Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Trigger Finger or Thumb


Related Terms

  • Stenosing Tenosynovitis

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Rheumatologist

Comorbid Conditions

Factors Influencing Duration

If the dominant hand is involved, ability to perform work tasks requiring fine motor skills, such as writing or typing, may be limited. The individual may need to temporarily reduce repetitive motions or other activities that aggravate the symptoms. Effective treatment usually overcomes the need for activity restrictions within 6 weeks. For surgical treatment, those with heavy or very heavy work often take longer to get back to that level of work.

Medical Codes

ICD-9-CM:
727.03 - Trigger Finger (Acquired)

Overview

© Reed Group
Trigger finger or thumb refers to a sensation when the fingers or thumb feels stuck or temporarily catches or snags during efforts to straighten (extend) or bend (flex). In early stages, there may simply be a click with movement, tenderness in the palm over the tendon, and a diminished range of motion with a gradual loss of full flexion or extension of the finger or thumb.

Trigger finger may be due to stiffness of the first annular pulley or from thickening of the tendon (or the synovium surrounding the tendon) (Miyamoto). Rarely there is inflammation that narrows the tunnel (flexor sheath) where the tendon glides back and forth to allow movement of the fingers. The tendon itself may develop a knot (nodule) caused by irritation from rubbing against the narrowed tunnel walls of the sheath. During initial attempts at finger motion, the tendon tries to move the finger but encounters resistance to movement as the swollen part of the tendon tries to move through the narrowed part of the tunnel. During further attempts at digit motion, the tendon nodule pulls through the short tunnel, and a snapping sensation (triggering) accompanied by pain may then be felt. The snapping movement likely will create more irritation to the affected area, resulting in even more inflammation and swelling that creates additional narrowing and interference with finger movement. This cycle of damage can result in the finger or thumb becoming stuck or locked, with movement becoming increasingly painful and difficult.

The cause of most cases of trigger finger is unknown (idiopathic). In some cases, the condition is associated with repetitive forceful grip activity. Stenosing tenosynovitis is caused by synovial proliferation and fibrosis and is associated with diseases such as rheumatoid arthritis, gout, diabetes, and kidney (renal) failure.

Incidence and Prevalence: Trigger finger or thumb is a relatively common condition. It has a higher incidence (75%) in women than in men. Most cases occur in individuals between 52 and 62 years of age (Foye). It often occurs in both hands (bilateral).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Studies suggest some evidence for trigger finger and occupational risk factors, including force and repetition, force and posture, vibration, and highly repetitive work. Individual risk or non-occupational factors include diabetes. For more information, please refer to "Disease and Injury Causation," page 159.

Source: Medical Disability Advisor



Diagnosis

History: A sensation of discomfort or pain may begin in the base of the thumb or finger. Individuals may report a limited range of motion that progresses to snapping or locking of the finger or thumb during grasping and releasing of the hand. As the condition progresses, some individuals report that passive assistance or forceful voluntary effort is required to correct it. Pain and swelling over the palm of the hand near the metacarpal head may be noted. Swelling or stiffness in the fingers, particularly in the morning, may be reported. Pain with motion is more common with trigger thumb; reduced range of motion is more common with trigger finger (Silver). Individuals may report a history of repetitive or sustained activities such as gripping.

Physical exam: Finger and thumb movements may be observed through bending and straightening each joint (flexion/extension). Snapping and locking in the affected area may be noted with range of motion movements. A mobile nodule in the affected tendon may be detected through touch (palpation) at the palmar aspect of the metacarpal head (annular pulley 1 or A-1 pulley); it is usually point tender.

Tests: Diagnosis of trigger finger or thumb typically is based on the individual's history and results of physical examination (clinical diagnosis). X-rays may be used to rule out bone or joint abnormalities, especially if the individual has a history of arthritis or injury (trauma) to the affected area. An MRI is rarely required to confirm tenosynovitis of the flexor sheath (Silver).

Source: Medical Disability Advisor



Treatment

In the absence of vascular disease, application of ice packs to the palm of the hand for 20 minutes 2 or 3 times a day may be recommended. Anti-inflammatory medications to reduce swelling also may be prescribed. Treatment plans generally include corticosteroid injections into the tendon sheath. These are reported to be from 64% to 93% successful (Murphy; Rhoades); however, individuals with diabetes do not respond as well to corticosteroid injection and have only a 50% success rate (Stahl).

Splinting can be effective but most individuals are unwilling to wear a splint on affected fingers for up to 6 weeks to reduce swelling and allow hand and finger movement to return to normal. Additionally, splinting of the thumb is very difficult and severely limits hand function. Splinting has been shown to resolve early trigger finger in 55% of a manual labor population (Rodgers).

The individual may be advised to avoid activities, particularly repetitive ones, that irritate the affected area. Padded gloves may be worn to provide protection from direct trauma (Silver). If the pain is not reduced, or if the clicking / locking of the digit is not alleviated by the nonoperative protocol, the physician may consider surgery to open the tunnel area and allow freer movement of the tendon (open surgical release) (see Tendon Release). Percutaneous tendon releases are less invasive and may be as effective as open procedures (Hegmann; Wright).

Source: Medical Disability Advisor



Prognosis

Prognosis usually is very good. Some individuals recover spontaneously; most require corticosteroid injection with or without associated splinting. Some individuals may require up to three injections, but approximately 90% of cases are resolved satisfactorily. Surgery (open surgical release) usually has a very good outcome (Foye), although recovery may take several weeks. Ongoing (chronic) or recurring problems may result if the condition and accompanying inflammation are caused by an underlying disease. Some spontaneously resolved cases can recur without any known correlation with treatment or aggravating factors (Foye).

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation of trigger finger or thumb addresses the constriction of the tendon sheath. Because corticosteroid injections are effective in up to 80% of cases, formal physical or occupational therapy is usually not necessary for this condition unless surgery is required. (Hegmann; Ferri). Splints may be tried for those who do not wish to have any injections, and wearing padded gloves may help to reduce direct trauma to the affected digit (Silver). An ergonomic assessment may be useful for workplace modifications to reduce the risk factors associated with this condition, and the individual should be instructed to avoid aggravating activities.

In severe cases of trigger finger or thumb, rehabilitation may be helpful as an adjunct to corticosteroid injection or following tendon release surgery (Silver). Modalities such as ice massage and therapeutic ultrasound may be used to reduce pain and inflammation, and the individual is instructed in a home exercise program for stretching and strengthening to reduce the risk of joint contracture and restore the hand to full function. Occupational therapy may be recommended following surgery to restore normal hand movement.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistTrigger Finger or Thumb
Occupational / Hand / Physical TherapistUp to 4 visits within 6 weeks
Surgical
SpecialistTrigger Finger or Thumb
Occupational / Hand / Physical TherapistUp to 6 visits within 6 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

The triggering condition may recur in the affected area or, more commonly, in another digit of the hand. Even after treatment, other conditions involving inflammation of the tendons (tendinitis and tenosynovitis) may remain active. Unresolved cases of trigger finger or thumb may result in increased pain and decreased functional use of the hand.

Digital nerve laceration can occur during surgery resulting in numbness to the digit and requiring additional surgery for nerve repair (Carrozzella; Thorp).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions may include temporarily limiting or avoiding forceful grip of the affected hand, which may be protected by a splint. Individuals who require full use of both hands for job tasks may need to be reassigned to other duties until the condition improves. For more information, please refer to "Work Ability and Return to Work," pages 204-205.

Risk: Risk for injury is low. Even in severe cases it is very rare for the involved tendon to rupture. Digits that do not move may become permanently stiff.

Capacity: Capacity or grip strength and hand dexterity are minimally affected. However the individual may feel pain with activities (see tolerance) and therefore limit the use of the affected hand.

Tolerance: The decision to stay at work or return to work is primarily based on tolerance. If it hurts to grip, some individuals will choose not to work while other will.

Accommodations: If griping is painful, the key is accommodation. Can the job be done with less forceful grip? Trigger finger release surgery is almost always successful; thus trigger finger is rarely a reason for any permanent work accommodation.

Source: Medical Disability Advisor



Maximum Medical Improvement

28 to 42 days post surgery.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has diagnosis of trigger finger/thumb been confirmed?
  • Have conditions with similar symptoms been ruled out?
  • Is trigger finger/thumb associated with an underlying disease, such as rheumatoid arthritis or diabetes mellitus that may affect recovery?

Regarding treatment:

  • If underlying cause or aggravating condition is known, how is it being managed?
  • Would splinting the affected fingers or thumb encourage healing and recovery?
  • Were anti-inflammatory medications or ice packs successful in reducing the swelling? If not, are corticosteroid injections now indicated?
  • Would padded gloves be useful in protecting the hands?
  • If surgery was required to open the tunnel area, was it followed by physical or occupational therapy to restore normal hand movement?

Regarding prognosis:

  • Was condition resolved by surgical intervention?
  • Did individual experience any complications as a result of the open surgical release?
  • If inflammation was caused by an underlying disease, how is that condition being addressed?
  • Is there a chance that chronic inflammation may cause recurring trigger finger problems?
  • If condition developed relative to a certain occupation or repetitive task, will individual be able to avoid that activity?
  • Have methods of performing job tasks been evaluated?
  • What preventive measures are being taken to avoid recurrence?

Source: Medical Disability Advisor



References

Cited

Carrozzella, J. P., et al. "Transection of Radial Digital Nerve of the Thumb during Trigger Release." Journal of Hand Surgery 14 (1989): 198-200.

Ferri, Fred, ed. "Trigger Finger (Section I - Diseases and Disorders)." Ferri's Clinical Advisor 2010. Mosby Elsevier, 2010.

Foye, Patrick M., and Todd Stitik. "Trigger Finger." eMedicine. Eds. Robert E. Windsor, et al. 9 Aug. 2012. Medscape. 24 Apr. 2013 <http://emedicine.medscape.com/article/328996-overview>.

Hegmann, Kurt E., and Matthew A. Hughes. "Chapter 11 - Hand, Wrist and Forearm Disorders." Occupational Medicine Practice Guidelines. Ed. Kurt E. Hegmann. 2nd ed. ACOEM, 1-156.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Miyamoto, H. , et al. "Stiffness of the first annular pulley in normal and trigger fingers." Journal of Hand Surgery 36 (9) (2011): 1486-1491.

Murphy, D., et al. "Steroid Versus Placebo Injection for Trigger Finger." Journal of Hand Surgery 20 (1995): 628-631.

Rhoades, C. E., et al. "Stenosing Tenosynovitis of the Fingers ans Thumb." Clinic Orthop 190 (1984): 236-238.

Rodgers, J. A. "Functional Distal Interphalangeal Joint Splinting for Trigger Finger in Laborers: A Review and Cadaver Investigation." Orthopedics 21 (1998): 305-309.

Silver, Julie K., et al. "Trigger Finger." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Stahl, S., et al. "Outcome of Trigger Finger Treatment in Diabetes." Journal of Diabetes Complications 11 (1997): 287-290.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Wright, Phillip E. "Chapter 73 - Carpal Tunnel, Ulna Tunnel and Stenosing Tenosynovitis." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Source: Medical Disability Advisor






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