What is the treatment for carpometacarapal (CMC) hand osteoarthritis (OA)?

Treatment for Carpometacarpal (CMC) Hand Osteoarthritis

First-line treatment for CMC hand osteoarthritis should include hand orthoses (splints) for the first CMC joint, as they are strongly recommended based on high-quality evidence and provide significant pain relief and functional improvement. 1

Non-Pharmacological Interventions

Orthoses/Splints

• First CMC joint orthoses: Strongly recommended (both neoprene and rigid types)
  • Should be considered as initial therapy for all patients with first CMC joint OA
  • Provides joint stabilization, reduces pain, and improves function
  • Patients may benefit from evaluation by an occupational therapist for proper fitting 1
• Orthoses for other hand joints: Conditionally recommended 1

Exercise and Physical Modalities

• Exercise programs: Strongly recommended
  • Range of motion exercises
  • Strengthening exercises (particularly for thumb stabilizing muscles)
  • Should be performed regularly 1
• Thermal interventions: Conditionally recommended
  • Local application of heat (particularly before exercise)
  • Paraffin wax treatments for hand OA 1
• Kinesiotaping: Conditionally recommended for first CMC joint OA 1

Other Non-Pharmacological Approaches

• Self-efficacy and self-management programs: Strongly recommended 1
• Acupuncture: Conditionally recommended 1
• Joint protection education: Recommended to avoid adverse mechanical factors 1

Pharmacological Interventions

Topical Treatments

• Topical NSAIDs: Conditionally recommended for hand OA
  • Should be considered before oral NSAIDs due to better safety profile
  • Practical considerations (frequent hand washing) may limit effectiveness 1
• Topical capsaicin: Conditionally recommended against for hand OA due to risk of eye contamination 1

Oral Medications

• Oral NSAIDs: Strongly recommended
  • Use lowest effective dose for shortest duration
  • Consider cardiovascular and gastrointestinal risk factors
  • Monitor for adverse effects 1
• Acetaminophen (Paracetamol): Conditionally recommended
  • Up to 4g/day
  • First-line oral analgesic due to favorable safety profile 1
• Duloxetine: Conditionally recommended 1
• Tramadol: Conditionally recommended 1
• Chondroitin sulfate: Conditionally recommended for hand OA 1

Injections

• Intraarticular glucocorticoid injections: Conditionally recommended for hand OA
  • Particularly effective for painful flares of trapeziometacarpal joint OA 1

Surgical Interventions

For patients with severe symptoms who have failed conservative management:

• Ligament reconstruction
• Resection arthroplasty
• Tendon interposition
• Total joint arthroplasty 2, 3

Treatment Algorithm

1. Initial Management:

   • First CMC joint orthosis/splint
   • Education on joint protection
   • Exercise program (range of motion and strengthening)
   • Thermal modalities as needed

2. If inadequate response:

   • Add topical NSAIDs
   • Consider acetaminophen up to 4g/day

3. For persistent symptoms:

   • Consider oral NSAIDs at lowest effective dose
   • Intraarticular glucocorticoid injections for flares

4. For refractory cases:

   • Consider duloxetine or tramadol
   • Referral for surgical evaluation if conservative measures fail

Common Pitfalls and Caveats

• Relying solely on pharmacological management without addressing mechanical factors through orthoses and exercise
• Using oral NSAIDs before trying topical NSAIDs, increasing risk of systemic side effects
• Failing to provide adequate patient education on joint protection and self-management
• Not recognizing when conservative management has failed and delaying appropriate surgical referral
• Using topical capsaicin on hands, which increases risk of eye contamination

The evidence strongly supports a stepwise approach beginning with orthoses, exercise, and education, followed by topical and then oral medications as needed, with surgery reserved for those who fail conservative management.