What are the management and treatment options for wrist and thumb pain?

Management and Treatment Options for Wrist and Thumb Pain

For wrist and thumb pain, a comprehensive approach including non-pharmacological interventions, topical NSAIDs as first-line medication, and surgery for severe cases refractory to conservative treatment is recommended. 1

Non-Pharmacological Management

Self-Management and Education

• Enroll patients in self-efficacy and self-management programs 1
• Teach joint protection techniques to minimize stress on affected joints 1
• Provide education about avoiding adverse mechanical factors 1

Physical Interventions

• Prescribe hand exercises to improve joint mobility and grip strength 1

  • Range of motion exercises
  • Strengthening exercises
  • Individualized programs based on patient's capabilities

• Apply splints/orthoses 1, 2

  • Particularly effective for thumb base OA (trapeziometacarpal joint)
  • Helps prevent/correct lateral angulation and flexion deformity
  • Improves function at long-term follow-up and pinch strength at short-term follow-up

• Apply local heat therapy 1

  • Paraffin wax
  • Hot packs
  • Apply before exercise to relieve pain and stiffness

• Consider manual therapy 2

  • Moderate quality evidence supports manual therapy combined with therapeutic exercise for pain relief at short and intermediate-term follow-up

• Consider magnetotherapy 2

  • Low to moderate quality evidence shows improvement in pain and function at short-term follow-up

Pharmacological Management

Recommended Treatment Algorithm 1

1. Topical NSAIDs (First-line)

   • Strongly recommended due to efficacy and safety profile
   • Lower systemic exposure than oral medications
   • Particularly appropriate for patients ≥75 years

2. Oral Acetaminophen/Paracetamol (Second-line)

   • Up to 4g/day for mild to moderate pain
   • First oral analgesic choice

3. Oral NSAIDs (Third-line) 1, 3

   • Use at lowest effective dose for shortest duration
   • Consider only in patients who respond inadequately to paracetamol
   • Use with caution due to potential side effects:
     • Gastrointestinal ulcers and bleeding
     • Cardiovascular risks
     • Renal complications
   • In patients with increased gastrointestinal risk, use non-selective NSAIDs with gastroprotective agent or COX-2 inhibitor

4. Adjunctive Therapies

   • Chondroitin sulfate may provide symptomatic benefit with low toxicity 1
   • Topical capsaicin may be considered for pain relief 1

5. Intra-articular Corticosteroid Injections 4, 1, 5

   • May be considered for painful interphalangeal joint OA
   • Not recommended as first-line therapy
   • Short-term pain relief (approximately one month) for trapeziometacarpal joint OA
   • Dosage: 2.5-5 mg for smaller joints, 5-15 mg for larger joints 5

6. Medications to Use with Caution

   • Opioid analgesics are conditionally not recommended 1
   • Tramadol may be considered only if other options fail 1

Surgical Interventions

• Consider surgical consultation if symptoms persist despite optimal non-surgical management for 6-12 months 1

• Surgery is an effective treatment for severe thumb base OA refractory to conservative treatments 4, 1

  • Options include:
    • Trapeziectomy
    • Interposition arthroplasty
    • Osteotomy
    • Arthrodesis (joint fusion)

• Important: Single surgical procedures (e.g., trapeziectomy alone) appear to be as effective as combined procedures with fewer complications 4

Follow-up and Monitoring

• Schedule follow-up within 4-6 weeks to assess response to initial therapy 1
• Monitor for medication side effects, particularly with oral NSAIDs 1
• Consider referral to occupational therapy for specialized hand therapy 1

Special Considerations

• For acute flares of pain, intra-articular corticosteroid injections may provide short-term relief, though evidence is limited 4
• For tenosynovitis conditions like trigger finger, laser therapy and therapeutic ultrasound may be beneficial 6
• For De Quervain's tenosynovitis, laser therapy and ultrasound have shown effectiveness 6
• Extracorporeal shock wave therapy (ESWT) may be beneficial for trigger finger 6

Treatment Pitfalls to Avoid

1. Using combined surgical procedures when single procedures are equally effective with fewer complications 4
2. Relying solely on oral NSAIDs without considering topical options first 1, 3
3. Failing to incorporate non-pharmacological approaches like splinting and exercises 1, 2
4. Not considering the patient's cardiovascular and gastrointestinal risk factors when prescribing NSAIDs 1, 3
5. Overlooking the importance of self-management education and joint protection techniques 1