What is the initial management for mild arthritic changes at the first metacarpal (MCP) carpal joint?

Management of Mild Arthritic Changes at the First Metacarpal Carpal Joint

For mild arthritic changes at the first metacarpal carpal joint, first-line treatment should include thumb splinting/orthoses and topical NSAIDs, which are strongly recommended based on current evidence. 1

Non-Pharmacological Management

Orthotic Devices

• Thumb splinting/orthoses:
  • Strongly recommended specifically for first carpometacarpal (CMC) joint osteoarthritis 2, 1
  • Most effective when used for at least 3 months 1
  • Both neoprene and rigid orthoses are effective for first CMC joint 2
  • Helps prevent/correct deformities and reduces pain during activities

Physical Interventions

• Heat therapy:

  • Local application of heat (paraffin wax or hot packs) before exercise provides temporary pain relief 1
  • Strong evidence supports this approach (77% recommendation) 1

• Exercise therapy:

  • Range of motion exercises for the thumb
  • Strengthening exercises for hand muscles
  • Supervised exercise programs are more effective than unsupervised 1

Patient Education

• Joint protection techniques
• Ergonomic principles
• Activity pacing
• Evaluation of ability to perform activities of daily living 1

Pharmacological Management

First-line

• Topical NSAIDs:
  • Strongly recommended for hand OA 1
  • Safer profile than oral NSAIDs, especially in older adults
  • Evidence strength = 0.77 (95% CI 0.32 to 1.22) 1

Second-line

• Oral paracetamol (acetaminophen):
  • For mild to moderate pain not responding to topical treatments 1

Third-line

• Oral NSAIDs:
  • Consider only if topical NSAIDs and paracetamol are ineffective
  • Use lowest effective dose for shortest duration
  • Monitor for side effects, especially in older adults 1

Additional Options

• Chondroitin sulfate:
  • May be considered, though evidence for hand OA is limited 1
  • Results for structure modification in hand OA are inconclusive 2

Invasive Interventions (for persistent symptoms)

Injections

• Intra-articular corticosteroid injections:
  • Effective for painful flares, especially in trapeziometacarpal joint OA 2, 1
  • One uncontrolled trial showed significant pain reduction at one month but not at 3,6, or 12 months 2

Hyaluronic Acid

• Intra-articular hyaluronan:
  • May be useful in treating trapeziometacarpal OA 2
  • One active controlled RCT suggested it was as effective as corticosteroid for pain relief with potentially more prolonged benefit 2

Surgical Options (for severe cases only)

• Consider only when conservative treatments have failed and there is marked pain and/or disability 2, 1
• Options include interposition arthroplasty, osteotomy, or arthrodesis 2, 1

Treatment Algorithm

1. Initial management:

   • Thumb splinting/orthoses + topical NSAIDs
   • Heat therapy + exercise program
   • Patient education on joint protection

2. If inadequate response after 4-6 weeks:

   • Add oral paracetamol
   • Consider intra-articular corticosteroid injection for acute flares

3. For persistent symptoms:

   • Consider oral NSAIDs (with appropriate precautions)
   • Consider intra-articular hyaluronan

4. For refractory cases:

   • Surgical consultation if conservative management fails after 3-6 months

Follow-up and Monitoring

• Evaluate response to treatment in 4-6 weeks 1
• Monitor for medication side effects, particularly with oral NSAIDs
• Assess ability to perform activities of daily living
• Provide assistive devices as needed

Common Pitfalls to Avoid

• Relying solely on oral NSAIDs without addressing mechanical factors 1
• Using splinting for less than 3 months (insufficient duration for benefit) 1
• Delaying treatment (early intervention leads to better outcomes) 1
• Failing to recognize that CMC joint OA is more common in postmenopausal women 1, 3