Trigger Finger from Both Sides of the Table: A Hand Therapist’s Experience as a Patient

Written by:

David M. Houck, OTR/L, CHT

VHSF Fellow '24/'25

I have spent half of my occupational therapy career practicing hand therapy.  Earning my CHT credential in 2010 has been one of the most satisfying accomplishments in my professional life.  Even having attended scores of weekend conferences and picking the brains of every hand therapy specialist I could find, finding and building relationships with mentors has been more challenging than passing the CHT exam.  Looking back, I have come so far.  I’ve gained knowledge, competence, and confidence.  Even so, there have been gaps that were hard to bridge, and I’m not done bridging them. The VHSF curriculum and resources have helped reassure me of what I already know, and what I can know more thoroughly.  

There are many avenues leading towards that balance we seek in understanding the sources of our patients’ impairments and facilitating their healing.  One of those avenues of learning is simply being a patient, and that can feel like having the shoe on the other foot, or hand, if you please.  Over the years, I’ve come to experience many of the conditions my patients have suffered.   There have been lacerations, punctures, cellulitis, and 50 shades of tendinosis. I shortened my long finger (a wee bit); the fingertip amazingly regenerated.  There have been other, uhm, incidents, which might tempt you to confiscate my power tools and Crayon box with the built in sharpener.  During those infrequent times when I’ve needed to facilitate my own recovery, it has given me a new perspective on what our patients go through.  Sharing my own injury and recovery examples with patients often helps them accept that healing is a long, sometimes incomplete process.  The purpose of this blog is to describe that process, as a patient and as a therapist.  

Stenosing tenosynovitis, AKA: trigger finger. I’ve had that condition for two decades, and it never bothered me much, until the past couple of years.  I’m sure it was the patio project I started this Spring that tipped the scales.  At the urging of an unnamed person of significance, I embarked on clearing and excavating an overgrown area alongside the house which was poor to look at. I moved roughly 10 cubic yards of dirt and debris, one shovel-full at a time.  The whole process was labor intensive and time consuming. I listened to many of the Fellowship lectures while leveling pavers, and burning mosquito repellent sticks into the night. And my left ring finger began to trouble me more.

The reader is familiar with the mechanism of trigger finger: Swelling in the flexor tendon sheath prevents smooth motion under the first of several ligaments (pulleys), and there is characteristic clicking and snapping during tendon excursion ⁽⁹⁾.  The bad ones lock. Mine went from grade 1 to grade 3a on the 4-point severity scale by Greene ⁽⁷⁾ within a few weeks. These symptoms weremeaner than before. Besides triggering and locking, I could feel that the tendon itself was inflamed from my palm to the middle phalanx.  When the patio project was done, I assumed that my finger would recover, but it got worse.  I started to lose pip joint extension. I diligently applied all the knowledge and skills I possessed to reduce swelling and regain motion in both directions. Passive and active exercises, RMO flexion and extension use, edema massage, pulsed ultrasound (yeah, I know there’s poorevidence).  None of these interventions made an appreciable difference.  The only thing that improved was my empathy.  Nadar ⁽⁷⁾found that use of an orthosis to immobilize the pip joint for 6 weeks was more effective than exercise in resolving trigger finger symptoms.  Like my own patients, I did not find it possible to immobilize my finger to that extent. I had to switch hands when demonstrating home exercises in the clinic. A year previous, my primary care doctor injected the same finger with cortisone, and it worked like a charm.  As a diabetic, there is greater incidence of trigger finger compared to the general population, and greater risk of complications from injections or surgical release. Bryant⁽¹⁾ and colleagues suggested that diabetes and tobacco use are the top predictors of complications after hand surgery, greater than obesity.   Complications can range from persistent edema, stiffness, wound site infection, and chronic regional pain syndrome (CRPS), as well as  pain at the dorsal aspect of the PIP joint^(5,6)_.  A presentation of three case studies by Effendi, et al⁽²⁾ described serious complications after A1 pulley release resulting in permanent functional impairment.  These included bowstringing, neurovascular bundle injury, infection, and flexor tendon rupture.  One of the individuals was an orthopedic surgeon, a nondiabetic, who had to modify her own surgery  techniques to continue practicing. When I met with a surgeon, he told me to get my A1c level down into the 7% range, or he wasn’t going to touch me.

Fast-forward six weeks.  I lowered my A1c, let the surgeon know, and waited in line for an opening on his schedule.  I got the call on a Wednesday.  There was a Friday cancellation, which he offered to me.  I cleared my own Friday afternoon appointments, except for my last one. I could not reach the patient. I told my boss I could go over to the Ortho department and come back to finish my shift.  Her facial expression made no attempt to hide her skepticism regarding my state of mind.

            “Cancel it,” she said. “I’ll block your schedule for the next two weeks .”

            “Oh no,” I said, “I’ll be back Monday.” She reluctantly agreed.  Yeah, bad idea.

“You’ll feel a little pinch, like a shot at the dentist,” the surgeon said, “only a little worse.”  My vision was screened by a curtain.  I felt the pinch, which was much like the cortisone injection I had a year ago. There was a pause, then the needle went deeper.  As the effects of the numbing agent spread, I felt other pinches, and that needle taking the liberty to explore every part of my palm. Someone rotated my forearm and I felt something cold splash over the back of my hand.   

            “We’re sanitizing your hand again,” the surgeon said. 

            He used a tourniquet to reduce bleeding.  This improves visualization of the relevant structures during the surgery.   By comparison, the Wide-Awake Local Anesthetic No Tourniquet (WALANT) method achieves a nearly bloodless surgical field through use of epinephrine, which constricts blood vessels for a few minutes.  In recentstudies^(3,8) surgeons preferred WALANT over tourniquet with local anesthesia, and patients had higher satisfaction ratings, with less medication use. The authors noted a high risk for bias, however ⁽⁸⁾. A study from 2007⁽⁴⁾ described the excision of the ulnar slip of flexor digitorum superficialis as an adjunct to or instead of releasing the A1 pulley to decrease tendon bulk and found it to be safe, also with high patient satisfaction.

I felt tugging, but no pain.  I imagined the scalpel opening a window in my palm and decided that the incision was about twice the length I thought it would be.  There was a crunchy sound, which I presumed meant he was starting to excise the A1 pulley.  I thought I could sense exactly what he was doing, though I couldn’t feel a thing. Maybe I was feeling with my ears somehow.  I expected him to close the incision next, though I heard scraping noises, and felt more pulling.  That went on for a few minutes.

            “How does it look in there,” I asked? 

           “There’s quite a bit of synovitis, “he answered, which did not surprise me.

It wasn’t long before he finished the procedure.  The postsurgical dressing was covered by Coban, and my fingers were free.  There was no way this dressing was going to last until my two week follow up appointment.  I thanked him for his care and skipped back to my truck, delighted that it was Friday, and I was heading home early. 

One week post-op

We had a house full of guests, because our daughter was getting married in a week.  For the next few hours, we caught up on old times with our guests, and I played with my fingers. I squeezed them, rubbed them, flicked them, and tried to make a fist through invisible resistance.  I thought I’d be happy when I could feel my hand.  Wrong again.  An ache slowly surfaced from under the cloud of anesthesia.  The fingers felt like they had been stuffed into two gardening gloves. Later, I woke from a dream that someone had nailed my left hand to the bed frame, though my main concern was the - swelling.  I called my boss to ask for the two weeks off she had already offered .

Our daughter got married – she was beautiful, and so was the outdoor venue.  They flew off to Oahu and we spent a couple of days cleaning up.  I used one of my last days off to go hiking.   Maggie’s peaks in the Lake Tahoe Basin are a group of rocky outcrops overlooking the lake from the southwest. I was concerned that hiking might exacerbate swelling, but it also gave me a chance to do some self-care.  I was determined to make my first full fist by the time I reached the summit.  I performed countless reps of every variation of finger motion.  Within a couple of hours my sore hand and I reached the top, my hand tightly fisted, for the first time.

Two weeks post-op

Since then, recovery has been more of a struggle than I anticipated.  My Quick DASH score after one week was 59.1% impaired in the ADL section and 87.5% impaired in the sports and performing arts section. Now at ten weeks post-procedure, those ratings are 13.6% and 25%. Playing the guitar is both frustrating and amusing.  The G major chord is no longer this guitarist’s best friend, and a B flat barre chord exposes that slight pip flexion contracture with a lot of string buzz. It’s good therapy.  My flexibility varies greatly throughout the day; so does swelling.  The incision scar is thick and tough and sore.  A recent patient who had the same procedure agreed to let me take a photo of our surgical scars (see appendix). After another month I was able to slide my wedding ring back onto my left hand for the first time since surgery. 

All said, there's a definite advantage to having the knowledge and experience of a hand therapist when recovering from your own injury or hand surgery, and I also appreciate how being a patient can help to become a more empathetic and effective therapist.  In the end, I'm still made of proteins and water, like everyone else.  I’m fifty-eight, a little overweight, I don’t smoke, but I’m diabetic. This tiny surgery has been more challenging than I imagined. Professionally, I welcome any mentors I can find on a long or short-term basis, and I mentor others.  The VHSF Fellowship has helped build confidence that shows when I interact with my patients and their referring physicians.  Physicians ask me to take the lead on some cases. 

Relative Flexion Orthosis

A good life rule is to be humble enough to learn and confident enough to teach. It’s intimidating sometimes to consider just how amazing and complex the human body is, and understanding how the components work together requires devotion to continual learning.  Lately, I’ve been trying to look at things from this perspective: Education is an adventure, like the hiking I love, and I never get bored with it.  I can’t wait to see what’s around the next corner or over the next rise.  Perhaps my shoe was on the other foot when I started off.  I thought I would hit the ground running after hand surgery, but I’m a hiker, not a runner.  Walking will do just fine.

Ten weeks post-op

References:

1.     Bryant BSH, Marsh K, et al. Patient Risk Factors Associated with Postoperative Complications After Common Hand Procedures. Hand. 2022; Vol 17(5): 993-998

2.     Effendi M, Yuan F, et al. Not Just another Trigger Finger. Hand. 2025; Vol20(1): 43-48

3.     Levit T, Declan CT, et al. Trigger Finger Release Using Wide-Awake Local Anesthesia No Tourniquet Versus Local Anesthesia with a Tourniquet: A Systematic Review and Meta-analysis. Hand. 2025; Vol 20(4): 533-541

4.     Marcus A, Culver J. Treating Trigger Finger in Diabetics using Excision of the Ulnar Slip of the Flexor Digitorum Superficialis with or Without A1 Pulley Release.  Hand. 2007. Vol 2:227-321

5.     Mirza A, Mirza J, et al. Complications Following endoscopic and Open Trigger Finger Release: A Retrospective Comparative Study Hand. 2023. Vol 18(7)1089-1094

6.     Monteerarat Y, Misen P. Dorsal Proximal Interphalangeal Joint Tenderness is Associated with Prolonged Postoperative Pain after A1 Pulley Release for Trigger Fingers. BMC Musculoskeletal Disorders. 2023 Vol 24 (13) 1-7

7.     Nadar M. Orthosis vs. Exercise for the treatment of adult idiopathic trigger fingers: A randomized clinical trial. Prosthetics and Orthotics International. 2024; Vol 48 (6) 713-719

8.     Pina M, Cusano A. Wide Awake Local Anesthesia No Tourniquet in Hand Surgery: The Patient Experience. Hand. 2023; Vol 18(4) 655-661

9.     Sharma B, Sah D. The Efficacy of Local Corticosteroid Injection in the Treatment of Trigger Finger. Janaki Medical College Journal of Medical Science. 2017 Vol 5 (2) 13-18