Diabetes & Tigger Finger

I recently had the article below published by Diabetes Daily. You can find it here on their site. Trigger Finger is something I’ve personally dealt with in the past, having to eventually have minor surgery to address the issue. I hope anyone reading this finds the article interesting and informative.

Diabetes and Trigger Finger

Diabetes is a chronic condition that increases the risk for serious health problems for those saddled with the disease. Among the most common complications connected to diabetes are cardiovascular disease, neuropathy, retinopathy and depression. One of the lesser known conditions is trigger finger, or stenosing tenosynovitis.

Trigger Finger is a musculoskeletal ailment that affects the ligaments and tendons in the hand. Those dealing with this condition have a finger or thumb that gets stuck in a bent position, then the digit straightens with a snap, not unlike a trigger being pulled then released.

Trigger finger is more common in women than men and occurs most often in people between the ages of 40 and 60. The condition occurs when there’s an overgrowth or swelling of tissue in the tendon sheath of the flexor muscles. When the tendon can no longer glide smoothly through the sheath, it catches and remains bent. It releases with a painful click as it straightens.

What’s the connection?

The cause of trigger finger is unknown, but there are a number of factors that increase the likelihood of developing the condition. One of those factors is diabetes. Trigger finger gets lumped with other diabetes-related joint conditions, including frozen shoulder, diabetic stiff hand syndrome and carpel tunnel syndrome.

Trigger finger is fairly common complication of diabetes, particularly in long-standing diabetes. It’s thought that chronically elevated blood glucose levels cause the connective tissue to become glycated, which means an irreversible bond between glucose and protein forms in the tissue which damages it.

This condition affects 2 to 3 percent of the general population, but 10 to 20 percent of those with diabetes.

Trigger Finger Treatment

Treatment for this condition varies depending on its severity. Anti-inflammatory drugs like ibuprofen or naproxen may relieve the pain but typically won’t address the underlying tendon issue. Noninvasive treatments include rest, wearing a splint and specific stretches.

If the conservative treatments don’t work, doctors often suggest one of two more invasive options: a corticosteroid injection or surgery. Sometimes called a trigger finger release, the surgery is an outpatient procedure completed under local anesthesia.

Concerns with Corticosteroid Injections and Diabetes

Corticosteroid injections are commonly used to treat a variety of hand and wrist conditions. The local injection involves administering the medication near or into the tendon sheath in order to reduce inflammation and it has the potential for a definitive cure in the case of trigger finger. This option for diabetic patients comes with caveats though.

A 2007 study by the Washington University School of Medicine found that corticosteroid injections were significantly more effective in the digits of nondiabetic patients than those of diabetic patients. In patients with diabetes, the injections did not decrease the surgery rate or improve symptom relief when compared to the placebo group of the study.

Additionally, the study cited a pair of previous investigations that reported transient increases in blood glucose levels after corticosteroid injections in the hand or wrist. The study noted a varying impact on glucose control in participants.

What to do when suffering with Trigger Finger and Diabetes

If you’re suffering from trigger finger as a diabetic, the first step is to consult your physician. Your endocrinologist may refer you to an orthopedic specialist, who will evaluate the severity of your condition. Once you have a solid grasp on what you’re facing, then you can make the best decision possible.

As with all things diabetes, you should maintain vigilant glucose monitoring, and should you elect to have a corticosteroid injection, be ready to adjust your medications accordingly.

Citation

Baumgarten, Keith M.; Gerlach, David; and Boyer, Martin I., “Corticosteroid injection in diabetic patients with trigger finger: A prospective, randomized, controlled double-blinded study.”  eJournal of Bone and Joint Surgery. 89, 12.2604-2611. (2007). http://digitalcommons.wustl.edu/open_access_pubs/847

Advertisements

Some Post-Op Pondering

So. The hand surgery ate up most of the first Friday of June–a minor procedure to correct a year’s worth of discomfort and pain. Some ten days removed from the surgery, the physical aspect remains simple, straight forward. It’s the mental unease I wasn’t prepared for. The procedure corrected a condition known as “trigger finger,” something diabetics are prone to. This development was the first to fall into the category of “complications” stemming from my disease.


Office visits with my endocrinologist have a rhythm to them. I arrive a few minutes early, check in with the secretary, exchange small talk pleasantries. “The same insurance?” she asks, her heavy Latin accent chewing up syllables.  My answer is always “Yes,” in part because diabetes is impossible to manage without insurance, but mostly because it’s too much of a hassle to change.

From there, I wait. My endocrinologist graduated from the Dr. Gregory House School of Bedside Manner, so I’m glad most check-ups are with the nurse practitioner. Her office is small–a desk dominates the space perpendicular to a patient’s exam table. We speak briefly about life, work, family, and our mutual friend’s one-year-old son–how everything is crazy, how our kids are getting too old too fast, and how we still can’t believe our friend’s luck having another baby well into his forties.

Then we discuss my numbers. Blood Sugar numbers.

Diabetes is a numbers game. And I hate numbers. Depending on how the numbers read over the past few weeks, she makes adjustments to my dosages. Then there’s a quick physical exam. I sit on the table, the crepe paper crunching with each slight shift. She checks my breathing, my heart beat, then thumbs my thyroid, my ankles. Finally, she draws three vials of blood for testing.

This is all normal. It happens during at every visit every three months or so. But after I settle back into the chair opposite her desk, and she begins inputing notes in my file, her normal question is met with an abnormal answer. She asks if I was having any other issues, and while normally the answer is no, this time, it’s yes.

I describe to her the discomfort I’d been feeling in my hand for the better part of a year. The pain had grown progressively worse over the last several months and I realized it wasn’t simply soreness or a bruise. That’s when she said it:

“It’s diabetic nerve damage.” She nodded from behind her desk. “Let me give you the name of the orthopedic we work with. He’s really good.”


Trigger finger is a painful condition that causes the fingers or thumb to catch or lock when bent. It happens when the tendon in the finger becomes inflamed, preventing the tendon from gliding easily through the tissue that covers it. Diabetes is a cause, and it’s a condition more common in women and tends to happen most in people 40-60 years old.

hand
It’s a half-inch scar. Size doesn’t matter.

The symptoms start small–soreness at the base of the affected finger. The most common symptom is painful clicking or snapping when bending or straightening the finger. The catching sensation tends to get worse after resting and loosens up with warmth and movement. It’s not a dangerous condition by any means, but it can affect quality of life. I spent months thinking it was soreness from yard work, or a bruise, but by the time I was ready to talk to my doctor about it, I couldn’t serve myself coffee with my right hand in the mornings. I couldn’t shoot a basketball correctly.

After meeting with the orthopedic, I was given three options: wear a splint for 6 weeks and see if that helps, take steroid injections that might help and will certainly shoot up my blood sugar, or corrective surgery.

 


An intern removed my stitches. He was going to use a suture removal kit, until the nurse handed him a new suture knife. He took to it like a child with a new toy. It was a moment before he got the feel for it. He mentioned my stitches were wrapped tightly. No shit.

The surgeon and his bow tie came in after–I had to wait a while. He showed me a few exercises I’d probably go over with the PT, then mentioned it was weird to have a case of trigger finger in someone before the age of forty. He also said it’ll probably happen again.

“You’ve got nine other ones.” He wiggled his digits in some perverse spirit finger promise.  “At least you’ve got me for when it happens again.” With that, he left.


Type 1 diabetes increases the risk of developing several medical complications, but the risk of these complications decreases with better blood sugar control. Diabetes is a game of numbers.

Tigger finger lines up with diabetic neuropathy, or nerve damage. The biggie for me, and most diabetics, is blindness caused by diabetic retinopathy. It’s the leading cause of blindness among working-age adults. Yikes. Then there’s other stuff like heart disease, kidney damage, and even depression, known as “diabetic distress.”

Like I said, diabetes is a numbers game. What’s my blood sugar? What’s my A1c? How many carbs am I eating? What should my insulin dose be? How many hours will it be until I need to eat again? It’s stressful, dare I say, distressing. “Diabetic Distress” seems like a silly name for it, but I get it. According to the American Diabetes Association (ADA), it’s more common than clinical depression and affects almost half of all the people with Type 1. I feel like I struggle sometimes, but I’m not sure I suffer from this complication.

My biggest question when pondering these complications had to do with life expectancy. Good news on this front though. According to the Juvenile Diabetes Research Foundation, life expectancy in people with Type 1 is no different than the general population. A 2012 study published by the Diabetes Journal found that people with Type 1 diagnosed between 1965-1980 had a life expectancy of 69 years, a marked improvement compared to those diagnosed in the 15 years prior, who had an average life expectancy of 53. I was diagnosed in 1993, so I’m probably immortal.

A1c Table

Unlike Alice, this rabbit hole I fell down has a solid, sane floor. Of all the numbers in this game, A1c is probably the most important. The Hemoglobin A1c test measures, generally, the glucose concentration in your blood. Red blood cells live about three to four months, so this measure indicates what percentage of the hemoglobin is glycated (read: covered in sugar) during that time. Non-diabetics measure less than 5.7%. Pre-diabetics measure 5.7-6.4%. Diabetics measure above 6.5%. Most doctors set a diabetic’s A1c goal at 7% or below, and while that still puts us at risk for long-term complications, it’s the best bet. My last A1c was 7.3%. Not my best work, but not terrible.

 


The hand surgery ate up most of the first Friday of June, leaving a little scar as a reminder. The orthopedic was good. Less than two weeks out, I’m already closing my fist.  I have an appointment at my endocrinologist’s office coming up soon, and I’m sure there will be a new rhythm to that visit, a new A1c number. Diabetes might be a numbers game, but I’m a pretty good player.