Key messages
1. A single injection of a medicine called an NSAID (non-steroidal anti-inflammatory drug) to treat trigger finger offered little to no benefit 6 months later
2. One injection of an NSAID may not work better than one injection of a steroid to treat the symptoms of trigger finger
3. More people may continue to have moderate to severe symptoms 3 to 6 months after an NSAID injection compared with those who had a steroid injection
4. There were no differences in the numbers of unwanted effects reported after injections of either type of medicine (steroid or non-steroid)
What is trigger finger?
Trigger finger is a condition that affects one or more of the tendons in your hand. Tendons are tissues that join muscle to bone, to let you move your joints. When a tendon in your hand is swollen and inflamed, bending the affected finger is difficult and painful. Without treatment, the affected finger may become permanently bent, making everyday tasks difficult.
Treating trigger finger
For some people, trigger finger might get better without treatment. If it doesn't, treatments include:
1. rest - avoiding certain activities;
2. physical therapy;
3. strapping the finger to a piece of plastic (splint) to reduce movement;
4. medicines known as NSAIDs taken by mouth or directly through the skin to reduce pain; and
5. steroid medicines injected to reduce swelling.
If none of these treatments works, surgery may be needed to help the tendon move freely again.
Why did we do this Cochrane Review?
Injecting steroid medicines into the hand to treat trigger finger may cause unwanted effects. We wanted to find out if injecting NSAID medicines into the hand could help people with trigger finger and cause fewer unwanted effects than steroids.
What did we do?
We searched for studies that tested NSAID medicines injected to treat trigger finger. We compared results of the studies we found to arrive at an overall estimate of how well an NSAID injection can treat trigger finger.
How up-to-date is this review?
We included evidence up to 30 September 2020.
What did we find?
We found 2 studies in 231 adults (average age 59 years; 60% women) who were treated for trigger finger at outpatient clinics in Singapore and Malaysia. One study lasted 3 months; the other lasted 6 months. One study did not report its source of funding; the other study received no commercial funding.
In both studies, the people taking part were given one injection of either:
1. a steroid medicine (called triamcinolone); or
2. an NSAID (diclofenac or ketorolac).
What are the main results of our review?
Compared with a steroid injection, an NSAID injection may have little to no effect on:
1. whether symptoms disappear (evidence from 2 studies in 231 people);
2. how much someone can move the affected finger 3 to 6 months later (1 study in 99 people);
3. how many people still have pain after 3 to 6 months of treatment (2 studies in 231 people); and
4. how many people say their treatment was successful (1 study in 121 people).
On average, for every 100 people treated:
1. symptoms may disappear after 3 months in 34 people who had an NSAID compared to 41 people who had a steroid;
2. 28 people who had an NSAID may still have moderate to severe symptoms after 3 to 6 months compared to 14 people who had a steroid;
3. 20 people who had an NSAID may still feel pain after 3 to 6 months compared to 24 people who had a steroid;
4. 64 people who had an NSAID may say their treatment was successful compared to 68 people who had a steroid.
We are uncertain if an NSAID injection:
1. affects whether symptoms of trigger finger come back after treatment; or
2. causes fewer unwanted effects than a steroid injection (evidence from 2 studies in 231 people).
Limitations of the evidence
Our confidence in the results is limited because they come from two small studies only. These studies used different doses of steroid for injection, which may have affected our comparison of the studies. Further research is likely to change these results or increase our confidence in them..
For adults with trigger finger, by 24 weeks' follow-up, results from two trials show that compared to glucocorticoid injection, NSAID injection offered little to no benefit in the treatment of trigger finger. Specifically, there was no difference in resolution, symptoms, recurrence, total active motion, residual pain, participant-reported treatment success, or adverse events.
Trigger finger is a common hand condition that occurs when movement of a finger flexor tendon through the first annular (A1) pulley is impaired by degeneration, inflammation, and swelling. This causes pain and restricted movement of the affected finger. Non-surgical treatment options include activity modification, oral and topical non-steroidal anti-inflammatory drugs (NSAIDs), splinting, and local injections with anti-inflammatory drugs.
To review the benefits and harms of non-steroidal anti-inflammatory drugs (NSAIDs) versus placebo, glucocorticoids, or different NSAIDs administered by the same route for trigger finger.
We searched CENTRAL, MEDLINE, Embase, CINAHL, CNKI (China National Knowledge Infrastructure), ProQuest Dissertations and Theses, www.ClinicalTrials.gov, and the WHO trials portal until 30 September 2020. We applied no language or publication status restrictions.
We searched for randomised controlled trials (RCTs) and quasi-randomised trials of adult participants with trigger finger that compared NSAIDs administered topically, orally, or by injection versus placebo, glucocorticoid, or different NSAIDs administered by the same route.
Two or more review authors independently screened the reports, extracted data, and assessed risk of bias and GRADE certainty of evidence. The seven major outcomes were resolution of trigger finger symptoms, persistent moderate or severe symptoms, recurrence of symptoms, total active range of finger motion, residual pain, patient satisfaction, and adverse events. Treatment effects were reported as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs).
Two RCTs conducted in an outpatient hospital setting were included (231 adult participants, mean age 58.6 years, 60% female, 95% to 100% moderate to severe disease). Both studies compared a single injection of a non-selective NSAID (12.5 mg diclofenac or 15.0 mg ketorolac) given at lower than normal doses with a single injection of a glucocorticoid (triamcinolone 20 mg or 5 mg), with maximum follow-up duration of 12 weeks or 24 weeks.
In both studies, we detected risk of attrition and performance bias. One study also had risk of selection bias. The effects of treatment were sensitive to assumptions about missing outcomes. All seven outcomes were reported in one study, and five in the other.
NSAID injection may offer little to no benefit over glucocorticoid injection, based on low- to very low-certainty evidence from two trials. Evidence was downgraded for bias and imprecision. There may be little to no difference between groups in resolution of symptoms at 12 to 24 weeks (34% with NSAIDs, 41% with glucocorticoids; absolute effect 7% lower, 95% confidence interval (CI) 16% lower to 5% higher; 2 studies, 231 participants; RR 0.83, 95% CI 0.62 to 1.11; low-certainty evidence). The rate of persistent moderate to severe symptoms may be higher at 12 to 24 weeks in the NSAIDs group (28%) compared to the glucocorticoid group (14%) (absolute effect 14% higher, 95% CI 2% to 33% higher; 2 studies, 231 participants; RR 2.03, 95% CI 1.19 to 3.46; low-certainty evidence). We are uncertain whether NSAIDs result in fewer recurrences at 12 to 24 weeks (1%) compared to glucocorticoid (21%) (absolute effect 20% lower, 95% CI 21% to 13% lower; 2 studies, 231 participants; RR 0.07, 95% CI 0.01 to 0.38; very low-certainty evidence). There may be little to no difference between groups in mean total active motion at 24 weeks (235 degrees with NSAIDs, 240 degrees with glucocorticoid) (absolute effect 5% lower, 95% CI 34.54% lower to 24.54% higher; 1 study, 99 participants; MD -5.00, 95% CI -34.54 to 24.54; low-certainty evidence). There may be little to no difference between groups in residual pain at 12 to 24 weeks (20% with NSAIDs, 24% with glucocorticoid) (absolute effect 4% lower, 95% CI 11% lower to 7% higher; 2 studies, 231 participants; RR 0.84, 95% CI 0.54 to 1.31; low-certainty evidence). There may be little to no difference between groups in participant-reported treatment success at 24 weeks (64% with NSAIDs, 68% with glucocorticoid) (absolute effect 4% lower, 95% CI 18% lower to 15% higher; 1 study, 121 participants; RR 0.95, 95% CI 0.74 to 1.23; low-certainty evidence).
We are uncertain whether NSAID injection has an effect on adverse events at 12 to 24 weeks (1% with NSAIDs, 1% with glucocorticoid) (absolute effect 0% difference, 95% CI 2% lower to 3% higher; 2 studies, 231 participants; RR 2.00, 95% CI 0.19 to 21.42; very low-certainty evidence).