Trigger thumb is among the many common conditions we treat via occupational therapy and trigger thumb release surgery at Proliance Hand, Wrist and Elbow Physicians. As with trigger fingers, trigger thumb patients typically experience a click or locking sensation in the afflicted thumb as the hand goes from a grip position to an open palm or vice versa. Experts believe that overuse or repetitive activities may cause trigger digits, even though the exact cause remains unknown. While they often associate with other conditions such as diabetes or carpal tunnel syndrome, they can also exist independently. Trigger fingers and thumbs can be particularly bothersome in the morning as they often become “stuck” overnight.
Why is my thumb clicking and painful?
The best explanation we have for why trigger digits hurt involves a tunnel that’s too tight for a tendon to easily move through. This too-tight fit manifests itself as pain and a clicking sensation. Our article on trigger finger release symptoms discusses this more in depth. Classically, overuse mechanically irritates and leads to the thickening of the flexor tendon and/or tendon sheath. This can manifest as a swollen area with a small, moving nodule in the palm.
As the nodule gets larger and friction increases, the finger goes from just painful to painful clicking to painful locking. At the locking phase, the thumb or finger is no longer able to fully mobilize on its own without using the other hand to force the digit open or closed. The worst trigger thumbs are those that present completely stuck and are unable to mobilize even when applying gentle force.
What do we know about trigger thumb release treatment?
Despite the fact that finger and thumb triggering is one of the most common issues a hand surgeon sees, trigger thumbs seem to always get lumped together with fingers. There are limited studies on trigger thumbs alone. Conservative management is very similar to trigger fingers and can include patient observation, splinting, anti-inflammatory medications, and corticosteroid injections.
Much like trigger fingers, natural history has been studied for trigger thumbs and there are reports of complete symptom resolution at an average of 6.8 months without any particular treatment. Unfortunately, many patients do not see relief with any conservative management and they elect to proceed with trigger thumb release.
When should trigger thumb release surgery be performed?
Trigger thumb release surgery is currently being researched more deeply as some surgeons are pursuing a more minimally invasive approach. Much like our trigger finger sheath system, the anatomy of a thumb flexor sheath includes a proximal annular pulley (A1), a variable annular pulley (Av), an oblique pulley, and a distal annular pulley (A2). Most trigger thumbs generally involve the pathology of the A1 pulley, and surgeons use special care to preserve the oblique and A2 pulleys to avoid complications.
The goal of trigger thumb release surgery
In surgery, the A1 pulley is divided to create more space for the flexor tendon and resolve the pain that occurs with powerful grip. Many studies demonstrate that performing an open release under local anesthesia can largely achieve low rates of recurrence. One study even showed the complete resolution of symptoms after trigger thumb release surgery is on average about 1.5 weeks afterwards as compared to 5.2 weeks for trigger fingers.
Recent surgical research has explored performing this trigger finger and thumb release entirely percutaneously. This means that there is no incision and only a needle is used to divide the A1 pulley. However, the particular anatomy of the digital nerve in relation to the A1 pulley causes surgeons to prefer the procedure that allows visualization of the nerve.
While some surgeons perform and advocate percutaneous trigger thumb releases, nerve injury complications do occur in approximately 5.7% of these procedures. The 2020 American Society for Surgery of the Hand president Martin Boyer once wrote a commentary that summarizes the current nature of percutaneous trigger thumb releases: “Percutaneous release adds an unnecessary layer of risk and complexity to a treatment that is straightforward and has withstood the test of time.” So while many surgeons continue to advocate for percutaneous trigger thumb release, it may be that the latest and greatest is not an improvement on the tried and true!
How Can Proliance Hand, Wrist and Elbow Physicians Help?
A consultation with Proliance Hand, Wrist and Elbow Physicians can help determine if your hand suffers from trigger thumbs. Our highly skilled occupational therapists are onsite at our Kirkland and Bellevue offices for your convenience. Whether it is time to try a splint, a steroid injection or surgery for your trigger thumb, our staff can help you find relief today at any of our five convenient Eastside locations.
About the Author:
Samuel E. Galle, M.D. is a board-certified orthopedic surgeon with subspecialty fellowship training in conditions of the hand and upper extremity. He has published numerous peer-reviewed articles and surgical technique videos. He lives in Kirkland, WA with his wife, two kids and one especially spoiled Cavalier King Charles Spaniel.
