Tiny Trigger Thumb
A Strategy for Young Clients
By Douglas Nelson
This article was originally published in the September/October 2012 issue.
"It isn't clicking anymore. Cool, huh?" My little client, A., flashed a smile that lit up the room. She glanced at her mom, as if she needed approval to show her elation. Her mom was clearly thrilled with her daughter's progress.
This story began two years earlier, with little A.'s older brother, J., in my office and the whole family in tow. J. was 8 years old when he began complaining to his family about a pain in his thumb. Each time he would completely flex the digit, it would get stuck, and he would manually "unclick" it, which was painful. J.'s pediatrician referred the family to a hand specialist, who correctly identified the problem as trigger thumb, and recommended surgery.
Resigned to that fate, the family told J.'s piano teacher that he would miss several lessons. The piano teacher (who happened to be a client of mine) recommended they might want to consult with me before committing to surgery. Shortly thereafter, the family was in my office.
J. demonstrated his movement limitations--clearly a case of trigger thumb. While I have addressed trigger thumb in many adults, I had never seen it in someone so young. His parents were research scientists and the conversation that followed was candid. They wanted to know what my success rate was, what strategy I would pursue, and why soft-tissue treatment was a reasonable approach. I shared with them my experience with trigger thumb and the science behind my approach, but also my lack of experience addressing trigger thumb with children.
"We are conflicted about surgery," they said. "If we need to do that, we will. We'd like to explore all the options before we commit to that."
Pondering the situation for a minute, I offered them an option.
"I have an idea. First, speak with the hand specialist and find out if the surgery is time sensitive. That is, are there any downsides to waiting for four months? If he says waiting will not place your child at risk, let's plan on a four-month window of time to make a difference. If what we do isn't successful, you can still do the surgery. Sound reasonable? In the meantime, I need to comb the literature to see what I can find about presence of trigger thumb in children."
I spoke with the family about a week later to compare notes. The doctor said waiting would not be harmful in any way, but would simply delay the inevitable surgical intervention. My literature search revealed that there seems to be a genetic component to trigger thumb when it happens in children. The mechanics of trigger thumb seem to be the same as in adults, so this information did not alter my treatment protocol, but it did put the outcome slightly in question.
After comparing notes, we decided to proceed. Now it was up to me to set the game plan. My experience addressing trigger thumb had taught me that the key to success is short-duration, high-frequency sessions. Trigger thumb (and finger) is a form of tenosynovitis, an inflammation of the sheath around a tendon. The tendon affected in trigger thumb is the flexor pollicis longus, which originates all the way up the forearm near the pronator teres. While the inflammation is at the sheath, the whole muscle must be addressed. In fact, hyperaggressive treatment only at the sheath can make things worse, not better.
We decided to set a very precise protocol, one in which I would see J. in my office and the parents would also be working on J. at home every day. The home treatments lasted exactly four minutes, with emphasis placed on various aspects of the flexor pollicis longus. Every detail was scripted, as was the time allotted. His parents took the time to do this every night. At first, they brought J. into my office weekly for me, then they came less frequently. Over time, the improvement in J.'s trigger thumb was obvious. Within the four-month window, the clicking completely disappeared. The family revisited the hand specialist, who admitted that there were no symptoms and no need for further sessions.
I was surprised, then, to get a phone call from the family two years later. I assumed that J. had a relapse.
"No, this isn't about J.," his mother told me. "This is about A., his little sister. That genetic component of trigger thumb in children seems to hold true. Can we use the protocol we established with J. to help our daughter?"
Thus began round two, following almost exactly the same procedure. These amazing parents worked with A. consistently, and the most noticeable improvement began after week six. With A. now beaming and making goofy faces as she flexed her thumb painlessly, the room erupted in laughter and celebration.
Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com or email him at firstname.lastname@example.org.