PRACTICE RECOMMENDATIONS
• Do not treat de Quervain’s tenosynovitis with a corticosteroid injection plus a nonsteroidal anti-inflammatory drug; the combination is no more effective than the injection alone. B
• Resection arthroplasty of the carpometacarpal (CMC) joint is the gold standard for surgical treatment of thumb CMC osteoarthritis, but should be offered only if conservative measures fail. C
• Percutaneous release of trigger thumb combined with a corticosteroid injection provides greater symptom relief than the injection alone. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Among the many possible causes of nontraumatic thumb pain are 3 conditions that primary care physicians are likely to encounter again and again: de Quervain’s tenosynovitis (dQT), first carpometacarpal osteoarthritis (CMC OA), and trigger thumb (TT). Common as they are, however, there are no consensus guidelines for the treatment of these conditions.
With that in mind, we did a literature search for studies of treatments for common causes of nontraumatic thumb pain. After reviewing the findings, we developed this evidence-based summary—and the “bottom line” treatment guide—as an aid to clinical decision making.
de Quervain’s tenosynovitis: An overuse injury
dQT is characterized by a gradual onset of pain in the first dorsal compartment of the wrist. The pain is reproduced on physical exam with clenched fist ulnar deviation of the wrist (Finkelstein test) (FIGURE). The suspected cause is overuse, leading to thickening of the tendons of the first dorsal compartment and subsequent resisted gliding of the tendons in their fibro-osseous canal.1
FIGURE
Finkelstein test for de Quervain’s tenosynovitis
With elbows flexed to 90°, the forearms parallel to each other and the floor, and the thumb clenched gently inside a fist (A), the patient drops the hand down (adduction) at the wrist (B). Pain over the first dorsal compartment is considered a positive test.
NSAIDs and injection: No better than injection alone
Conservative treatment of dQT consists of topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs), splinting, and corticosteroid injection.1 We identified 2 studies using such conservative modalities. The first was a randomized double-blind, placebo-controlled trial, which found that oral NSAIDs combined with corticosteroid injection provided no statistically significant benefit compared with corticosteroid injection alone (P=.69).2 The second study was a pooled qualitative analysis and showed that 83% (n=495) of patients were asymptomatic after corticosteroid injection alone.3 Treatment failure in the remaining 17% of patients was attributed to poor technique and anatomic variation within the first dorsal compartment.
Another arm of the study compared the combination of corticosteroid injection and splinting with splinting alone, which yielded 61% and 14% success rates, respectively. Some patients were treated with NSAIDs and rest alone, but this intervention had a 0% success rate.3
Surgery has a high “cure rate”
Symptoms of dQT of >9 months’ duration may not respond as well to conservative therapy.4 In such cases—and for patients for whom conservative measures bring only short-term relief—a surgical referral may be the best approach.
Surgery for dQT, a relatively simple procedure in which the sheaths surrounding the inflamed tendons at the base of the thumb are released to relieve the pain and swelling, has uniformly positive results. The “cure rate”—resolution of symptoms without complications—is reported to be >90%.1 One researcher found a positive correlation between a longer duration (>9 months) of preoperative symptoms and increased postoperative satisfaction (P<.4). 4
First carpometacarpal OA: Pain, deformity, functional impairment
In a study of patients with joint-specific arthritis of the hand, the prevalence of first CMC OA was reported at 21%.5 Symptoms include pain and deformity that may result in significant functional impairment of the thumb. Physical findings may include pain with palpation and swelling and warmth over the dorsal aspect of the CMC joint. The “grind test”—axial compression with internal and external rotation of the CMC joint—should reproduce the pain and may demonstrate crepitus.6 As with osteoarthritis in general, CMC OA radiographic findings do not directly correlate with the physical exam.
Splinting and physical therapy bring considerable relief
Conservative treatment options for CMC OA include NSAIDs, physical therapy, splinting, and corticosteroid injection. American College of Rheumatology guidelines support NSAIDs or acetaminophen as a first-line treatment for osteoarthritis pain of the knees and hips, but no guidelines specifically address CMC OA.7 Nor have there been any studies focused on NSAID therapy for CMC OA.
One retrospective study (n=130) evaluated splinting the thumb in abduction, and found that it reduced symptoms of CMC OA by an average of 54% to 61% at 6-month follow-up.8 The researchers studied the results of splinting in patients with stage 1 or 2 (mild to moderate) CMC OA vs those with stage 3 or 4 (moderate to severe) CMC OA, and found no significant difference in levels of improvement. In another study of patients with first CMC OA who were treated with splinting and physical therapy for 7 months, 70% of those who underwent treatment declined subsequent surgery, suggesting symptom improvement.9