What is the appropriate management for a 67-year-old male painter with intermittent sharp thumb pain that limits his grip?

Management of Thumb Pain with Grip Limitation in a 67-Year-Old Painter

For this 67-year-old painter with intermittent sharp thumb pain and grip limitation, initiate a custom-made rigid thumb orthosis worn continuously for at least 3 months combined with topical diclofenac gel, joint protection education, and thumb-specific strengthening exercises—this represents the evidence-based first-line approach for suspected thumb base osteoarthritis, the most likely diagnosis given his occupational risk factors. 1, 2

Diagnostic Considerations

The clinical presentation strongly suggests carpometacarpal (CMC) joint osteoarthritis of the thumb base, which is the most common cause of thumb pain in this demographic, particularly in occupations requiring repetitive thumb movements like painting. 3, 4

Key features to assess on examination:

• Pain localized to the base of the thumb (CMC joint) versus interphalangeal or metacarpophalangeal joints, as treatment differs significantly by location 1
• Grind test positivity (axial compression with rotation of the thumb metacarpal)
• Weakness with pinch and grasp activities 5
• Visible subluxation or deformity at the thumb base 6

While radiographs are not mandatory for initiating conservative treatment, obtain two-view radiographs if trauma history exists or structural abnormality is suspected to evaluate for fracture or advanced joint destruction. 1

First-Line Conservative Management (Months 0-3)

Orthotic Intervention

Prescribe a custom-made thermoplastic long thumb orthosis (covering both CMC joint and wrist) to be worn during all activities of daily living and work. 1, 2

Critical implementation details:

• Custom fabrication is essential for proper fit and compliance 2
• Full splint provides superior pain relief compared to half splint (effect size 0.64, NNT=4) 1
• Minimum 3-month continuous use is required—shorter durations show no benefit 1, 2
• Patients must understand that immediate benefit should not be expected 1

Topical Pharmacotherapy

Apply topical diclofenac gel as first-line pharmacological treatment. 1, 2 This is particularly appropriate for a 67-year-old given the favorable safety profile compared to oral NSAIDs. 1

Evidence supporting this approach:

• Small but significant improvements in pain and function after 8 weeks compared to placebo 1
• Similar pain relief to oral NSAIDs but significantly fewer gastrointestinal side effects 1
• Preferred over systemic treatments for localized joint involvement 7, 2

Occupational Modifications

Provide explicit joint protection education focused on:

• Avoiding forceful pinch and grip activities 7, 2
• Using ergonomic tools with larger handles to reduce thumb stress 3
• Activity pacing to prevent symptom flares 1
• Assistive devices for painting tasks (e.g., modified brush handles) 1

Exercise Program

Prescribe CMC-specific exercises targeting joint mobility, muscle strength, and thumb base stability—these differ fundamentally from interphalangeal joint exercises. 1, 2

Key points:

• Range of motion and strengthening exercises both required 7, 2
• Benefits are not sustained when patients stop exercising 1
• Apply heat therapy (paraffin wax or hot packs) before exercise sessions for symptomatic relief 7, 2

Second-Line Management (If Inadequate Response at 6-8 Weeks)

Oral Analgesics

If topical NSAIDs provide insufficient relief:

• Add acetaminophen up to 4g/day as the oral analgesic of first choice due to efficacy and safety 7, 2
• Avoid oral NSAIDs in patients ≥75 years; continue topical NSAIDs instead 2
• If oral NSAIDs are necessary in younger patients, use the lowest effective dose for the shortest duration 7, 2

Intra-articular Corticosteroid Injection

Consider corticosteroid injection for painful flares, especially if localized to the trapeziometacarpal joint. 7, 1, 6

Evidence and technique:

• Effective for acute symptom relief though evidence quality is limited 1
• One RCT suggests hyaluronic acid may provide more prolonged benefit than corticosteroid 1
• Triamcinolone acetonide 5-15mg for larger joints using strict aseptic technique 8
• Injection should be into the joint space, not surrounding tissues to avoid fat atrophy 8

Surgical Referral Criteria

Refer for surgical consultation if marked pain and/or functional disability persist after ≥6 months of comprehensive conservative management including orthosis use, pharmacologic therapy, and targeted exercise. 1, 2

Surgical options:

• Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is the gold standard for severe CMC osteoarthritis 2
• Simple trapeziectomy alone is as effective as combined procedures but with fewer complications 1
• Multiple studies support surgery as clinically effective for refractory symptoms 1

Critical Pitfalls to Avoid

• Do not discontinue orthosis before 3 months—no benefit is evident with shorter use periods 1, 2
• Do not prescribe generic hand exercises—CMC joint requires specific exercise protocols 1, 2
• Do not use oral NSAIDs without assessing cardiovascular, gastrointestinal, and renal risk, particularly in elderly patients 1
• Do not continue conservative management indefinitely without reassessment—escalate to injections or surgical consultation if symptoms remain severe after 3 months of appropriate treatment 1
• Do not rely on acetaminophen alone—its efficacy is limited compared to NSAIDs for thumb pain 1

Occupational Prognosis

Given his occupation as a painter, this patient faces high risk for symptom persistence due to repetitive thumb use. 3 Successful management requires strict adherence to ergonomic modifications and consistent orthosis use during work activities. 1, 2 If conservative measures fail, surgical intervention provides reliable long-term pain relief and functional restoration, allowing return to occupational activities. 1, 2