Signs and Symptoms
- Pain at the base of the thumb worsened by activities such as pinching
- Swelling and occasionally redness around the thumb base at the level of the wrist
- May feel grinding at the thumb base
Diagnosis
- Usually diagnosed by history and physical exam
- X-rays can confirm the diagnosis. While x-rays can help determine how advanced the arthritis is, they do not always correlate with the degree of pain one experiences. For example there may be advanced disease on the x-ray but the patient may not be experiencing a lot of pain. The converse is also true.
Background
Osteoarthritis describes the wear and tear that occurs in joints over time, especially with repetitive use. Supportive cartilage and soft tissue between two bones tends to wear down with time, and the bones moving against one another can damage each other, create bone spurs, and slowly erode. A common place this can occur is the base of the thumb.
This guideline refers to conservative therapeutic management of base-of-thumb osteoarthritis. Your hand therapist can walk you through these different options, and short-term therapy will be helpful; however, many of these things can ultimately be done independently as part of a home program.
Treatment
Conservative (Non-Surgical)
General Strategies:
- Discomfort is typically the most common and troublesome symptom of thumb arthritis, so pain management strategies are a mainstay of therapeutic treatment. This can include:
- Moist heat packs and paraffin wax dipping, for deep heating
- Compression gloves or compressive wraps, for support and comfort
- Custom splinting, for support, stabilization, and comfort
- Therapeutic ultrasound, for deep heating and inflammation management
- Range of motion activities are helpful for preventing stiffness and atrophy
- Gentle, selective strengthening of some of the base-of-thumb muscles that provide joint stability (be careful and follow therapist instructions — unnecessary exercises can lead to more inflammation and pain)
Activity Modification:
- Avoid mechanical stresses on the joint such as repetitive pinching and twisting, pinching and pulling, or forceful squeezing.
- Avoid carrying heavy objects with your fingers/thumbs (use both hands together in a “palm-up” position to carry things)
- Use adaptive equipment that helps take pressure off your hands (equipment is available for activities such as opening jars, starting your car, opening doors, cutting food, pulling weeds, cooking, computer work, etc)
Surgery
- This is indicated when the above conservative measures are no longer providing consistent relief of pain. When the pain interferes with your activities of daily living it may be time to consider surgery.
- The goal of surgery is to remove and replace the painful arthritic joint.
Hand Therapy
This guideline refers to post-op therapeutic management after one common method of “reconstructive” surgery for base-of-thumb osteoarthritis first developed by Burton and Pelligrini. The purpose of the procedure is to eliminate pain and improve joint stability.
The surgical technique involves removal of the trapezium (one of the wrist carpal bones). One of the tendons of the forearm is removed, rolled up into an “anchovy,” and anchored into place where the trapezium bone used to be. This prevents further joint degeneration of the trapezium against the thumb metacarpal bone, while preserving functional range of motion of the thumb. Two pins will then be inserted through the joint to stabilize it while it heals.
*The tendon selected from the forearm is redundant, and when it is removed, other muscle/tendon units continue to do the same job; therefore, no movement or strength is lost.
Week 1-2:
- 3-5 days after surgery, the bulky dressing will be removed. Compressive gloves, fingersocks, or dressings may be applied for swelling management.
- Sutures will be removed 10-14 days after surgery. A custom thumb splint will be created for you to protect the incision and stabilize the joint while it heals. You should wear this at all times, day and night.
- Keep your hand elevated about the level of your heart when possible to minimize swelling.
- You should move your fingers frequently (within the confines of the splint) to prevent unnecessary stiffness. Tell your doctor or therapist if you feel any significant pain or swelling in your fingers.
Week 4:
- Therapy will begin around this time. Your therapist will provide you with special movements and exercises, for your thumb and fingers. Follow this exercise program, which will help you regain range of motion.
- It is important that you continue wearing the splint at all times, except during exercise. Wear it day and night to protect the thumb.
- Manual techniques will be initiated to help control swelling and prevent scar adhesions. Your therapist will show you different methods to gently mobilize the scar tissue.
- Your discomfort should be fairly low at this point, though movement may be a little uncomfortable. Swelling will improve considerably once therapy is started, though it may not disappear entirely for several months.
Week 6:
- The two pins will be removed roughly six weeks after surgery. This should further help improve any persistent discomfort or swelling.
- Your therapist will begin gentle passive movement or stretching of your thumb, to maximize range of motion. Other techniques may be used to manage scarring and swelling.
- Continue wearing your splint as instructed, removing to complete your home exercise program.
Week 8:
- Progressive strengthening will begin around this time. Splint wear can be gradually decreased, or your splint can be adjusted to allow you to begin doing some basic activities with your hand. Your therapist will continue to use scar management techniques and may use other modalities such as therapeutic ultrasound to facilitate healing and to help soft tissue rebound faster.
Week 10-12:
- Strengthening and exercises will have been upgraded throughout this time. You will most likely be discharged from therapy around this time, to continue independently with your home program. You can typically use the hand normally in daily activities. Ask your doctor if you intend to return to sports or strenuous work or other hand-intensive activities.
- Your grip strength and pinch strength outcomes will vary, but strength will continue to improve through about six months.
