TDR Massage: The Trigger Finger

By Linda LePelley , RN, NMT
2016-10-7

TDR Massage: The Trigger Finger

By Linda LePelley , RN, NMT
2016-10-7

Trigger Finger (TF) is a dysfunctional condition of the hand in which symptoms of the affected finger or thumb advance from movement hesitance with noticeable clicking, to painful snaps or clicks, eventually progressing to a state of immobilized flexion. The medical term for TF is commonly known as stenosing flexor tenosynovitis, although Giugale and Fowler (2015) state that tissue analyses and tendon biopsies show, "No significant amount of inflammatory cell or synoviocyte proliferation was discovered in these studies." Based on these observations, the authors suggest that a more accurate name for the condition is flexor tendovaginosis. Dr. Carolyn Kerrigan provides a good overview of the TF and offers typical medical responses to the condition of Trigger Finger.

Current medical treatments for TF/TT include corticosteroid injections and surgical procedures. Although not commonly occurring, the injections carry the risk of joint infection, nerve damage, pain, inflammation, weakening or rupture of tendons, thinning or even death of nearby bone tissue. Corticosteroids can also cause a temporary increase in the blood sugar levels of diabetics. Surgical risks are similar as far as the risk for infection, scarring, and nerve injuries.

The Quinnell Grading System is commonly used in the clinical and research setting to classify the severity of TF, and is as follows:

  • Grade 0 – Pain with flexion, no mechanical symptoms.
  • Grade 1 –Uneven motion during flexion/clicking.
  • Grade 2 – Locked digit that is actively corrected.
  • Grade 3 – Locked digit that is passively corrected.
  • Grade 4 – Locked digit, uncorrectable/fixed flexion contracture.

Normally, massage is contraindicated for inflammation, however, in the case of TF, usually a few of the five cardinal signs of inflammation (redness, heat, swelling, pain, and loss of function) are not present; such as redness and heat, as well as pain and loss of function in the initial stages. The swelling noted with TF is likely a fullness associated with stenosis, rather than inflammatory. In the absence of redness, heat, and pain at rest, massage for TF is a viable treatment option.

An old friend came up to me at church recently, holding her hand out to me with fingers smoothly waving, telling me that she still appreciates the work I did on her trigger finger more than ten years ago. It was in the process of progressing from grade 2 to grade 3 on the Quinnell Grading System when I first worked on it. At that time, I was uncertain that I could do anything to help, but the Tissue Density Restoration (TDR) Massage treatment was very successful. I also showed her how to maintain the joint, and she has kept it clear and prevented other fingers from triggering over the years. She told me that her sister had the same hand problems, but would not consider that massage could help, therefore she has had a couple of different hand surgeries in recent years. Her sister recently called her and asked for the directions for treating herself, because once again, the condition is returning.

I have read very few articles and watched a few YouTube presentations that suggest massage, but they also advocate the use of ice and suggest working on the hand for as little as three to five minutes, which I think can be counter-productive and ineffective. While ice may temporarily relieve pain, it causes the tissues to contract, which will increase tissue density and pain, and decrease proper circulation. Ice halts the warmth needed to soften and mobilize the tissues. I have consistently found that by spending at least 45-minutes at a time massaging an area that has been adequately warmed creates an actual change of density in the affected tissues, resulting in the relief of pain.

Rather than being exposed to the risks and cost of injections and surgical procedures, it would be prudent to first attempt relief through non-invasive massage techniques. In my clinical experience, I have seen TFs respond well regardless of the stage they presented in. The sooner you treat TF, the less time it takes for full restoration of mobility and relief of pain. I usually give the initial treatment as a training session, teaching my clients how to complete and maintain the restoration themselves.

Protocol

TDR Massage is based on my theory that all pain and dysfunction is associated with an elevation in tissue density at the exact location of the pain (Tissue Density's Relationship to Pain and Dysfunction, Massage Today, April, 2012). Familiarize yourself with the principles of TDR Massage (The Seven Principles of Tissue Density Restoration, Massage Today, July 2015). Warm the affected hand, and work with it on a warm surface, in an area free of drafts. Giugale & Fowler (2015) state, "A nodule is usually present and palpable on the FPL [flexor pollicis longus] tendon. This is termed Notta nodule, after the physician who first described it." Locate this nodule. Begin the massage by gently massaging the tissues around the nodule, getting them warm and well-mobilized before carefully massaging the nodule itself. The goal is to soften the nodule and increase its movement until it "melts" away. I like to use the eraser end of an oversized pencil, or a large pink eraser to apply light pressure to very small nodules and spurs. Rather than moving the eraser or your fingers over the nodule, just press lightly into it, then move the affected finger and hand. The important thing to remember is to take the time required to achieve the goal of pain relief and restoration of normal tissue density. Trying to rush the process could cause pain and irritation that results in swelling, so remember to stay below a 3 on the 1/10 pain scale. The more focused, localized movement you apply, the better the internal friction will resolve the nodules and stenosis of TF. What I teach my clients to do to complete and maintain the TDR is to simply warm their hands, rubbing and massaging them with olive oil, coconut oil, or other slick moisturizer, focusing on any residual nodule and any area that feels tight or hurts, until it softens and is relieved. Once the hands are pain-free, just a few minutes a week will keep them in good shape. It sounds simple and easy, which it is, but in the beginning it is not quick, it takes time to work the initial hardness out of dense tissues.

I have said it before, but I would like to reiterate that I am not claiming that TDR Massage is the only productive massage for this and other conditions. I use it because I find it highly effective. As a nurse, I must be able to provide sufficient rationales for my interventions. By focusing on palpable elevated tissue density (ETD), and using the Tissue Density Grading Scale (The Tissue Density Grading Scale: A Communication Tool, Massage Today, March 2014), I am able to assess and document the state of affected tissues before, during, and after treatment. The combination of this objective data with my clients' subjective responses to treatment provides me with all the evidence I need to justify my work.

References:

  1. Mayo Clinic. (2016). Cortisone shots. Mayo Clinic. Retrieved from www.mayoclinic.org/tests-procedures/cortisone-shots/details/risks/cmc-20206857
  2. Giugale, J.M., & Fowler, J. R. (2015). Trigger finger: Adult and pediatric treatment strategies. The Orthopedic Clinics of America 46(4) 561-569. DOI: 10.1016/j.ocl.2015.06.014.