What are the treatment options for first metacarpophalangeal (MCP) joint osteoarthritis (OA)?

Treatment of First MCP Joint Osteoarthritis

For first MCP (metacarpophalangeal) joint osteoarthritis, begin with a custom-made rigid or neoprene orthosis worn for at least 3 months, combined with hand exercises, joint protection education, and topical NSAIDs as first-line therapy. 1, 2, 3

First-Line Non-Pharmacological Treatment

Orthosis/Splinting (Strongly Recommended)

• Custom-made orthoses for the first MCP joint are the cornerstone of initial treatment, with long-term use (minimum 3 months) required for optimal benefit 1, 2, 3
• Shorter periods of splinting show minimal benefit, so consistent use is critical 2
• Custom-made orthoses are preferable to prefabricated ones as they improve compliance and ensure proper fit 1, 2
• Either rigid thermoplast or neoprene material can be used; no clear superiority of one type over another has been established 1
• Orthoses can be worn during activities of daily living (daytime use) or at night, depending on patient preference and symptom pattern 1

Exercise Therapy (Strongly Recommended)

• Hand exercises should target joint mobility, muscle strength, and thumb base stability 1, 2
• Exercise regimens for the first MCP joint differ from those for interphalangeal joints and must be tailored accordingly 1, 2
• Supervised exercise programs yield better outcomes than unsupervised home programs 3
• Exercises should include both range of motion and strengthening components 2

Patient Education and Joint Protection (Strongly Recommended)

• Provide education on the nature and course of hand OA, self-management principles, and treatment options 2, 3
• Train patients in joint protection techniques to minimize stress on affected joints 1, 2
• Instruction in pacing activities and ergonomic principles is essential 3
• Evaluate ability to perform activities of daily living and provide assistive devices as needed 2

Heat Therapy (Conditionally Recommended)

• Local application of heat (paraffin wax, hot packs) before exercise provides symptomatic relief 2
• Heat therapy has stronger evidence (77% recommendation strength) compared to other physical modalities 2

First-Line Pharmacological Treatment

Topical NSAIDs (First Choice)

• Topical NSAIDs are the first-line pharmacological treatment due to favorable safety profile compared to oral analgesics 1, 2
• Preferred over systemic treatments, especially for mild to moderate pain affecting only a few joints 2
• Apply 3-4 times daily to affected area 4

Second-Line Treatment (If First-Line Inadequate)

Oral Analgesics

• Acetaminophen (paracetamol) up to 4g/day is the oral analgesic of first choice due to efficacy and safety profile 2
• Use as the lowest effective dose for symptom control 2

Third-Line Treatment (If Second-Line Inadequate)

Oral NSAIDs

• Use at the lowest effective dose and for the shortest duration possible 1, 2, 5
• In patients ≥75 years, topical rather than oral NSAIDs are strongly recommended due to safety concerns 1, 2
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agent or selective COX-2 inhibitor 1
• Monitor for gastrointestinal, cardiovascular, and renal adverse effects 5

Alternative Topical Agent

• Topical capsaicin may be considered as an alternative topical treatment 2

Fourth-Line Treatment (For Acute Flares)

Intra-articular Corticosteroid Injection

• Effective for painful flares of OA, particularly in the first MCP joint 1, 2, 3
• Provides temporary relief during acute exacerbations 3
• Initial dose: 2.5-5 mg for smaller joints like the MCP 6
• Use strict aseptic technique and inject into joint space, not surrounding tissues 6

Fifth-Line Treatment (When Conservative Management Fails)

Surgical Consultation

• Consider surgery when there is radiographic evidence of OA, marked disability, reduced quality of life, and other treatment modalities have failed to relieve pain 1, 3
• Surgical options include interposition arthroplasty, osteotomy, or arthrodesis 1

Common Pitfalls and Caveats

• Splinting duration matters: The most common error is discontinuing orthosis use before 3 months; benefits are not evident with shorter periods 1, 2
• Avoid long-term oral NSAIDs: Prolonged use increases risk of gastrointestinal, cardiovascular, and renal complications 1, 5
• Do not use disease-modifying antirheumatic drugs: Conventional or biological DMARDs have no role in hand OA management 1
• Intra-articular injections are not first-line: Reserve for acute flares, not routine initial management 2, 3
• Exercise specificity is critical: Generic hand exercises are less effective; tailor exercises specifically for MCP joint pathology 1, 2
• Occupational therapy referral: Patients benefit from evaluation by an occupational therapist for proper orthosis fitting and exercise instruction 1