855686

Roberts et al.2019
HANXXX10.1177/1558944719855686HAND

Surgery Article
HAND

Choice of Corticosteroid Solution

2021, Vol. 16(3) 321­–325
© The Author(s) 2019
Article reuse guidelines:
and Outcome After Injection for sagepub.com/journals-permissions
DOI: 10.1177/1558944719855686
https://doi.org/10.1177/1558944719855686

Trigger Finger journals.sagepub.com/home/HAN

John M. Roberts1, Brittany J. Behar1, Laila M. Siddique1,

Morgan S. Brgoch1, and Kenneth F. Taylor1

Abstract
Background: Many techniques for injection of trigger fingers exist. The purpose of this study was to determine whether
the type of steroid or technique used for trigger finger injection altered clinical outcomes. Methods: Six hand surgeons
at a single institution were surveyed regarding their injection technique, preferred steroid used, and protocol for repeat
injection or indication for surgery for symptomatic trigger finger. A retrospective chart review of patients who underwent
trigger finger injections was performed by randomly selecting 35 patients for each surgeon between January 2013
and December 2015. Demographic data at the time of presentation were collected. Outcome data during follow-up
appointments were also recorded. Results: A total of 210 patient charts were reviewed. Demographic data and initial
presenting grade of triggering were similar among all groups. There was no significant difference in clinical course or eventual
outcomes noted with injection technique. There were 70 patients in each steroid cohort. Patients receiving triamcinolone
required additional injections compared with those receiving methylprednisolone and dexamethasone. Eventual surgical
intervention was significantly higher in those patients receiving methylprednisolone. The methylprednisolone group also
underwent operative release significantly earlier. Conclusions: Trigger finger injections with triamcinolone demonstrate a
higher rate of additional injections when compared with dexamethasone and methylprednisolone. Patients who underwent
methylprednisolone injection had surgical release performed earlier and more frequently than the other 2 groups. The
choice of corticosteroid significantly affected clinical outcome in this study population. Clinicians performing steroid
injections for trigger finger may wish to consider these results when selecting a specific agent.

Keywords: trigger finger, steroid injection, nonoperative treatment, hand, anatomy, tendon, basic science, surgery, specialty

Introduction long-term follow-up symptoms across a variety of trigger

Stenosing flexor tenosynovitis or “trigger finger” is one of
the most common sources for referral to hand surgery. A
size mismatch between the tendon and the tendon sheath
retinacular pulley at the level of the metacarpal head (A1
pulley) has been implicated in the painful catching or pop-
ping as the patient flexes and extends the digit. Occasion-
ally, patients will lock in flexion, or rarely in extension,
and require passive manipulation.1,2 Initial treatment of
trigger finger often involves a corticosteroid injection at
the trigger site. This has been shown to be efficacious both
acutely and at 1-year follow-up.3,4
Previous studies have compared dexamethasone to tri-
amcinolone with respect to efficacy as well as patients’
perceived pain with various injection techniques.1,5 These
studies did not include methylprednisolone. We hypothe-
sized there is no difference in initial symptom relief and
finger injection methods using each of these 3 agents.
Materials and Methods
Each of the 6 fellowship-trained hand surgeons at our insti-
tution was asked to participate in a questionnaire regarding
their protocol for trigger finger injections over the study
time frame. They were asked several questions regarding
the details of the injection solution, including the type and
1
Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
Corresponding Author:
Kenneth F. Taylor, Department of Orthopaedics and Rehabilitation,
Penn State Health Milton S. Hershey Medical Center, 30 Hope Drive,
P.O. Box 859, Hershey, PA 17033, USA.
Email: ktaylor3@pennstatehealth.psu.edu
322
Table 1. Results of Surgeon Survey for Injection Technique.
Surgeon Steroid (dose in mg) Use ethyl chloride Add lidocaine (1%, 1 mL)
1 Triamcinolone (10) Yes
2 Triamcinolone (10) No
3 Dexamethasone (4) No
4 Dexamethasone (4) No
5 Methylprednisolone (40) Yes
6 Methylprednisolone (40) Yes
Note. MCP = metacarpophalangeal.
amount of steroid. Three specific corticosteroids were iden-
tified: dexamethasone (Decadron, Clint Pharmaceuticals
Old Hickory, Tennessee), triamcinolone (Kenalog-10, Bris-
tol-Myers Squibb Company, Princeton, New Jersey), and
methylprednisolone (Solu-Medrol, Pfizer, New York City,
New York). In addition, they were asked about how the
injection is administered, including the landmarks for nee-
dle insertion and the angle of injection. Finally, each sur-
geon identified a protocol they follow for patients who
return in follow-up and remain symptomatic. This included
recommendations for an additional injection versus pro-
ceeding with a trigger (A1 pulley) release.
This study is an institutional review board–approved ret-
rospective analysis of existing data. As such, patient con-
sent was not required. Patients who received a trigger finger
injection by one of the 6 hand surgeons from January 1,
2013, through December 31, 2015, were identified using
the Current Procedural Terminology code 20550. This time
frame allowed at least a 1-year follow-up from the initial
injection. A statistical power analysis, with power set to
80%, was performed prior to the study to determine the
number of subjects needed to detect a difference (P < .05)
between each surgeon’s outcomes. Using a random number
generator, 35 participants from each surgeon’s cohort were
selected for a total of 210 subjects.
Patients included in this study were 18 years of age or
older with an initial trigger finger injection during the time
frame of the study. Patients were excluded if they were
younger than 18 years or they did not have documentation
of the location or the type of injection. If a patient was seen
by different surgeons within the study period, the patient’s
data were recorded under the initial treating physician.
Data collection included demographic information such
as sex, age, and body mass index (BMI). During the initial
evaluation, each patient’s comorbidities, handedness, length
of triggering symptoms prior to presentation, degree of
severity, history of prior trigger finger injection or treat-
ment, and the involved fingers were recorded. At subse-
quent follow-up appointments, further details regarding the
patient’s treatment were reviewed, including the number of
additional injections required and, if applicable, the time
from initial injection to trigger finger surgical release.
HAND 16(3)
Angle of injection Entry point landmark
Yes 90 MCP joint crease
Yes 90 Just proximal to MCP crease
Yes 45 Distal palmar crease
Yes 90 Mid proximal phalanx
Yes 45 Distal palmar crease
Yes 45 Distal palmar crease
Patients without further follow-up after initial injection
were assumed to have been successfully treated and were
not included in follow-up data statistics.
Data were de-identified and assessed by Pearson correla-
tion of primary and secondary outcome evaluation, Fisher
exact test, 1-way analysis of variance, and t test where
appropriate. Matched groups were evaluated with 2-sample
t tests, Wilcoxon rank sum tests, and χ2 analyses when
appropriate. To further assess possible practice biases, mul-
tiple post hoc comparisons between the participating sur-
geons and the specific steroid used were assessed and
calculated with both the least significant difference and
Bonferroni methods with an α of less than or equal 0.05
considered statistically significant.
Results
Surgeon preference was equally split between the triam-
cinolone, dexamethasone, and methylprednisolone groups.
All surgeons used a 3-mL syringe with a 25-gauge needle
(Table 1). There was no appreciable difference in their
approach to the patient returning after incomplete relief
with the initial injection. Each offered a second injection if
it was not otherwise contraindicated.
A total of 210 patient charts were reviewed. There were
70 patients in each of the steroid cohorts. Demographic data
and initial presenting grade of triggering were similar
among all groups. The mean age for all patients was 64.6
(±15.0) years with an average BMI of 31.2 (±6.9). Sixty-
four percent were women. Associated comorbidities also
did not differ significantly between groups with highest
prevalence of diabetes (27.6% ± 3.1%), carpal tunnel syn-
drome (19.5% ± 2.7%), osteoarthritis (16.7% ± 2.6%), and
hypothyroid disease (8.6% ± 1.9%). The most commonly
affected digits were the long (37.1% ± 3.3%), ring (28.6%
± 3.1%), and thumb (28.6% ± 3.1%) with an average pre-
injection degree of severity (grade = 0-4) of 2.1 ± .06.
One hundred fifty patients had follow-up after their ini-
tial visit for an average length of 13.1 months (Table 2).
Additional injections were performed in 25.0% ± 3.0%.
This was significantly higher in the triamcinolone group
(38.6% ± 5.9%) than in the dexamethasone (21.4% ±
Roberts et al. 323

Table 2. Comparison of the 3 Different Types of Steroids thumb due to inflammation of the flexor tendon sheath. His-
Used for Trigger Injection and the Variability on Outcomes. tological evaluation of the tissues implicates fibrocartilagi-
Steroid N Mean P value nous metaplasia along the tendon sheath and pulleys
secondary to the inflammation.7
Any prior Dexamethasone 66 9.1% ± 3.5% .003*
Multiple management options are available for the
injections or Triamcinolone 66 33.3% ± 5.8%
treatments Methylprednisolone 68 24% ± 5.3%
treating physician. Noninvasive measures include splint-
noted? Total 200 22.5% ± 2.9% ing, nonsteroidal anti-inflammatory medications, and
Preinjection Dexamethasone 69 2.3 ± 0.0 .122 hand therapy. If these fail to provide relief, corticosteroid
degree of Triamcinolone 70 2.1 ± 0.0 injection into the tendon sheath in the area of the first
severity Methylprednisolone 70 2.0 ± 0.0 annular (A1) pulley or surgical release of the pulley can
Total 209 2.1 ± 0.0 be performed. Numerous studies have demonstrated the
Were additional Dexamethasone 70 21.4% ± 4.9% 003*
effectiveness of steroid injections for trigger finger.2,4,5,8-18
injections Triamcinolone 70 38.6% ± 5.9%
performed? Methylprednisolone 68 14.7% ± 4.3%
The overall long-term success rate of corticosteroid injec-
Total 208 25.0% ± 3.0% tion is variable in the literature with avoidance of surgery
How many Dexamethasone 15 1.2 ± 0.0 .081 in 47% to 87% of patients.16-19 There is also very good
additional Triamcinolone 27 1.6 ± 0.0 evidence that in nondiabetic patients, 2 rounds of steroid
injections were Methylprednisolone 10 1.2 ± 0.0 injections for trigger finger are cost-effective.20 However,
performed? Total 52 1.4 ± 0.0 in diabetic patients, proceeding directly to surgery may be
Was open Dexamethasone 70 22.9% ± 5.1% <.001*
more cost-effective.21 Steroid injections in this popula-
release Triamcinolone 69 17.4% ± 4.6%
eventually Methylprednisolone 68 57.4% ± 6.0%
tion may result in elevated blood glucose levels for up to
performed? Total 207 32.4% ± 3.3% 5 days.22
How many Dexamethasone 16 10.7 ± 2.2 <.001* There have been few studies comparing injection tech-
months from Triamcinolone 12 21.8 ± 3.0 niques and effectiveness between different types of steroids.
first injection Methylprednisolone 39 4.3 ± 0.5 One prospectively compared dexamethasone and triamcin-
to surgery? Total 67 8.9 ± 1.1 olone. In this randomized trial, triamcinolone worked more
How long was Dexamethasone 42 13.7 ± 1.7 <.001*
quickly but had shorter lasting results compared with dexa-
follow-up? Triamcinolone 50 18.1 ± 2.1
Methylprednisolone 58 8.3 ± 1.0
methasone.1 The type of steroid and the technique for injec-
Total 150 13.1 ± 1.1 tion used among the 6 hand surgeons evaluated in the
current study was guided by their fellowship training. Com-
*P < .05. parison of several parameters including size of needle,
angle of injection, and landmarks used for localization did
not demonstrate a significant difference. Conversely, dexa-
4.9%) and methylprednisolone (14.7% ± 4.3%) groups methasone, triamcinolone, and methylprednisolone which
(P = .003). Open release was eventually performed in were each used by 2 hand surgeons did demonstrate statisti-
32.4% ± 3.3% of patients. The rate of operative interven- cally significant differences.
tion differed significantly between groups receiving meth- The biochemical difference between the corticoste-
ylprednisolone (57.4% ± 6.0%), dexamethasone (22.9% roids used in this study resulting in the observed range of
± 5.1%), and triamcinolone (17.4% ± 4.6%) (P < .001). success was not the main focus of this study, but should
The mean length of time from first injection to surgery be pointed out. All injectable steroid solutions act through
among all drug cohorts was 8.9 ± 1.1 months, although similar pathways whereby genes are modified, proinflam-
this was also statistically correlated with the drug used. matory cytokine production is decreased, and the overall
The methylprednisolone group required operative release inflammatory process is limited.23 However, there are
significantly earlier (4.3 ± 0.5 months) compared with some pharmacologic differences between each steroid
dexamethasone (10.7 ± 2.2 months) and triamcinolone moiety, including the size, solubility, and rate of metabo-
(21.8 ± 3.0 months) (P < .001). lism which may account for differences in clinical effi-
cacy. Dexamethasone is a soluble preparation. As such, it
is metabolized quickly and diffuses rapidly from the site
Discussion of injection. Insoluble forms, such as triamcinolone and
Stenosing tenosynovitis or trigger finger is a common ail- methylprednisolone, have the theoretical advantage of
ment with a lifetime incidence of 2.5% for the general pop- longer duration of effect. These 2 agents have very simi-
ulation and up to 10% in diabetic patients.6 Women are lar solubilities and terminal half-lives (triamcinolone =
more commonly affected, and the disease has the highest 3.2-6.4 days, methylprednisolone = 1.8-7.2 days),
predilection for the thumb and ring finger.5 Trigger finger is whereas the half-life of dexamethasone is nonapplica-
characterized by painful catching or locking of a finger or ble.24 The authors caution that inferring pharmaceutical
324
properties correlate with clinical effectiveness is difficult
due in part to the subjective nature of patient and physi-
cian-reported outcome.24 Our observations that the rate of
additional injection (triamcinolone > dexamethasone >
methylprednisolone) and subsequent surgery (methyl-
prednisolone > dexamethasone > triamcinolone) are not
readily explained by these properties.
The operating surgeons were also surveyed regarding
their protocols for patients who return to follow-up with
persistent symptoms of trigger finger. There are multiple
variables in this decision-making process including a his-
tory of prior trigger fingers that eventually required sur-
gery or the patient’s risk of undergoing conscious sedation
or general anesthesia. However, all of the surgeons replied
that they ultimately give the patient the option of another
injection versus proceeding with surgery. Anecdotally,
they admit that the decision to proceed directly to surgery
may be influenced by the complete absence of change
after first injection. Alternatively, the patient returning
with measurable but incomplete relief is more likely to
attempt a second injection. Although all patient education
is persuasive to some degree, we believe that the fact that
all hand surgeons offer a similar clinical pathway mini-
mizes the potential for bias that could otherwise account
for our findings.
The results of this study suggest that patient presenting
with similar grades of triggering may have different
responses to injection depending on the specific type of
steroid used. This may be the result of different efficacy of
the steroid. There are several limitations of this study
which could also result in these findings. First, this is a
retrospective study from a single institution which may
result in limitations to its generalizability. The observation
that different clinical outcomes are attributable to the spe-
cific steroid used could be due to unrecognizable differ-
ences in treatment protocols for individual each surgeon.
As mentioned earlier though, all surgeons discuss the
option of a second injection to an otherwise straightfor-
ward trigger finger patient. Another limitation of this
study relates to the distinction between recurrence after
initial resolution of symptoms and the simple absence of
relief from triggering after injection. Unfortunately, the
nature of a retrospective review and the reliance on clini-
cal documentation make this distinction unreliable at best.
In addition, the limited time of follow-up may be insuffi-
cient and result in underreporting this observation. Finally,
the length of follow-up was statistically different among
the 3 groups with methylprednisolone having the shortest
follow-up and triamcinolone having the longest. This may
be somewhat predictable given the fact that the methyl-
prednisolone group underwent definitive therapy earlier
and had fewer injections. Ultimately, a double-blinded
study comparing all 3 steroid types is needed to confirm
the results of this study.
HAND 16(3)
Conclusions
Three steroid cohorts with similar demographic and clinical
presentations were compared with one another. There were
several statistically significant differences regarding the
number of additional injections, eventual need for surgical
release, and the time from initial injection to surgery.
Patients receiving triamcinolone were more likely to
undergo additional injection. Patients who received methyl-
prednisolone underwent surgical intervention earlier and
significantly more frequently compared with the 2 other
groups. A prospective, blinded study is needed to defini-
tively determine whether the type of injectable steroid used
to treat trigger finger is related to differing outcomes.
Ethical Approval
This study was approved by our institutional review board.
Statement of Human and Animal Rights
This article does not contain any studies with human or animal
subjects.
Statement of Informed Consent
No identifying details of any patient were included in this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Kenneth F. Taylor https://orcid.org/0000-0001-5310-9809
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