What is the best treatment approach for chronic thumb inflammation?

Treatment Approach for Chronic Thumb Inflammation

The optimal management of chronic thumb inflammation should involve a stepwise approach starting with non-pharmacological interventions, followed by topical treatments before considering systemic medications or surgery, with treatment tailored to the specific location and severity of inflammation. 1

Initial Assessment and Diagnosis

When evaluating chronic thumb inflammation, it's important to determine the specific location and type of inflammation:

• Thumb base (carpometacarpal/CMC) osteoarthritis - most common, affecting approximately 33% of postmenopausal women 2
• Interphalangeal joint inflammation
• De Quervain tenosynovitis - swelling of extensor tendons at the wrist 2

First-Line Treatment: Non-Pharmacological Approaches

1. Education and Ergonomic Training

   • Joint protection principles
   • Activity pacing
   • Use of assistive devices
   • These interventions have strong evidence (Level 1b, Grade A recommendation) 1

2. Exercise Therapy

   • Exercises to improve joint mobility and muscle strength
   • Focus on thumb stability exercises
   • Beneficial effects on pain, function, joint stiffness and grip strength (Level 1a evidence) 1
   • Different regimens needed for carpometacarpal vs. interphalangeal joints

3. Orthoses (Splints)

   • Strongly recommended for thumb base OA (Level 1b evidence) 1
   • Long-term use (at least 3 months) is necessary for beneficial effects
   • Custom-made orthoses are preferred for better compliance
   • Options include:
     • Custom-made thermoplast long orthosis for daytime use
     • Custom-made neoprene long orthosis for nighttime use

4. Physical Therapy Modalities

   • Manual therapy combined with exercise therapy shows moderate quality evidence for pain reduction 3, 4
   • Local heat application (paraffin wax, hot packs) before exercise 1
   • Magnetotherapy may provide short-term benefits for pain and function 3

Second-Line Treatment: Topical Medications

Topical treatments are preferred over systemic treatments due to safety considerations 1

1. Topical NSAIDs

   • First-line pharmacological treatment (Level 1b evidence) 1
   • Effective for pain relief with favorable safety profile
   • Apply to affected area as directed

2. Topical capsaicin

   • Alternative topical option for pain relief 1

Third-Line Treatment: Systemic Medications

1. Oral Analgesics

   • Paracetamol (acetaminophen) up to 4g/day is the oral analgesic of first choice 1
   • Use for limited duration for symptom relief (Level 1a evidence) 1

2. Oral NSAIDs

   • Consider when paracetamol is inadequate
   • Use at lowest effective dose for shortest duration
   • Naproxen has been shown to be effective for osteoarthritis with fewer gastrointestinal side effects than aspirin or indomethacin 5
   • Safety considerations:
     • For patients with increased GI risk: use gastroprotective agent or COX-2 inhibitor
     • For patients with cardiovascular risk: avoid COX-2 inhibitors and use non-selective NSAIDs with caution

3. Chondroitin Sulfate

   • May be used for pain relief and functional improvement (Level 1b evidence) 1
   • Effects are modest

Fourth-Line Treatment: Injections

Intra-articular corticosteroid injections

• May be considered for painful flares, especially in trapeziometacarpal joint OA 1
• Evidence is inconclusive but expert opinion supports short-term benefit
• Not recommended for long-term or repeated use

Fifth-Line Treatment: Surgical Options

Consider surgery when other treatments have failed to provide adequate pain relief and function:

• Indicated for patients with marked pain/disability after failed conservative management 1
• Trapeziectomy is recommended for thumb base OA 1, 6
• Simple surgical procedures (e.g., trapeziectomy alone) appear to have similar efficacy with fewer complications compared to more complex procedures 1
• Arthrodesis or arthroplasty may be considered for interphalangeal OA 1

Common Pitfalls to Avoid

1. Skipping non-pharmacological interventions

   • Many patients and providers rush to medications without adequate trial of splinting and exercises

2. Short-term orthosis use

   • Benefits only appear after at least 3 months of consistent use

3. Relying solely on oral medications

   • Topical treatments should be tried first due to better safety profile

4. Inadequate patient education

   • Proper instruction on exercises and orthosis use is essential for compliance and effectiveness

5. Premature surgical referral

   • Surgery should only be considered after comprehensive conservative management has failed

By following this structured approach, most patients with chronic thumb inflammation can achieve significant improvement in pain and function while minimizing risks associated with more invasive treatments.