is planned. Patients at risk include those with a history of gastrointestinal bleeding, the elderly, diabetics, and cigarette smokers..

   Frequency/Dose/Duration: Misoprostol, sucralfate, and H2 blockers are all recommended. Dose and frequency are determined by the manufacturer. There are no significant differences in efficacy for preventing gastrointestinal bleeding, according to most experts.

   Indications for Discontinuation: Intolerance, adverse effects, or discontinuation of an NSAID.

    

3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

   Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should have the risks and benefits of NSAID therapy for pain discussed.

    

4. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended Acetaminophen or aspirin as first-line therapy appears to be the least risky in terms of cardiovascular side effects.

      

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended If necessary, non-selective NSAIDs are preferred over COX-2 specific drugs. To reduce the possibility of the NSAID counteracting the beneficial effects of aspirin in patients receiving low-dose aspirin for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.

      

5. Acetaminophen for Treatment of Flexor Tendon Entrapment Pain

   Acetaminophen for Treatment of Flexor Tendon Entrapment Pain is recommended for the treatment of flexor tendon entrapment pain, especially in patients who cannot take NSAIDs.

   Indications: All patients suffering from flexor tendon entrapment pain, whether acute, subacute, chronic, or post-operative.

   Dose/Frequency: According to the manufacturer’s recommendations; may be used as needed. When taken in excess of four grammes per day, there is evidence of hepatic toxicity. Suggestions for

    

6. Opioids of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit)

    

   • Opioids of Hand, Wrist and Forearm Injuries are not recommended for acute, subacute, or chronic flexor tendon entrapment.

      

   • Opioids of Hand, Wrist and Forearm Injuries are recommended for short-term (no more than seven days) use as an adjunctive therapy to more effective treatments for postoperative pain management.

     Indications: For post-operative pain management, a brief prescription of opioids as an adjunct to more effective treatments (particularly NSAIDs and acetaminophen) is frequently required, particularly at night.

     Frequency/Duration: Prescribed as needed during the day, then only at night until completely weaned off.

     Rationale for Recommendation: Because NSAIDs do not provide adequate pain relief for some patients, judicious use of opioids, particularly at night, may be beneficial.

     Opioids are only recommended for short-term, selective use in postoperative patients, with the primary use being at night to achieve postoperative sleep.

      

7. Treatments of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit)

    

   • Glucocorticosteroid Injections

     Glucocorticosteroid Injections is recommended for the treatment of flexor tendon entrapment, whether acute, subacute, or chronic

     Indications – The presence of a triggering digit or symptoms of pain over the A1 pulley is thought to be indicative of stenosing tenosynovitis. Injection may be the best first line of defence.

     Frequency/Duration – A single injection with results evaluated to demonstrate progress

      

   • Glucocorticosteroid Injections

     Glucocorticosteroid Injections are not recommended Ultrasound-guided glucocorticosteroid injections for acute, subacute, or chronic flexor tendon entrapment.

     Splint of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit)

     Splint of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit) is recommended for the treatment of select cases of acute, subacute, or chronic flexor tendon entrapment (i.e., patients who refuse injection).

      

8. Rehabilitation of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit)

   Rehabilitation (supervised formal therapy) required as a result of a work-related injury should focus on restoring functional ability required to meet the patient’s daily and work activities and return to work, with the goal of restoring the injured worker to pre-injury status to the greatest extent possible.

   Active therapy necessitates a patient’s internal effort to complete a specific exercise or task. Passive therapy refers to interventions that do not require the patient to exert any effort, but instead rely on modalities provided by a therapist.

   In general, passive interventions are viewed as a means of facilitating progress in an active therapy programme while also achieving objective functional gains. The importance of active interventions should be emphasised over passive interventions.

   In order to maintain improvement levels, the patient should be instructed to continue both active and passive therapies at home as an extension of the treatment process.

   To facilitate functional gains, assistive devices may be included as an adjunctive measure in the rehabilitation plan.

    

   • Therapy: Active

      

     • Therapeutic Exercise

       Therapeutic Exercise is not recommended for acute cases and the vast majority of patients with flexor tendon entrapment

        

     • Therapeutic Exercise – Patients with Residual Deficits

       Therapeutic Exercise – Patients with Residual Deficits is recommended especially post-operatively,

       Frequency/Dose/Duration – Total visits may be as few as two to three for patients with mild functional deficits or as many as 12 to 15 for patients with more severe deficits who have documented ongoing objective functional improvement.

       More than 12 to 15 visits may be indicated if there is documentation of functional improvement toward specific objective functional goals when there are ongoing functional deficits (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities).

       A home exercise programme should be developed and performed in conjunction with therapy as part of the rehabilitation plan.

        

9. Surgery of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit)

   Surgery of Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit) is recommended in patients who have been partially or temporarily responsive to two glucocorticosteroid injections for persistent or chronic flexor tendon entrapment (Trigger Finger).

   Those who do not respond should be carefully evaluated for possible alternate conditions. If two glucocorticosteroid injections fail to produce a therapeutic response in the presence of an obvious trigger finger, surgery may be necessary.

What our office can do if you have Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit)

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.