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Wrist extensor compartments series#
One series reported success rates of 69% for physical therapy programs versus 97% resolution for injection at 3 months, but patients who responded to physical therapy experienced no recurrence of pain or triggering at 6 months, indicating that physical therapy was more effective than injection in preventing recurrence. Supervised physical therapy programs, often aimed at developing differential gliding between the FDS and FDP tendons, tend to be less effective than other modalities, such as steroid injection, in preventing pain and triggering. Compliance may be an issue because patients may find the splints to be cumbersome. 14-16 These aids typically immobilize the metacarpophalangeal (MCP) joint but allow PIP joint and distal interphalangeal joint motion, although one splint described by Rodgers et al 17 immobilized only the distal interphalangeal joint and was reported to be successful in 55% of cases. Orthoses are reported to provide relief in 40% to 87% of cases. Initial management strategies may include a supervised therapy program or instruction in a home exercise program, rest with splints, and NSAIDs. A high concordance with concomitant carpal tunnel syndrome is present, with >60% of patients with trigger digits demonstrating clinical or electrodiagnostic evidence of median nerve compression at the wrist. Patients also may have a proximal interphalangeal (PIP) contracture, which often fails to fully reverse even following successful release. In most patients, a tender nodule can be palpated at the site of the A1 pulley. Patients may report a reduced grip, clicking, catching, or locking. Presenting symptoms often include pain at the level of the A1 pulley, which progresses to triggering or locking. A = annular pulleys, C = cruciate pulleys, P = phalanges The A1 pulley is released during trigger finger release. Illustration demonstrating the flexor tendons and the pulley system of the digits. Proposed contributing factors include genetic changes, systemic conditions such as renal insufficiency, thyroid disease, or DM, and occupational issues. The etiology is varied, and an exact cause is unknown it is likely multifactorial. 8,9Ĭhanges occur in the pulley, including thickening of the A1 pulley, and in the flexor tendons, primarily the flexor digitorum profundus (FDP) but also the flexor digitorum superficialis (FDS) ( Figure 1). The prevalence of trigger digit is 2% to 3%, but in patients with diabetes, the prevalence rises to 10% to 20%. Women are affected six times more often than are men, with a higher incidence in patients with DM and RA. Stenosing tenosynovitis at the A1 pulley is by far the most common tendon pathology seen. Pain may be mediated by neurochemical cytokines and potentiated by vascular changes. Changes in gene expression have been noted in the tendons. 1-5 Because of the lack of a robust intrinsic blood supply and uneven strain, the healing and remodeling responses are altered. It has been proposed that the prolonged repetitive stress of these conditions puts mechanical strain on the tendon, causing microruptures. In stenosing tenosynovitis and tendinosis, the conspicuous absence of inflammatory cells typically is noted. Tendinosis refers to chronic degenerative changes in the tendon.
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Common histologic findings in the sheath include collagen degradation, vascular ingrowth, and fibrocartilage metaplasia, believed to be a response to compression and shear during tendon gliding. The pathophysiology can be varied, ranging from overuse to inflammatory pathology from such disorders as rheumatoid arthritis (RA) or crystalline disease (ie, gout) to systemic disorders such as diabetes mellitus (DM) or thyroid disease, which result in tendon adhesions or thickening. This distortion prevents the easy and smooth gliding of the tendon. This condition may occur because the sheath or pulley becomes narrowed or because of the increased size of the tendon secondary to degeneration or tendinosis. Stenosing tenosynovitis, or trigger finger, occurs when a size discrepancy exists between the tendon and the pulley or sheath through which the tendon passes.
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As its name suggests, tendinopathy is an affliction of the tendon, occurring anywhere along its course.