What are the treatment options for wrist and thumb pain?

Treatment of Wrist and Thumb Pain

For mild to moderate wrist and thumb pain, start with topical NSAIDs or capsaicin as first-line therapy, combined with splinting that includes both the thumb base and wrist for thumb carpometacarpal osteoarthritis. 1

Initial Treatment Approach

Non-Pharmacological Management

Splinting is essential and should be implemented early:

• For thumb base osteoarthritis, use a full splint covering both the thumb base AND wrist rather than a half splint covering only the thumb base, as this provides superior pain relief (effect size 0.64) with a number needed to treat of 4 for improving daily activities 1
• Splinting is particularly effective for de Quervain tenosynovitis when combined with other treatments 2, 3
• Continue splinting for at least 8 weeks, with reassessment at regular intervals 4

Exercise and joint protection:

• Education on joint protection techniques to avoid adverse mechanical factors should be provided to all patients 1
• Range of motion and strengthening exercises are recommended, though evidence is based primarily on expert opinion 1
• For de Quervain tenosynovitis specifically, eccentric training exercises performed multiple times daily for 8-12 weeks can provide significant improvement 4

Heat application:

• Local heat (paraffin wax, hot packs) may be applied before exercise, though evidence is limited to expert opinion 1
• Ultrasound is not recommended as it has shown no benefit over placebo in controlled trials 1

Pharmacological Management

Topical agents are preferred over systemic medications for mild to moderate pain:

• Topical NSAIDs are highly effective (effect size 0.77) with efficacy equal to oral NSAIDs but significantly safer gastrointestinal profile (RR 0.81 for GI side effects vs placebo) 1
• Topical capsaicin is effective with a number needed to treat of 3 for clinical improvement within 4 weeks 1
• Both topical agents cause only minor local skin reactions with no more systemic side effects than placebo 1

Oral analgesics when topical therapy is insufficient:

• Paracetamol (acetaminophen) up to 4 g/day was traditionally recommended as first-line oral therapy 1, but the 2018 update notes its efficacy is uncertain and likely small, with potential for liver test abnormalities and dose-dependent cardiovascular, gastrointestinal, and renal adverse effects in long-term use 1
• Use paracetamol preferably for limited duration in selected patients, particularly when oral NSAIDs are contraindicated 1
• Tramadol (with or without paracetamol) may be considered as an alternative oral analgesic, though no specific evidence exists for hand conditions 1

Oral NSAIDs for inadequate response to topical therapy:

• Use at the lowest effective dose for the shortest duration 1
• For patients with increased gastrointestinal risk: use non-selective NSAIDs plus gastroprotective agent (H2-blockers or PPIs), or COX-2 selective inhibitors 1
• COX-2 specific inhibitors (coxibs) are contraindicated in patients with cardiovascular risk; use non-selective NSAIDs with caution in this population 1
• Re-evaluate requirements and response periodically 1

Injectable Therapies

Corticosteroid injections:

• First-line therapy for trigger finger, with approximately 72% symptom relief, though less efficacious in insulin-dependent diabetes 2
• Effective for de Quervain tenosynovitis when combined with immobilization, with 72% symptom relief 2, 3
• For thumb carpometacarpal (trapeziometacarpal) joint osteoarthritis: should NOT generally be used based on 2018 updated evidence showing no benefit over placebo 1
• May be considered for painful interphalangeal joints where one trial showed benefit for pain during movement and joint swelling 1

Nutraceuticals

Chondroitin sulfate may be used for hand osteoarthritis pain relief and functional improvement, though evidence is limited to one well-performed trial and this is formulated more as a suggestion than a strong recommendation 1

Surgical Intervention

Surgery should be considered when conservative treatments fail:

• Carpal tunnel release (open or endoscopic) for carpal tunnel syndrome unresponsive to splinting or steroid injection 2
• Surgical release for trigger finger in patients with diabetes, recurrent symptoms, or those not responding to steroid injection 2
• First dorsal extensor compartment release for de Quervain tenosynovitis with recurrent symptoms despite steroid injection and immobilization 2, 3
• Trapeziectomy for severe thumb base osteoarthritis with marked pain and/or disability after conservative treatment failure 1
• Arthrodesis or arthroplasty for interphalangeal osteoarthritis 1

Critical Pitfalls to Avoid

• Do not use half splints for thumb base osteoarthritis—always include the wrist component for superior clinical effect 1
• Avoid ultrasound therapy—it has no proven benefit and wastes resources 1
• Do not routinely inject corticosteroids into the thumb carpometacarpal joint—updated evidence shows no benefit over placebo 1
• Do not prescribe COX-2 inhibitors to patients with cardiovascular risk factors—they are contraindicated in this population 1
• Recognize that steroid injections are less effective in insulin-dependent diabetes for trigger finger 2
• Do not delay surgical referral in patients with progressive disease despite adequate conservative therapy, particularly those with diabetes and trigger finger who may benefit from early surgical release 2