What is the suggested treatment for a patient with severe degenerative arthritis at the right radial scaphoid joint, experiencing sharp pain when throwing a football and low-level pain when articulating the wrist, who has found relief with Voltaren (Diclofenac)?

Treatment Approach for Severe Radial-Scaphoid Osteoarthritis with Activity-Related Pain

Continue topical diclofenac (Voltaren) as your primary treatment since it is already providing relief, and add structured hand therapy with splinting for the radial-scaphoid joint to address the severe bone-on-bone articulation. 1, 2

Current Management: Optimizing Topical NSAID Therapy

Your patient's positive response to topical Voltaren (diclofenac) is evidence-based and should be continued as first-line therapy. The EULAR guidelines specifically recommend topical NSAIDs as preferred over systemic treatments for hand osteoarthritis, especially when only a few joints are affected and pain is mild to moderate. 1

• Topical diclofenac provides equivalent pain relief to oral NSAIDs but with markedly fewer gastrointestinal adverse events and significantly lower systemic absorption. 2
• Apply topical diclofenac gel to the affected right wrist 3-4 times daily, focusing on the radial-scaphoid joint area. 2
• The favorable safety profile makes this particularly appropriate for long-term management of chronic joint pain. 2, 3

Essential Non-Pharmacological Interventions

Add a custom thumb spica or wrist splint that immobilizes the radial-scaphoid joint, particularly during activities that provoke sharp pain like throwing. 1

• Splints are specifically recommended by EULAR for wrist and thumb base osteoarthritis with a strength of recommendation of 67%. 1
• The splint should be worn during provocative activities (throwing, forceful wrist articulation) and potentially at night if nocturnal pain develops. 1

Initiate a structured hand therapy program including range of motion and strengthening exercises for the wrist. 1

• Exercise regimens are recommended for all patients with hand osteoarthritis. 1
• Apply local heat (paraffin wax bath or hot pack) before exercise sessions to improve joint mobility and reduce stiffness. 1
• Heat application has a 77% recommendation rate from EULAR experts. 1

Escalation Strategy If Topical Therapy Becomes Insufficient

If topical diclofenac alone becomes inadequate, add oral paracetamol (acetaminophen) up to 4g daily before escalating to oral NSAIDs. 1

• Paracetamol is the oral analgesic of first choice with an 87% recommendation strength from EULAR, and if successful, is the preferred long-term oral analgesic. 1
• This stepwise approach minimizes systemic NSAID exposure and associated cardiovascular and gastrointestinal risks. 1

Only if paracetamol plus topical diclofenac fail, consider adding oral NSAIDs at the lowest effective dose for the shortest duration. 1

• Oral diclofenac 50mg three times daily (150mg/day total) is the FDA-approved dosage for osteoarthritis. 4
• Alternative oral NSAIDs include ibuprofen at lower doses (1.2g daily) due to lower gastrointestinal risk compared to diclofenac. 5
• All oral NSAIDs should be prescribed with a proton pump inhibitor for gastroprotection. 1

Interventional Options for Severe Disease

For acute pain flares in the radial-scaphoid joint, consider intra-articular corticosteroid injection. 1

• Intra-articular long-acting corticosteroid injection is effective for painful flares of osteoarthritis with a 60% recommendation strength. 1
• This is particularly useful for the severe bone-on-bone articulation documented on imaging. 1
• Injections can provide 4-12 weeks of relief and may be repeated every 3-4 months if needed. 1

Surgical Consultation Threshold

Refer to hand surgery if conservative management (topical NSAIDs, splinting, oral analgesics, and corticosteroid injections) fails to provide adequate pain control or if functional disability significantly impacts quality of life. 1

• Surgery (such as radial styloidectomy, proximal row carpectomy, or wrist fusion) is effective for severe wrist osteoarthritis when conservative treatments have failed. 1
• The EULAR recommendation strength for surgery in severe thumb base OA (analogous joint) is 68%, indicating strong expert consensus. 1
• Given the severe bone-on-bone articulation on imaging, surgical evaluation should not be delayed if symptoms progress despite optimal medical management. 1

Activity Modification

Advise temporary avoidance of provocative activities like throwing a football until pain control improves with splinting and therapy. 2

• Activity modification is a core component of acute musculoskeletal pain management. 2
• Gradual return to throwing activities can be attempted once pain is controlled with the splint in place. 2

Critical Safety Considerations

Monitor for cardiovascular risk factors if oral NSAIDs become necessary, as diclofenac carries increased thrombotic event risk. 5

• In patients with cardiovascular risk factors, naproxen may be preferred over diclofenac if oral NSAIDs are required. 5
• Use oral NSAIDs at the lowest effective dose for the shortest possible duration. 1, 5

Avoid glucosamine, chondroitin, or other symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) as they have small effect sizes and unproven structure modification benefits. 1