What is the treatment for pain and swelling of the thumbs that worsens with activity?

Treatment of Thumb Pain and Swelling Worsening with Activity

For thumb pain and swelling that worsens with activity, begin with topical NSAIDs as first-line pharmacological treatment combined with a long thumb orthosis worn during activities, and add hand exercises targeting thumb base stability—this conservative approach should be maintained for at least 3 months before considering more invasive options. 1, 2

Initial Conservative Management

Non-Pharmacological Interventions (First Priority)

• Provide education on ergonomic principles, activity pacing, and assistive devices to every patient with thumb symptoms—this foundational care improves self-management and has demonstrated efficacy. 1, 2

• Prescribe a custom-made thermoplastic long thumb orthosis (covering thumb base and wrist) to be worn during activities of daily living—evidence shows beneficial effects on pain when used for at least 3 months, though no benefit appears with shorter duration use. 1, 2

  • A full splint covering both thumb base and wrist provides more pain relief than a half splint (effect size 0.64, NNT = 4 for improving daily activities). 1
  • Long-term orthosis use is advocated; ensure proper fitting by a specialized health professional to improve compliance. 1

• Initiate hand exercises aimed at improving joint mobility, muscle strength, and thumb base stability—multiple trials demonstrate small but beneficial effects on pain, function, joint stiffness, and grip strength. 1, 2

  • Exercise regimens for the first carpometacarpal (CMC-1) joint differ from those for interphalangeal joints and should be tailored accordingly. 1
  • Benefits are not sustained when patients stop exercising, so ongoing adherence is essential. 1

Pharmacological Interventions

• Apply topical NSAIDs (diclofenac gel) as first-line pharmacological treatment—topical NSAIDs are preferred over systemic treatments due to their favorable safety profile, particularly in older patients with comorbidities. 1, 2

  • Topical diclofenac gel shows small improvements in pain and function after 8 weeks compared to placebo. 1
  • Topical NSAIDs demonstrate similar pain relief to oral NSAIDs but with significantly fewer gastrointestinal side effects (RR = 0.81 for GI events vs placebo). 1

• Consider oral NSAIDs at the lowest effective dose for short-term use if topical treatment is insufficient—ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily. 3

  • Assess cardiovascular and gastrointestinal risk before prescribing, particularly in elderly patients or those with comorbidities. 3
  • Avoid prolonged NSAID use beyond 7-14 days, as evidence supports only short-duration therapy. 3

• Add acetaminophen up to 4 g/day for multimodal analgesia if needed, though its efficacy is limited and likely inferior to NSAIDs. 3

Second-Line Interventions (If Conservative Management Fails After 3 Months)

Intra-articular Injections

• Consider intra-articular corticosteroid injection for painful flares, especially in trapeziometacarpal (thumb base) joint OA—one uncontrolled trial showed significant pain reduction at one month, though effects were not sustained at 3,6, or 12 months. 1

  • The evidence for corticosteroid injection is inconclusive (Level Ib) and primarily supported by expert opinion for acute flares. 1

• Intra-articular hyaluronic acid may be useful for trapeziometacarpal OA—one RCT suggested hyaluronan was as effective as corticosteroid for pain relief with potentially more prolonged benefit. 1

  • Multiple studies show HA injections improve pain relief up to 6 months and hand function (DASH score, pincher and grip strength), though the effect requires more time to develop than corticosteroids. 4
  • Evidence quality is moderate (Level IIb), and further research with larger cohorts is needed. 1, 4

Surgical Intervention (For Severe, Refractory Cases)

• Surgery should be considered for severe thumb base OA with marked pain and/or disability when conservative treatments have failed—numerous studies support surgery as clinically effective for refractory symptoms. 1, 5, 2
  • Surgical options include trapeziectomy, interposition arthroplasty, osteotomy, or arthrodesis. 1, 5
  • Simple trapeziectomy alone is as effective as combined procedures (trapeziectomy + ligament reconstruction and tendon interposition) but with fewer complications. 1, 2
  • Arthrodesis of the metacarpophalangeal and interphalangeal joints yields a stable yet functional thumb with reliably good pain relief for long-term results. 6

Critical Diagnostic Considerations

• Determine the exact location of thumb involvement—treatment differs significantly for interphalangeal (IP) joint, metacarpophalangeal (MCP) joint, or thumb base (carpometacarpal joint). 2, 7

  • Thumb carpometacarpal joint arthritis affects approximately 33% of postmenopausal women radiographically, with 20% requiring treatment for pain and disability. 7
  • The Durkan maneuver (firm digital pressure across the carpal tunnel) should be performed to rule out carpal tunnel syndrome (64% sensitive, 83% specific). 7

• Obtain radiographic assessment with at least 2 views (PA and lateral) if trauma or structural abnormality is suspected—this evaluates fracture displacement and articular involvement. 5

Common Pitfalls to Avoid

• Do not prescribe oral NSAIDs without assessing cardiovascular, gastrointestinal, and renal risk factors—this is particularly critical in elderly patients. 3

• Do not expect immediate benefit from orthoses used for less than 3 months—no improvements are evident with shorter periods of use. 1

• Do not rely on acetaminophen alone for thumb pain—its efficacy is limited compared to NSAIDs. 3

• Do not inject NSAIDs intra-articularly—a Cochrane review of 231 participants found NSAID injection offered little to no benefit over glucocorticoid injection and may result in higher rates of persistent moderate to severe symptoms (28% vs 14%, RR 2.03). 8

• Do not continue conservative management indefinitely without reassessment—if symptoms remain severe after 3 months of appropriate conservative treatment, escalate to injections or surgical consultation. 1