Graston Technique Improves Trigger Finger Treatments

Trigger Finger Causes and Treatments

Trigger finger, also known as stenosing tenosynovitis, produces a snap or sticking feeling as the tendon slides through the tendon sheath. Damage to either the tendon or sheath leads to inflammation and narrowing of the space within the sheath. As the condition worsens, it becomes more difficult for the finger to extend. It becomes "stuck" and clicks or snaps as the nodule slides through the sheath. At this point people feel a soft tissue nodule that is tender to the touch and is preventing normal tendon gliding through the sheath. Worse yet, the finger becomes locked or stuck in a bent position when the nodule is too large to fit inside the tendon sheath.

Trigger finger can affect any finger tendon leading to the digits or thumb. It is common in the palm of the hand or at the "knuckle." Most commonly the nodules form at the base of the fingers or digits on the palm side of the hand. Some people develop trigger finger in only one finger, while others are affected at multiple fingers or thumbs.

Early and mild to moderate cases of trigger finger can be treated with Graston Technique, cold laser, massage therapy, acupuncture, occupational therapy, and physical therapy. Severe cases may require fasciectomy or fasciotomy to reduce the scar tissue or excessive collagen formation. An incision is made near the nodule, and the operation removes the scar tissue preventing tendon sliding. Other cases may respond to needle injection of collagenase, which is an enzyme that helps break down collagen or scar tissue bonds.

Causes of Trigger Finger

The finger tendon or sheath can become irritated and inflamed with both acute and chronic traumatic activity. Damage to the tissue interferes with the normal gliding motions of the tendon through the sheath, creating more irritation which can lead to scarring and tendon thickening. Eventually the thickening produces the formation of nodules (bumps) that prevent the normal gliding motion.

Excessive amounts of collagen or scar tissue is being formed on top of the injured tendon. Occasionally in the body it forms excessive amounts of scar tissue to overuse or repetitive trauma. Scar tissue formation is normally utilized as a "short-term patch" within the body, giving it time to properly repair and heal.

Normally scar tissue is removed within a short period of time. However in some cases scar tissue continues to accumulate. This is the nodule people feel in their hand and fingers that continues to increase in size over time.

Some people are more at risk for developing trigger finger, especially if they are in occupations, sports, activities, or hobbies that involve repetitive hand use with gripping. Repeated strain on the finger tendons increases the likelihood of developing trigger finger.

It is also more common with certain health conditions such as rheumatoid arthritis or diabetes. It is also more common in females compared to males.

The formation and development of nodules occur at different rates in different people. Some people experience a very slow gradual development of the nodule and clicking sensations. Other people experience a faster onset that quickly develops a clicking within one to two months. A faster onset is more likely to occur with a recent finger or hand injury that damaged the tendons and limits the ability to straighten or move the finger.

Diagnosis

Diagnosing hand tendon injuries begins with the mechanism of injury. Acute and traumatic hand injuries are more likely to causes avulsions, fractures, or acute compression syndromes. Chronic repetitive activity is more likely to produce tendinitis or tenosynovitis.

Physical exams and history reveals the location of pain and probable tissue injured. Changes in sensation, blood flow, strength, and flexibility are also important in the examination and diagnoses. X-rays may be helpful to evaluate the bones for acute fractures or avulsions. An MRI is better at showing tendon tears and joint cartilage damage, or avascular necrosis of the scaphoid.

In most cases diagnosing trigger finger is relatively simple. Especially if there is clicking and "popping" causing altered finger flexing and extending. A soft tissue nodule causes a "clunk" as it enters the sheath.

Evidence of locking along with the mild palpable pain around the lump indicates trigger finger. Most times diagnosing trigger finger does not involve advanced imaging or additional tests, especially without a history of trauma or possible fracture.

Anatomy of Hand: Bones, Muscles, and Tendons

There is a complex network of tendons, sheaths, nerves, arteries, veins, and muscles in the hand. The tendons insert on specific locations of the carpal, metacarpal, and phalanges. In the palm of the hand are the longer metacarpals which connect to the phalanges. The phalanges or fingers can also be referred to as digits.

Any of the tendons can develop a soft tissue nodule, the finger flexors are the most common. Smaller hand muscles include the lumbricals, opponens pollicis, adductor pollicis, opponens digiti minimi, abductor digiti minimi, dorsal interosseous, flexor digiti minimi brevis, and abductor digiti minimi. Each of these muscles produce a distinct movement in the fingers to allow for flexion, extension, abduction, and abduction movements. Most people are amazed by the amount of muscles in the hand.

Graston Technique for Trigger Finger

Graston Technique is utilized in many professional, Olympic, and collegiate sports therapy programs. Specifically-designed stainless steel instruments have rounded, concave and convex edges. The edges are not sharp. Graston tools are classified under Instrument Assisted Soft Tissue Mobilization (IASTM) and are used to detect and effectively treat soft tissue fibrosis or chronic inflammation. With these instruments the practitioner can scan over and detect areas of fibrotic tissue.

There are six different Graston tools to help break up fascial restrictions or scar tissue that develops after trauma to muscles, ligaments, tendons, or fascia, which is commonly referred to as soft tissue. Scar tissue forms when tissue does not heal correctly, or is under chronic, repetitive stress. Scar tissue is weaker than normal muscle and connective tissue, which is why it becomes chronically sore with activity.

What is Scar Tissue and Fascial Adhesion?

Scar tissue accumulates in the body whenever tissue undergoes excessive stress and strain. Scar tissue is like the body's duct tape; it is meant as a short term patch to help support tissue. However, in some cases the scar tissue is not replaced with normal collagen fibers. Scar tissue is also referred to as fascial adhesions, as it causes restrictions between the body's fascia. Stiffness, loss of normal range of motion and chronic pain develops from patches of fascial adhesions.

The next time a scar tissue patch undergoes stress and strain it becomes aggravated and flares up. This process causes more scar tissue to be added to the outside of the patch and the process repeats itself over and over, leading to larger accumulation of scar tissue patches.

I like to describe scar tissue patches as "onions." Scar tissue ends up growing in layers around the initial injury. Stress to the area aggravates the outside layers and triggers another layer to be formed. The layers further from the center are easier to aggravate than the inside layers, which is why the onion continues to grow in size without causing the inside area to properly repair.

How Graston Technique Improves Treatment

Adding Graston Technique to any treatment decreases overall treatment time. It reduces the need for anti-inflammatory medication and enhances rehabilitation. Many patients with chronic conditions show significant improvement with IASTM. Your provider is trained in how to properly utilize the instrument assisted soft tissue mobilization of either Graston, Gua Sha, and ASTYM. Basic concepts and treatments with IASTM:

• Reduce the stress and strain to the injured areas.
• Decrease inflammation.
• Increase muscle flexibility and strength.
• Increase blood flow.
• Break up scar tissue.
• Promote proper tissue repair.
• Enhance functional movements.
• Accelerate fibroblast activity.

Home therapies are recommended to limit further scar tissue formation, encourage proper healing and speed up recovery. Braces and supports may be recommended for specific injuries.

Pulling Fascia Apart to Break Up Scar Tissue

Graston Technique works by stretching the outer layer of the "onion" and breaking it into several pieces. The Graston instruments use shear force to pull the top fascial layer across the bottom fascial layer. This pulling motion breaks up the scar tissue between the layers. The broken scar tissue triggers healing mechanisms to migrate into the tissue and properly repair the muscles and soft tissues.

Ice therapy helps limit additional scar tissue formation, inflammation, and pain. The next office visits breaks up the next layer of scar tissue, working toward the center of the onion. The goal is to get to the center of the onion so the body can fix the original problem.

Many sports therapy chiropractors, physical therapists, doctors, and athletic trainers have been properly trained in how to utilize the Graston tools.

Expectations of Therapy

Graston Technique is not meant to be painful and should be performed at a comfortably tolerable level to break up scar tissue. Being too aggressive with Graston Technique, Active Release Technique, manual therapy, cross friction therapy, or massage therapy causes excessive pain and actually slows the repair process by flooding the area with inflammation.

Treatment usually lasts a few minutes per area or region. As the treatment tool slides across the soft tissue fibrotic areas, the injury may feel bumpy or sandpaper-like. Redness and mild swelling may develop with treatment, especially after the first few treatments. In some cases, small petechiae or bruises may develop post-treatment. Ice therapy is commonly utilized post-treatment to limit the bruising, pain, and inflammation.

Most people notice a significant difference after 4-6 visits. Severe cases may take a little longer to see significant improvement. Runners, triathletes, and weekend warrior athletes have all benefited from this therapy. Over the course of treatment, most patients notice that less bumpiness, sandpaper, and tenderness is felt around the injury. As the treatment progresses, your healthcare provider will be able to apply more pressure, thereby treating deeper and deeper tissue levels.

Conservative Treatments Combined with Graston Technique

Therapeutic treatments for addressing soft tissue injuries involve massage therapy, manual therapy, trigger point therapy, or Active Release Technique combined with Graston Technique. These treatments increase blood flow, decrease muscle spasms, enhance flexibility, speed healing, and promote proper tissue repair.

When these treatments are incorporated into a treatment plan patients heal faster and are less likely to have long-term pain or soft tissue fibrosis or scar tissue in the injured muscle. These soft tissue treatments are integrated with therapeutic exercise and flexibility programs.

Soft tissue treatments restore proper muscle function and flexibility; and exercise restore strength, endurance, and neuromuscular control. Neuromuscular control is especially important and often not emphasised in many therapy clinics.

For any joint to work optimally the muscles need to contract and the exact right time. In many chronic injuries the muscles are not "firing" correctly leading to excessive strain on neighboring muscles and tendons. Many chronic rotator cuff injuries are the result of poor neuromuscular control.

Treatment for shoulder injuries often requires a variety of specific exercises, stretches, conservative treatments, medical treatments, and home therapies. Shoulder injuries can become chronic if all the muscles, tendons, and ligaments are not properly treated. Think of all the people who complain of their chronic rotator cuff or supraspinatus.

Elbow injuries often occur in people with severe or chronic shoulder and wrist injuries. People begin trying to alter their shoulder or hand motions to protect the original injury. Unfortunately these altered body mechanics tend to overwhelm the muscles and tendons around the elbow. People often develop a secondary cubital tunnel syndrome, lateral epicondylitis, tricep tendonitis, medial epicondylitis, pronator teres syndrome, double crush, carpal sprains, wrist tendinitis, de quervain's tendonitis, finger extensor strains, or carpal tunnel syndrome.

Treatment for elbow injuries can be extensive if the tendinosis is severe. Mild strains can be treated at home with PRICE, home stretches, and exercises. Don't wait for damage to both the shoulder and elbow to seek treatment and therapy.

Medical Treatments

NSAIDs are often prescribed for the initial acute injury stages. In severe cases that involve multiple joint regions, muscle relaxers or oral steroids can be given. Trigger point injections, botox, or steroid injections can be treatment options. Prolotherapy or Platelet Rich Plasma (PRP) Injection therapy can enhance healing, especially with internal joint injuries or difficult tendon injuries. Pain management is not usually required unless stronger medications or advanced joint injections are required for treatment.

MRI and X-rays will not usually be ordered to evaluate mild to moderate muscle, tendon, and ligament injuries. Severe cases may utilize advanced imaging to rule out bone fractures, edema, nerve entrapments, tendon or muscle ruptures. NCV testing may be utilized in cases that also involve muscle, sensory, or reflex loss.

Cervical spinal disc bulges and herniations onto the spinal cord or nerve root produce different symptoms and location of symptoms. Pain radiating in the hand is one symptom; along with numbness, weakness, fatigue, loss of sensation, or reduced reflexes. Your chiropractor, physical therapist, occupational therapist, or physician will evaluate your condition and make a proper diagnosis and treatment recommendations. Ask them any questions you might have about your injury.

Many people do have arthritis or degenerative changes in their elbow, wrist, finger, or thumb joints. Arthritis does not mean you will always have pain in the joints. Degenerative arthritis means the structural integrity of the bones have changed which alters its gliding, sliding, and hinging motions. The more severe the arthritic changes the easier it becomes to aggravate the joint and produce pain. Likewise joints may take longer to heal when joints have degeneration.

Osteoarthritis and rheumatoid arthritis will also slow healing and recovery time. However, arthritis does not mean a joint will always be painful. People with severe arthritis can eventually be pain free. In fact many times incorrectly blame their arthritis as the source of their pain when it is actually coming from injured tendons.

This is especially common in knee pain, where people believe their daily dull and sharp pain is osteoarthritis or meniscus tears when much of the pain is coming from chronic knee tendonitis in the small tendons that insert around the knee joint and patella bone. Graston Technique is especially effective at stimulating and enhancing tendon repair and eliminating chronic tendon pain.

Low level laser therapy is another treatment option for enhancing muscle and tendon healing. Class IV cold lasers stimulate the fibroblasts or healing cells to "work faster." Specific frequencies can also decrease inflammation in the soft tissues and inside of the joints. Combining low level laser therapy with Graston Technique enhances soft tissue healing and repair.

Conclusion

The upper extremity works as a comprehensive unit performing many of the repetitive tasks at home, work, and recreational sports. Injuries to one area of the musculature often indicate that additional damage has been incurred by other muscles.

Many therapeutic exercises can help restore proper strength and endurance to the shoulder and elbow muscles. Isometric exercises are often the initial treatment exercises. Followed by single plane rubber band exercises for flexion, extension, pronation, and supination, adduction, abduction, and rotational movements. Dynamic exercises involving stability ball push-ups can be performed on the wall or floor. The more unstable of the surface the more effort and stabilization is required of all the upper extremity muscles.

Push-ups on a stability ball enhances neuromuscular learning throughout the neck, scapula, shoulder, upper arm, and lower arm muscles. Additional strength exercises can be found on the arm and shoulder strengthening pages.

Our Chandler Chiropractic and Physical Therapy Clinic treats patients with a variety of muscle, tendon, joint, and ligament injuries. The clinic provides treatment for runners, tri-athletes, and weekend warriors in addition to common headache, neck, and back patients traditionally seen in Chiropractic, Physical Therapy, Massage Therapy clinics. We work with all ages and abilities of the residents in Phoenix, Tempe, Gilbert, Mesa, and Chandler AZ.