What is the best conservative treatment for bilateral first carpometacarpal (CMC) joint arthritis?

Conservative Treatment for Bilateral First Carpometacarpal Joint Arthritis

Hand orthoses are strongly recommended as the first-line conservative treatment for bilateral first carpometacarpal (CMC) joint arthritis, supported by high-quality evidence from recent guidelines. 1, 2

Primary Treatment Algorithm

First-line Interventions

1. Hand Orthoses/Splinting

   • Strongly recommended for first CMC joint OA 1
   • Custom-made orthoses are preferable to prefabricated ones for better compliance 2
   • Should be used for a minimum of 3 months for optimal outcomes 2
   • Various options include rigid or neoprene orthoses specifically designed for the first CMC joint

2. Therapeutic Exercises

   • Should be implemented alongside orthoses for all patients 2
   • Include:
     • Range of motion exercises
     • Strengthening exercises for intrinsic and extrinsic finger muscles
     • Joint mobilization techniques

Second-line Interventions

1. Topical Treatments

   • Topical NSAIDs (particularly diclofenac gel) as first-line pharmacological treatment 2
   • Preferred over systemic treatments due to safety considerations

2. Kinesiotaping

   • Conditionally recommended for first CMC joint OA 1
   • Permits range of motion while providing support
   • Different from braces which maintain the joint in a fixed position

Third-line Interventions

1. Oral Medications (if topical treatments are insufficient)

   • Oral paracetamol/acetaminophen (up to 4g/day) 2
   • Oral NSAIDs at lowest effective dose for shortest duration if inadequate response to paracetamol 2

2. Acupuncture

   • Conditionally recommended for hand OA 1
   • Benefits include large contextual effect plus small differences in outcomes between "true" and "sham" acupuncture

Patient Education Components

• Joint protection principles
• Ergonomic adaptations
• Activity pacing strategies
• Use of adaptive equipment

Assessment and Follow-up

• Regular clinical and functional assessments
• Reassessment after 12 months of treatment (or earlier if deformity worsens)
• Evaluation of range of motion, pain levels, and functional improvement

Important Considerations

Benefits of Hand Orthoses

Hand orthoses provide significant benefits for patients with first CMC joint arthritis:

• Pain relief
• Improved joint stability
• Prevention of further deformity
• Functional improvement

Occupational Therapy Referral

Patients should be evaluated by an occupational therapist who can:

• Properly fit orthoses
• Provide appropriate exercise instruction
• Teach joint protection techniques
• Recommend adaptive equipment

Surgical Considerations

Surgery should only be considered after failure of comprehensive conservative management for at least 12 months 2, 3. The most commonly performed procedure is trapeziectomy with ligament reconstruction 3.

Pitfalls to Avoid

1. Inadequate orthosis wear time - Patients often discontinue use too early; emphasize minimum 3-month commitment
2. Improper orthosis fit - Ill-fitting orthoses can cause additional pain or skin irritation
3. Over-reliance on oral medications - Systemic NSAIDs carry significant risks, especially with long-term use
4. Neglecting exercise component - Strengthening and range of motion exercises are essential complements to orthoses
5. Premature consideration of surgery - Conservative management should be maximized before surgical intervention

By following this evidence-based approach, most patients with bilateral first CMC joint arthritis can achieve significant pain relief and functional improvement through conservative measures.