Treatment of Ultrasound-Confirmed Thumb Tendinitis
For your patient with ultrasound-confirmed thumb tendinitis, initiate conservative management with relative rest, activity modification, topical NSAIDs as first-line pharmacological treatment, and consider thumb spica splinting—reserving corticosteroid injection only if these measures fail after an adequate trial. 1, 2
Initial Conservative Management Algorithm
Non-Pharmacological Interventions (Start Immediately)
- Relative rest: Reduce repetitive gripping and forceful hand activities that aggravate symptoms, but avoid complete immobilization to prevent muscle atrophy 1
- Activity modification: Identify and eliminate specific movements that reproduce pain during daily activities 1, 2
- Thumb spica splinting: Apply a thumb spica splint to unload and protect the affected tendons—this is safe, widely used, and particularly effective when combined with other conservative measures 1, 3, 4
- Cryotherapy: Apply ice through a wet towel for 10-minute periods to reduce pain and swelling 1
Pharmacological Treatment (Stepwise Approach)
First-line: Topical NSAIDs for mild to moderate pain—these eliminate gastrointestinal hemorrhage risk associated with oral NSAIDs while effectively relieving tendon pain 1, 2
Second-line: Oral acetaminophen up to 4g/day if topical NSAIDs provide inadequate relief 2
Third-line: Oral NSAIDs (ibuprofen 400mg every 4-6 hours) at the lowest effective dose for shortest duration if acetaminophen is inadequate 1, 2
- For patients with GI risk factors: add gastroprotective agent or use COX-2 inhibitor 2
- For patients with cardiovascular risk: avoid COX-2 inhibitors and use non-selective NSAIDs cautiously 2
Important Caveats About Corticosteroid Injections
Use corticosteroid injections with significant caution and only after conservative measures have failed. 1 The evidence reveals several critical concerns:
- No evidence-based guidelines support their use in tendinopathy, and optimal drugs, dosages, techniques, and intervals remain unknown 1
- Corticosteroids may provide short-term pain relief but do not alter long-term outcomes 1
- Deleterious effects on tendons: Injecting into tendon substance may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 1
- The role of inflammation in chronic tendinopathies is unclear, making anti-inflammatory treatment potentially counterproductive 1
When to Consider Advanced Interventions
If pain persists despite 6-8 weeks of well-managed conservative treatment, consider:
- Referral to hand surgery or orthopedics for surgical evaluation 1
- Surgical techniques typically involve excision of abnormal tendon tissue and longitudinal tenotomies to release scarring 1
Common Pitfalls to Avoid
- Do not inject corticosteroids as first-line treatment—this violates the evidence-based stepwise algorithm and may cause tendon damage 1, 2
- Do not completely immobilize the thumb—this causes muscle atrophy and deconditioning; allow activities that don't worsen pain 1
- Do not proceed to surgery without exhausting conservative measures—the treatment algorithm mandates stepwise progression 2
- Do not overlook cardiovascular and GI risk factors when selecting NSAIDs 2
Follow-Up Strategy
- Reassess at 2-4 weeks to evaluate response to conservative management 2
- Emphasize adherence to activity modification and splinting regimen 2
- Document specific activities that reproduce pain to guide ongoing modifications 2
- If symptoms persist beyond 6-8 weeks despite optimal conservative care, consider corticosteroid injection or surgical referral 1, 2