How is osteoarthritis pain managed?

Treatment of Trapezius/Trapezium Osteoarthritis Pain

Initial Management Approach

Begin with paracetamol (acetaminophen) at regular dosing intervals as first-line pharmacological treatment, combined with patient education about the condition and hand-specific exercises. 1

Core Non-Pharmacological Treatments (Should Be Offered to All Patients)

• Patient education addressing misconceptions that osteoarthritis is inevitably progressive and untreatable 1
• Hand-specific strengthening exercises and general aerobic fitness activities 1
• Weight loss interventions if the patient is overweight or obese, as this shows uniform positive effects on pain across osteoarthritis sites 1

Adjunct Non-Pharmacological Options

• Splinting for the thumb base/hand osteoarthritis, which shows small but consistent positive effects on pain 1
• Local heat or cold applications as self-administered adjunctive therapy 1
• Assistive devices (such as jar openers, adapted utensils) for patients with specific functional limitations in activities of daily living 1

Pharmacological Treatment Algorithm

First-Line: Paracetamol and Topical NSAIDs

• Paracetamol should be offered first for pain relief, with regular dosing as needed 1
• Topical NSAIDs should be considered before oral NSAIDs for hand osteoarthritis 1
• Topical capsaicin can be considered as an additional option 1

Second-Line: Oral NSAIDs/COX-2 Inhibitors

If paracetamol and topical NSAIDs provide insufficient pain relief:

• Add opioid analgesics OR substitute/add oral NSAIDs or COX-2 inhibitors 1
• Use oral NSAIDs at the lowest effective dose for the shortest possible period 1
• Always prescribe a proton pump inhibitor alongside oral NSAIDs or COX-2 inhibitors for gastroprotection 1
• Consider individual risk factors including age, cardiovascular disease, gastrointestinal bleeding risk, and renal function when selecting the specific agent 1

Third-Line: Intra-articular Corticosteroid Injections

• Consider intra-articular corticosteroid injections for moderate to severe pain that is localized to specific joints 1
• Injections can provide short-term relief during disease flares 2
• Typical dosing for smaller joints (such as thumb base): 2.5 to 5 mg triamcinolone acetonide 3

Important Caveats and Pitfalls

Treatments NOT Recommended

• Glucosamine and chondroitin products are not recommended 1
• Electroacupuncture should not be used 1
• TENS (transcutaneous electrical nerve stimulation) has insufficient evidence for hand osteoarthritis 1

Special Considerations for Oral NSAIDs

• All oral NSAIDs and COX-2 inhibitors have similar analgesic effects but vary in gastrointestinal, hepatic, and cardiorenal toxicity 1
• In patients taking low-dose aspirin, consider other analgesics before adding NSAIDs due to interaction concerns 1, 4
• Ibuprofen given within 8 hours before aspirin can interfere with aspirin's antiplatelet activity 4

Psychological and Social Factors

• Assess for pain catastrophizing, fear of movement, sleep problems, and mood disorders (depression, anxiety) as these influence pain perception and treatment outcomes 1
• Cognitive-behavioral therapy (CBT) shows uniform positive effects on pain in osteoarthritis and should be considered if psychological factors are prominent 1

When Conservative Treatment Fails

Surgical Considerations

• Surgery should be considered when conservative symptomatic management is ineffective 5
• For trapeziometacarpal (thumb base) osteoarthritis, surgical options include:
  • Trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI) yields better range of movement and has lower complication rates compared to arthrodesis 6
  • Arthrodesis carries unacceptably high rates of moderate-severe complications and should be considered only with careful deliberation 6
  • Maintaining scaphoid height and performing oblique trapezoidal osteotomy are crucial surgical elements 7

Monitoring and Follow-Up

• Provide periodic review tailored to individual needs, assessing the effect on function, quality of life, occupation, mood, relationships, and leisure activities 1
• Reassess within 1 month after initiating treatment to document symptom resolution or persistence 8
• Monitor for NSAID-related adverse effects, particularly gastrointestinal symptoms and renal function in elderly patients 1, 9