Working Diagnosis:
Trigger finger of the second digit.

Treatment:
His associated somatic dysfunctions were a flexed right capitate, abducted right ulna, and second metacarpal posterior glide. He was treated with a high-velocity, low-amplitude (HVLA) technique to the right capitate, and with muscle energy techniques to the second metacarpal and ulna. He was also provided with an ultrasound-guided corticosteroid injection of the second metacarpal flexor tendon sheath. He tolerated both treatments well, had a reduction in pain, and normalization of active range of motion compared to the contralateral side.

Case Photo #2 Positioning and force application for HVLA for radiocarpal flexion dysfunction. (5)
Case Photo #3 Positioning and force application for muscle energy for ulnar dysfunction. (5)

Outcome:
At his one-month follow-up, pain and symptoms had completely resolved. He was able to perform his work and recreational activities at his baseline level of function.

Author's Comments:
Trigger finger is caused by inflammation from irritative forces between the tendon and tendon sheath, most often occurring at the A1 pulley in the hand. (1) This most often occurs in the fifth and sixth decades of life. (2) Patients with diabetes mellitus are four times more likely to develop this condition. (3) Patients typically present with painless clicking/catching in the affected finger. Most cases can be managed conservatively with a combination of corticosteroid injections, therapeutic exercises, joint mobilization, and splinting. (4) Surgery is considered when conservative treatment fails.

Case Photo #4 Illustration: A1 pulley and trigger finger (4).

Editor's Comments:
Ultrasound is a useful tool for evaluation and management of trigger fingers. Comparing the sonographic appearance of the flexor tendon and pulley, as well as dynamic behaviors, between affected and unaffected fingers is helpful. Sonographically, the involved pulley will often appear hypoechoic, thickened, and hyperemic. (6) The flexor tendons, primarily the flexor digitorum superficialis, will appear thickened, hypoechoic, and less organized. Associated cysts formation, synovial effusion, or longitudinal tendon tears may also be seen. When viewing the tendon in long-axis while flexing and extending the finger, a thickened portion of the flexor digitorum superficialis may visibly impinge on the affected pulley. (7)

References:
Andreu JL, Oton T, Silvia-Fernandez L, Sanz J. Hand pain other than carpal tunnel syndrome (CTS): The role of occupational factors. Best Practice and Research Clinical Rheumatology. 2011;25:31–42.
Tendon trouble in the hand: de quarvain's tenosynovitis and trigger finger. Harvard Women's Health Watch.2010:4-5.
Howitt S. The conservative treatment of trigger thumb using Graston techniques and active release technique. JCCA. 206;50(4):249-254
Aaron, G. (2019, January 02). Trigger finger: All you need to know. Retrieved April 08, 2021, from https://www.mountelizabeth.com.sg/healthplus/article/trigger-finger-common-questions
Nicholas, A. S., DO. (2012). Atlas of Osteopathic Techniques (2nd ed.). Philadelphia, PA: Lippincot Williams & Wilkins.
Guerini H, Pessis E, Theumann N, et al. Sonographic appearance of trigger fingers. J Ultrasound Med 2008; 27: 1407– 1413.
Bianchi S, Gitto S, Draghi F. Ultrasound Features of Trigger Finger: Review of the Literature. J Ultrasound Med. 2019 Dec;38(12):3141-3154. doi: 10.1002/jum.15025. Epub 2019 May 20. PMID: 31106876.

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