Trigger finger injection cpt

without epinephrine was injected into the surgical site. After injection but prior to making incision, the MAC group utilized an esmarch to exsanguinate the ...

The key landmark when performing ultrasound-guided injection for trigger finger is the A1 pulley at the level of the metacarpophalangeal joint (see Figs. 77.4 and 77.6 ). The most common site of pathology in trigger finger is in the flexor tendon and tendon sheath of the flexor digitorum superficialis and profundus muscles of the second to ...Carpal tunnel syndrome and trigger finger (TF) frequently present concomitantly; some studies suggest that carpal tunnel release (CTR) is a risk factor for the ...Final word from Sportdoctorlondon about trigger finger steroid injection. A trigger finger is a common condition causing pain and clicking at the base of a finger or thumb. Simple treatments such as rest, physiotherapy, and anti-inflammatory cream help. In some cases, an ultrasound-guided trigger finger injection is very effective, and more ...Sep 15, 2005 · M65.30 Trigger finger, unspecified finger M65.311 – M65.359 Trigger finger M65.4 Radial styloid tenosynovitis [de Quervain] M65.80 Other synovitis and tenosynovitis, unspecified site M65.811 – M65.9 Other synovitis and tenosynovitis M65.841 – M65.849 Other synovitis and tenosynovitis, hand Trigger finger (also called stenosing tenosynovitis) is a condition where it’s hard to fully bend or straighten one or more of your fingers. When a finger gets stuck in the bent po...Article Text. The following billing and coding guidance is to be used with its associated Local Coverage Determination. Injection therapies for Morton's neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of …No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.

ICD-9 code: 727.03 “trigger finger” (acquired) ICD-10 code: M65.3 “trigger finger“ nodular tendinous disease. CPT code: 20550 “ Injection (s); single tendon sheath, …Trigger finger, or stenosing tenosynovitis, is when a finger remains in a bent position. It is painful to open or close the finger. A swollen tendon or formation of knots or nodules in …CPT Coding: 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) ... M65.30 Trigger finger, unspecified finger M65.311 – M65.359 Trigger finger M65.4 Radial styloid tenosynovitis [de Quervain] M65.80 Other synovitis and tenosynovitis, unspecified siteIt is appropriate to bill the 20551 CPT code when the provider performs an injection into the tendon origin or insertion site to treat pain, inflammation, and swelling caused by a diseased or damaged tendon. This code should not be used for injections directly into a tendon sheath. 6. Documentation requirements.Daniel Bubnis is a nationally certified personal trainer who works independently in the Scranton, Pennsylvania area. His specialties include exercise science, health promotion, wel...General anesthesia or monitored anesthesia care is rarely, if ever required for injections addressed in pain management LCD L33622 policy. Per medical findings and facts, general anesthesia is contraindicated for diagnostic blocks. Monitored anesthesia care or heavy sedation may provide false-positive results.History/Background and/or General Information. Trigger point injection is one of many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload.Daniel Bubnis is a nationally certified personal trainer who works independently in the Scranton, Pennsylvania area. His specialties include exercise science, health promotion, wel...

Article Text. The following billing and coding guidance is to be used with its associated Local Coverage Determination. Injection therapies for Morton's neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot.Trigger finger, right little finger M65.352 Trigger finger, left little finger M65.4 ... to the CPT/HCPCS Codes section Group 3 and ICD-10 Codes that Support Medical Necessity Group 3 for sacroiliac joint injections. CPT code 64451 has been added to the “Coding Information” section for sacroiliac joint injections. 10/01/2019 ... High-quality evidence supports the use of corticosteroid injections for adhesive capsulitis, de Quervain tenosynovitis, and trigger finger. 13 – 17 In a systematic review and network meta ... Trigger finger is a commonly occurring hand condition that presents with symptoms of pain, clicking, locking, and catching of the finger. A common non-operative management option is corticosteroid injection. The purpose of this study was to evaluate the short-term patient response to corticosteroid injections for trigger finger. MethodsOct 1, 2002 · The diagnosis is usually 727.05 (Other tenosynovitis of hand and wrist) or 727.03 (Trigger finger [acquired]). Florida Subscriber Answer: The diagnoses you offered indicate that the orthopedist is probably injecting the tendon sheath or ligament, which would point to 20550* ( Injection; tendon sheath, ligament, ganglion cyst ). According to Becker’s Spine Review, under the American Medical Association’s Current Procedural Terminology, or CPT, 20610 is the code for a cortisone injection in the shoulder, si...

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The finger will be numb for an hour. Sometimes the triggering increases due to the volume of fluid but this rapidly resolves. For further information, refer to Hand Injections – General. Tips for the administration of injections for the treatment of Trigger Fingers. Palpate the flexor sheath and mark the line with your thumb nail.20552 Injection(s), single to multiple trigger point(s) one or two muscle(s) 20553 Injection(s), single to multiple trigger point(s) three or more muscle(s) 20612 Aspiration and/or injection of ganglion(s) cyst any location. New CPT codes for joint injections that became effective January 2015 do not require the use of 76942:20604 ...Best answers. 0. Mar 25, 2008. #2. If the release was done through an incision try 26055; "The physician makes an incision in a tendon sheath to release tension in the tendon. (For example, this procedure would be performed to relieve trigger finger .) The physician incises the skin overlying the tendon and dissects to the tendon sheath The ...CPT ® 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle. Medication. The drug used for the injection must be on the same claim as the trigger point administration.without epinephrine was injected into the surgical site. After injection but prior to making incision, the MAC group utilized an esmarch to exsanguinate the ...

TRIGGER FINGER. Trigger finger, or stenosing tenosynovitis, occurs when the flexor tendons cannot pass through the A-1 pulley smoothly. Whether the pulley thickens, the tenosynovium thickens and/or the tendons deform and develop a "nodule," the result is the same: loss of smooth active flexion and extension in the digit. Article Text. The following billing and coding guidance is to be used with its associated Local Coverage Determination. Injection therapies for Morton's neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific …TRIGGER FINGER. Trigger finger, or stenosing tenosynovitis, occurs when the flexor tendons cannot pass through the A-1 pulley smoothly. Whether the pulley thickens, the tenosynovium thickens and/or the tendons deform and develop a "nodule," the result is the same: loss of smooth active flexion and extension in the digit.CPT codes 20560, 20561 and 64625 have been added to a new CPT/HCPCS Codes section (Group 4). CPT code 64451 has been added to the CPT/HCPCS Codes …CPT Codes. Injection, therapeutic; carpal tunnel (20526) Endoscopic carpal tunnel release (29848) Neuroplasty and/or transposition; median nerve at carpal tunnel (64721) Neuroplasty, major peripheral nerve, arm or leg; other than specified (64708) Tenotomy, open flexor or extensor tendon, forearm and/or wrist, single, each tendon (25290)CPT codes for procedures where 76942 and 76998 are covered if selection criteria are met: ... Median nerve block, Trigger finger injection/trigger finger release without hydro dissection, clavi-pectoral fascial plane block, iliotibial (IT) band injection, percutaneous bursectomy of the pretibial tubercle bursa, scar tissue injection, ...We billed Medicare the following: 99212 (25), 20600 (F3) and J1030- patient DX: trigger finger,swelling of limb & pain in finger. Medicare is denying both 99212 (25) & 20600 (F3) as inclusive and only paid on drug J1030? SHOULD the admin. CPT be corrected to 20552 for trigger point injection rather than injection of small joint/finger.toe 20600? Find the CPT and ICD codes for trigger finger injection, a procedure to release the tendon sheath around the finger. The web page lists the most common coding combinations, submenus, and alternative codes for trigger finger injection, as well as the related codes for tendon sheath incision, mucous cyst, and synovitis. Injection of the flexor tendon in the hand is most commonly performed for the treatment of stenosing tenosynovitis. Stenosing tenosynovitis, also known as trigger finger, involves a size mismatch between a thickened or stenotic first annular (A1) pulley in the hand and the flexor tendon trying to glide through the pulley.Price: $3,025. CPT Code: 26055. Trigger finger, trigger thumb, or trigger digit, is a common disorder characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain. A disparity in size between the flexor tendon and the surrounding retinacular pulley system, most commonly at the level ...

Trigger finger, or stenosing tenosynovitis, occurs when the flexor tendons cannot pass through the A-1 pulley smoothly. ... For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. ... Corticosteriod injections help trigger fingers 60% of the time with a 60% ...

High-quality evidence supports the use of corticosteroid injections for adhesive capsulitis, de Quervain tenosynovitis, and trigger finger. 13 – 17 In a systematic review and network meta ... The HCPCS drug code and dose is not required when CPT 20612 is reported for aspiration and not for injection or when the ICD-10-CM codes reported are M77.11 or M77.12 and there is no injection. The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for ... The CPT codes for injections into trigger points (which are based on the number of muscles treated) include –. 20552 – Injection (s); single or multiple trigger point (s), 1 or 2 muscle (s) 20553 – Injection (s); single or multiple trigger point (s), 3 or more muscles. However, only a single code from 20552 or 20553 should be reported on ... There are two CPT ® codes for Trigger point injections: 20552-Injection (s); single or multiple trigger point (s), 1 or 2 muscle (s) 20553-Injection (s); single or multiple trigger point (s), 3 or more muscles. Local anesthesia is included in these services. However, imaging guidance can be billed in addition to the injection if necessary ... Trigger finger release CPT code 26055 can be reported for stenosing tenosynovitis by incising the tendon sheath at the finger’s base. Trigger finger issue comes to the limelight when a finger stays in a stiff bent position for some time due to swollen tendon or inflammation, narrowing of A1 pulley, or formation of nodules among...M65.30 Trigger finger, unspecified finger M65.311 – M65.359 Trigger finger M65.4 Radial styloid tenosynovitis [de Quervain] M65.80 Other synovitis and tenosynovitis, unspecified site M65.811 – M65.9 Other synovitis and tenosynovitis M65.841 – M65.849 Other synovitis and tenosynovitis, handTendons, Ligaments, and Muscle Injections. Tendon sheath or Ligament (e.g., iliolumbar Ligament, trigger finger):CPT 20550; Tendon origin/insertion: CPT 20551; Trigger point injection (1 or 2 muscles):CPT 20552; Trigger point injection (3 or more muscles):CPT 20553; Sacroiliac joint (SIJ) without fluoroscopy (billed as a trigger point injection ...No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.

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Risks of steroid injection for trigger finger are very rare. These include infection, increased pain and swelling for a day or two after injection (steroid flare reaction) and thinning of the skin. It is extremely rare to have tendon ruptures. Surgery. Unfortunately, whether with rest and therapy or steroid injections, 30-50% of patients who ...... injection of cortisone. Injection can be used up to 3 times for treatment of a trigger finger, but the issue is resolved after the first injection in 80% of ...Article Guidance. This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33912, Injection of Trigger Points. Please refer to the LCD for reasonable and necessary requirements. Coding Guidelines.... injection of cortisone. Injection can be used up to 3 times for treatment of a trigger finger, but the issue is resolved after the first injection in 80% of ...CPT codes 20560, 20561 and 64625 have been added to a new CPT/HCPCS Codes section (Group 4). CPT code 64451 has been added to the CPT/HCPCS Codes …Coverage Guidance. This policy addresses the injection of chemical substances, such as local anesthetics, steroids, sclerosing agents and/or neurolytic agents into ganglion cysts, tendon sheaths, tendon origins/insertions, ligaments or near nerves of the feet (e.g., Morton's neuroma) to affect therapy for a pathological condition.Answer: Yes, you can report codes such as 26055 ( Tendon sheath incision [e.g., for trigger finger]) multiple times during the same procedure when appropriate. List each finger on separate lines on your claim and include the "F" modifier (such as F1, Left hand, second digit) to indicate the finger treated. Note: If the surgeon made two separate ...Trigger Release. Trigger finger is a condition that causes pain, stiffness, and a sensation of locking or catching when you bend and straighten your finger. The condition is also known as “stenosing tenosynovitis.”. The ring finger and thumb are most often affected by trigger finger, but it can occur in the other fingers, as well.Diazepam (Injection)(Injectable) received an overall rating of 8 out of 10 stars from 34 reviews. See what others have said about Diazepam (Injection)(Injectable), including the ef...Dec 8, 2021 · Trigger Finger (trigger thumb when involving the thumb) is the inhibition of smooth tendon gliding due to mechanical impingement at the level of the A1 pulley that causes progressive pain, clicking, catching, and locking of the digit. Diagnosis is made by physical examination with presence of active triggering and tenderness at the A1 pulley. Coding Trigger point injections are reported with the following CPT codes: • 20552: Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) • 20553: Injection(s); single or multiple trigger point(s), 3 or more muscles . Imaging guidance for the injection would be reported with one of the following codes, depending on ….

May 27, 2010 · Answer: Yes, you can report codes such as 26055 ( Tendon sheath incision [e.g., for trigger finger]) multiple times during the same procedure when appropriate. List each finger on separate lines on your claim and include the "F" modifier (such as F1, Left hand, second digit) to indicate the finger treated. Note: If the surgeon made two separate ... Conclusions: Trigger finger injections with triamcinolone demonstrate a higher rate of additional injections when compared with dexamethasone and methylprednisolone. Patients who underwent methylprednisolone injection had surgical release performed earlier and more frequently than the other 2 groups. The choice of corticosteroid significantly ...CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle. Medication. The drug used for the injection must be on the same claim as the trigger point administration.CPT code 20550 defines an injection to a single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”).CPT code 20551 defines an injection to single tendon at the origin/insertion site.Trigger finger injections are most commonly given to the flexor tendon, supporting CPT code 20550. *This response is based on the best information ...Basics the trigger finger/point injection cpt code 20550-20551. The physician injects a therapeutic agent toward a single tendon sheath, or ligament, aponeurosis like as this plantar fillet are 20550 real into a single tendon origin/insertion site to 20551.In order to treat both of these, your physician did two procedures: Primary: Open trigger finger release (through the standard palmer incision), and Secondary: Closed manipulation of the PIP joint. Therefore, I would not consider coding each to be "unbundling." Each should be CPT coded and submitted with a Modifier to the …Corticosteroid injections. A steroid injection can be used to reduce swelling. In cases of trigger finger, liquid corticosteroids are injected into the base of the affected finger or …Mar 31, 2024 · CPT ® 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle. Medication. The drug used for the injection must be on the same claim as the trigger point administration. Jan 17, 2024 · Here are ⁤some tips to help you navigate trigger finger release CPT coding with confidence: 1. Familiarize yourself with the ⁣relevant ‍CPT codes: CPT codes 26055, 64721, and 26341 are commonly⁢ used for trigger finger release‍ procedures. Understanding the specifics of each code and when to apply them is crucial for accurate coding. Best answers. 0. Mar 17, 2016. #1. My physician did bilateral trigger finger injections on the rt and lt 3rd digit and rt and lt 4th digits. He bill 20550-50 X1 unit. 20550 has an MUE of … Trigger finger injection cpt, 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles Injections for plantar fasciitis are addressed by 20550 and ICD-10-CM M72.2., Causes of swollen and painful hands include carpel tunnel syndrome, tendinitis, simple fractures, arthritis and trigger finger or stenosing tenosynovitis, according to WebMD. Forms..., Do not code the injections or how may injections are done on a single muscle, code the muscle (s). 20552 and 20553 are used to report single or multiple injections on 1-3 or more muscles. 20552 - 1 or 2 muscle (s) 20553 - 3 or more muscles. Modifier 50 - Bilateral. Bilateral surgical indicator 50 may apply as well, so be sure to code accordingly., Find the CPT and ICD codes for trigger finger injection, a procedure to release the tendon sheath around the finger. The web page lists the most common coding combinations, …, The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Trigger Point Injections L37635. More than four (4) trigger point injections in a year's time will not be covered. If a patient requires more than four (4) procedures of either CPT codes 20552 or 20553 during ..., if you inject two different muscle groups you can bill for two injections. Physician discussed patient's trigger fingers: "we discussed the role of repeat injection to the ring finger and a first time injection for the small finger. Under aseptic technique, 0.5 mL of Kengalog 40mg/mL was injected into the subcutaneous area above the A1 pulley ..., Object moved to here., If the provider performs joint aspiration/injection with US guidance, select 20604, 20606, or 20611 (depending on the joint targeted). If the provider aspirates/injects the joint/bursa without guidance of any kind, select from among 20600, 20605, and 20610. Report a single unit of 20600-20611 for each joint treated, regardless of how many ..., Trigger finger is thought to be caused by inflammation and subsequent narrowing of the A1 pulley of the affected digit, typically the third or fourth. The A1 pulley is most often affected, but there are some reported cases where the A2 and A3 pulleys were involved [1]. It can also occur in the thumb and is then called trigger thumb. [2] , Coding- Trigger Finger 11 •Injection- 20550- Injection(s); single tendon sheath, or ligament, aponeurosis •Trigger Finger Release- 26055- tendon sheath incision (eg, for trigger finger) •M65.3X- Trigger Finger •M65.331-Trigger Finger, right middle finger Dupuytren’sDisease 12 Nodule Cord of fibrous tissue, ICD-9 code: 727.03 “trigger finger” (acquired) ICD-10 code: M65.3 “trigger finger“ nodular tendinous disease. CPT code: 20550 “ Injection (s); single tendon sheath, …, CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle. Medication. The drug used for the injection must be on the same claim as the trigger point administration., Nov 20, 2023 · Learn how to bill and code trigger point injections for myofascial pain relief by physical therapists and pain management professionals. Find out the CPT codes, modifiers, units, and ICD-10-CM codes for this procedure. , The finger will be numb for an hour. Sometimes the triggering increases due to the volume of fluid but this rapidly resolves. For further information, refer to Hand Injections – General. Tips for the administration of injections for the treatment of Trigger Fingers. Palpate the flexor sheath and mark the line with your thumb nail., Trigger finger, right middle finger M65.332 Trigger finger, left middle finger M65.341 Trigger finger, right ring finger ... Billing and Coding: Trigger Point Injections (TPI). 10/01/2023 R13 Based on the annual ICD-10 code update, ICD-10 code D48.1 has been deleted from Group 2. 03/19/2023 R12 The article has been revised to remove all ..., Trigger finger release CPT code 26055 can be reported for stenosing tenosynovitis by incising the tendon sheath at the finger’s base. Trigger finger issue comes to the limelight when a finger stays in a stiff bent position for some time due to swollen tendon or inflammation, narrowing of A1 pulley, or formation of nodules among... , The injection is given after aspiration is negative for blood. The solution is typically a 3-cc mixture of a 2:1 ratio of anesthetic and corticosteroid respectively. Post procedure the injection area is cleansed and a bandage is applied to the site. Example of Intra-service Work Associated With Code 20551 The affected tendon(s) is identified ..., Find the CPT and ICD codes for trigger finger injection, a procedure to release the tendon sheath around the finger. The web page lists the most common coding combinations, …, This study aims to compare outcomes of A1 pulley resection versus the standard release (or division) for patients with trigger finger. We hypothesize that complete resection of the A1 pulley will result in fewer instances of scarring and potential redevelopment of the pulley and subsequent postoperative referrals to occupational therapy (OT ..., Trigger point injection- an invasive procedure where medication is injected directly into a trigger point. 5 . Background. ... Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. (You may have to accept the AMA License Agreement.) Look for a Billing and Coding Article in the results and open it., Properly Coding Trigger Point Injections (20552 and 20553). February 12, 2019. Have you ever had a knot in your back where the muscles simply cannot relax?, After a short eval, the doctor decided to perform a trigger point injection on the thumb. The doctor is insisting on billing a 99214-25 along with the 20550 injection procedure. Is this correct coding, or should the office visit be considered as included in the procedure? Diagnosis: M65.312 Simple ROS, and exam only of the left thumb. Thanks in ..., Watch this video tip to see how to reuse the fingers from latex gloves to keep your fingers clean when spreading glue or smoothing caulking. Expert Advice On Improving Your Home Vi..., A small effect size in pain reduction for trigger point injections was reported as pain intensity at 1 to 2, 3 to 4, 7 to 8-, 16-, 18-, and 24-weeks follow-up. The effect size for trigger point injections was significant only at the 3 to 4 weeks follow-up period (P=0.02)., Am Fam Physician. 2003;67 (4):745-750. Joint injection of the wrist and hand region is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures ..., If a ring is stuck too tight on your finger, you can remove it with dental floss or do what the pros in the ER do: spray some Windex. At least that’s what broadcaster and writer Bu..., Jul 28, 2022 · Injection of the flexor tendon in the hand is most commonly performed for the treatment of stenosing tenosynovitis. Stenosing tenosynovitis, also known as trigger finger, involves a size mismatch between a thickened or stenotic first annular (A1) pulley in the hand and the flexor tendon trying to glide through the pulley. , Injection, tendon sheath, ligament, trigger points or ganglion cyst (20550) Injection, therapeutic; single tendon origin or insertion (20551) Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst eg, fingers, toes) (20600), Trigger finger release CPT code 26055 can be reported for stenosing tenosynovitis by incising the tendon sheath at the finger’s base. Trigger finger issue comes to the limelight when a finger stays in a stiff bent position for some time due to swollen tendon or inflammation, narrowing of A1 pulley, or formation of nodules among..., A bilateral pudendal block was given under finger guidance into the Alcock’s canal. ... ileococcygeus, coccygeus and puborectalis muscles bilaterally. The provider has documented the injections as trigger point injections. However, when injecting a toxin such as botulinum, is it more appropriate to assign a code for chemodenervation from …, Trigger Finger Release Technique. Prep and drape in standard sterile fashion. Local anesthetic injected into skin and flexor sheath. Longitudinal incision over A1 pully between the distal transverse palmar crease and the base of the finger flexion crease. Blunt dissection under loop magnification down to A1 pulley., There are two CPT codes for Trigger point injections, which are based on the number of muscles treated –. 20552-Injection (s); single or multiple trigger point (s), 1 or 2 muscle (s) 20553-Injection (s); single or multiple trigger point (s), 3 or more muscles. Local anesthesia is included in these services., Do them as follows: Using the opposite hand, grasp the affected finger just below the crease nearest to the end of your finger. Bend just the tip of your finger five times. Move your hand to just below the middle knuckle of the finger, holding your large knuckle straight. Bend the middle knuckle five times.