Signs and Symptoms
- Pain in the thumb at the level of the joint closest to the web space. This can increase with use of the thumb
- May see swelling and bruising soon after injury
- Significant discomfort with lateral stress of the involved joint
Diagnosis
- History and physical exam can diagnose the majority of these injuries
- X-rays can help determine if there is an associated fracture. Fractures are not uncommon with this injury
- MRI can help determine the location and severity of the ligament injury but is not always necessary
Background:
Like many articulating joints, the thumb joints are each stabilized by a “capsule” of supportive soft tissue and ligaments. This prevents the joints from moving outside of normal flexion and extension.
A sprain is a type of injury that involves ligament damage. Often this is a stretched ligament, but it can also be more severe. The ligament can be torn or completely pulled out of the bone it is normally attached to. A sprain to the thumb usually involves either the radial collateral ligament (RCL) or ulnar collateral ligament (UCL), two ligaments that run on either side of the base of the thumb and prevent sideways motion. These injuries can happen from anything that causes a sudden sideways force to be applied to the thumb; however, two of the most common ways this can happen are from falling while skiing (while holding the ski poles), and from lifting up small children with thumbs extended. In both of these situations, a lateral force is applied to the UCL (the more commonly-injured ligament). Assuming the injury is not too severe, non-surgical management may be appropriate, as outlined below. There can be a lot of variability depending on the nature and severity of the injury.
Treatment
Conservative (Non-Surgical)
For those ligaments that are not completely torn
- Immobilization for approximately 6 weeks in a splint or cast
- and therapy following period of immobilization
Surgery
Surgery may be required if the injury is too severe to heal by itself, or if the ligament is completely ruptured; otherwise, this highly important joint will remain unstable and painful. If surgery is required, rehabilitation will generally follow the outline below.
Hand Therapy
(No Surgery)
Week 0-4:
- A custom splint will be made for you to immobilize the thumb and prevent further movement or damage. This will allow the ligament to heal in a safe position without allowing further stress. It is important to carefully follow instructions for splint wear, in order for it to be effective.
- Swelling or pain control measures may be used as needed for comfort.
Week 4-8:
- Once swelling decreases, and as healing occurs, gentle active movement exercises will be initiated. Your therapist will advise you on which movements are safe, and which should be avoided.
- These injuries can be painful, and discomfort may persist well past 4 weeks. Exercises should be performed only once pain and swelling have significantly improved, so the timeline may vary considerably from one person to the next.
- As symptoms continue to improve, the active motion exercises will be upgraded and increased as tolerated. The splint should continue to be worn between exercise sessions.
- Even once exercises and therapy are started and pain/swelling has improved, you should still carefully follow physician/therapist instructions regarding activity participation. Generally speaking, you should not be doing anything that involves repetitive gripping, pinching, grabbing, squeezing, pulling or pushing. This will impact school, sports, work, and home activities. Ask your doctor or therapist if you have questions specific to your situation. In order to heal as quickly as possible, it is always best to err on the side of caution.
Week 8+:
- If symptoms are persistent at this point, therapeutic modalities will be used to help expedite recovery. Typically you should still be avoiding strenuous activities for 10+ weeks after the initial injury.
- Depending on your progress, you splint may be discontinued sometime after 8 weeks. However, your doctor or therapist may want you to continue wearing it for protection during certain heavy activities.
Hand Therapy
(With Surgery)
Week 1-2:
- 1 week after surgery, the bulky dressing will be removed. Compressive gloves, fingersocks, or dressings may be applied for swelling management.
- A custom splint will be made for you to immobilize the thumb. This will allow the ligament to heal in a safe position without allowing any stress or movement. It is important to carefully follow instructions for splint wear, in order for proper healing to occur.
Week 4:
- Pins placed during surgery will be removed.
Week 6:
- Typically, therapy is initiated around 6 weeks post-op. Gentle active exercises will be initiated, involving movement of the forearm, wrist, hand, fingers, and thumb. Certain thumb movements should be avoided; follow your therapist’s instructions.
- Continue wearing the splint between exercises. Avoid all activities involving grasping, pinching, squeezing, or other thumb movements.
- Your therapist will use therapeutic techniques and massage to assist with pain and swelling control, as well as scar tissue modeling and softening.
- Even once exercises and therapy are started and pain/swelling has improved, you should still carefully follow physician/therapist instructions regarding activity participation. Generally speaking, you should not be doing anything that involves repetitive gripping, pinching, grabbing, squeezing, pulling or pushing. This will impact school, sports, work, and home activities. Ask your doctor or therapist if you have questions specific to your situation. In order to heal as quickly as possible, it is always best to err on the side of caution.
Week 7-8:
- Gentle stretches may be used to maximize thumb range of motion, and hand strengthening will begin at this time. Your home program may be updated to reflect these changes.
- Splint wear may be gradually decreased at this point, although your therapist may instruct you to wear it for certain activities.
Week 10-12:
- Depending on your progress, you can typically return to most activities by this time. Heavy grabbing, squeezing, pinching, pulling, or pushing should be avoided for several more weeks.
- If you are returning to sports, your therapist or physician may instruct you to continue wearing a special splint for sports only.