The guidelines provided by the New York State Workers Compensation Board present fundamental principles for addressing Flexor Tendon Entrapment. These directives are crafted to aid healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals specializing in managing Flexor Tendon Entrapment can depend on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.
It is essential to underscore that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of Flexor Tendon Entrapment should involve collaboration between the patient and their healthcare provider.
Flexor Tendon Entrapment
Diagnostic Studies
Flexor tendon entrapment of the digits is characterized by snapping or locking of the thumb or fingers, often with pain. The primary cause is thickening of the digit’s A1 pulley, though alternative pathogeneses are plausible.
Diagnostic Studies
There are typically no specialized tests performed, and X-rays are generally unhelpful. However, a low threshold for testing is advised, especially for conditions like diabetes mellitus, hypothyroidism, and connective tissue disorders, to prevent additional morbidity.
Medications
For most patients, initial medications include ibuprofen, naproxen, or other older-generation NSAIDs. Acetaminophen is a reasonable alternative for those ineligible for NSAIDs, although evidence suggests it is slightly less effective. NSAIDs, including OTC agents, are recommended for acute, subacute, or chronic flexor tendon entrapment. As-needed use is acceptable for many patients, with discontinuation upon symptom resolution, lack of efficacy, or development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
For patients at high risk of gastrointestinal bleeding, concomitant use of cytoprotective drugs is recommended. These may include misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors. These drugs should be considered, especially for longer-term treatments, in patients with a high-risk factor profile such as a history of gastrointestinal bleeding, elderly individuals, diabetics, and cigarette smokers.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors should discuss the risks and benefits of NSAID therapy for pain. Acetaminophen or aspirin is recommended as the first-line therapy due to their perceived safety regarding cardiovascular adverse effects. If NSAIDs are necessary, non-selective options are preferred over COX-2 specific drugs. In patients receiving low-dose aspirin, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen for Treatment of Flexor Tendon Entrapment Pain
Recommended for the treatment of flexor tendon entrapment pain, particularly in patients with contraindications for NSAIDs. All patients with flexor tendon entrapment pain, including acute, subacute, chronic, and post-operative cases, can use acetaminophen as recommended by the manufacturer. Caution is advised not to exceed four gm/day due to potential hepatic toxicity.
Not recommended for acute, subacute, or chronic flexor tendon entrapment. However, for postoperative pain management, a brief prescription of opioids as an adjunct to more effective treatments like NSAIDs and acetaminophen may be required, especially for nocturnal use. The frequency and duration should be per the manufacturer’s recommendations, with a gradual tapering off. This approach is recommended for brief, selective use in postoperative patients, with the primary use at night to aid sleep postoperatively.
Treatment
Injection Therapy
Glucocorticosteroid Injections
Recommended for acute, subacute, or chronic flexor tendon entrapment, especially in cases of triggering digit or pain symptoms over the A1 pulley indicative of stenosing tenosynovitis. A single injection is suggested, with results evaluated for improvement. Ultrasound guidance for these injections is not recommended.
Splint
Recommended for select cases (i.e., patients who decline injection) of acute, subacute, or chronic flexor tendon entrapment. Evidence supports the use of splints in these situations.
Rehabilitation
Rehabilitation for work-related injuries should concentrate on reinstating functional abilities necessary for daily and work activities, with the goal of returning the injured worker to pre-injury status. Active therapy, requiring internal effort from the patient, is preferred over passive interventions, which rely on therapist-delivered modalities. Both active and passive therapies are encouraged at home to sustain improvement levels. Assistive devices can be included in the rehabilitation plan to aid in functional gains.
Therapy: Active
Therapeutic Exercise
Not recommended for acute cases and for most patients with flexor tendon entrapment.
Therapeutic Exercise – Patients with Residual Deficits
Recommended, particularly post-operatively. The frequency and duration of visits may vary based on the severity of deficits and ongoing objective functional improvement. A home exercise program should be developed and performed in conjunction with therapy.
Surgery
Recommended for persistent or chronic flexor tendon entrapment (Trigger Finger) in patients partially or temporarily responsive to two glucocorticosteroid injections.
Patients with no response to two injections and an obvious trigger finger should be carefully evaluated for possible alternative conditions. If there is no therapeutic response in the presence of an obvious trigger finger, surgery may be deemed appropriate.
