Search for tag: "hand pain"

Interviewer: You don't realize how much you really use and depend on your thumb until you can't use it anymore because it hurts so badly. And if you're suffering from thumb pain, it can have a drastic impact on your quality of life. Luckily, if you have thumb pain from thumb arthritis, there are some excellent nonsurgical and also surgical options to relieve the pain and get functionality back.

Dr. Brittany Garcia is a hand surgeon and an expert on thumb arthritis. And today, she's going to talk us through both the nonsurgical options to give you some relief from your thumb arthritis and also the surgical options and their effectiveness.

So let's start out here. If somebody has thumb pain, is it a good idea to go see their family doctor or a general practitioner first, or go to a specialist like yourself?

Dr. Garcia: First up is primary care physician because they have a lot of non-operative options that they can offer patients. So, usually, when you present to your primary care, most people will take some X-rays and then they'll be able to parse out, "Are there arthritic changes on your X-rays that we think are probably causing your pain? Or is this something else like the trigger finger, or carpal tunnel, or things like that?"

And then primary care can start with some of the non-operative options, such as splinting, activity modifications, referring to a hand therapist who can work on a home exercise program to strengthen the muscles around the joint.

I like to think of strengthening, which is a really good option, similar to an ACL. So if you've got weak quads and hamstrings and calf, you're probably more at risk of developing ACL tear. Well, similar to the base of the thumb. It seems silly, but you've got lots of small little muscles that attach around the base of the thumb, and strengthening those muscles likely offloads the forces and supports the joint in general.

Interviewer: Let's talk about some of those non-operative treatments first. So are there any downsides to any of those, or is it always kind of a best practice to start with the non-operative stuff first?

Dr. Garcia: Definitely best practice to start with non-operative treatment. And by doing non-operative therapies and trying those first, you don't necessarily drastically change what we're going to do surgically. So it's not like you're losing time or making the surgery much more complicated for us by trying these things first.

And certainly, for some people, while non-operative options don't necessarily take away the arthritis, and we know that, many of them can help quiet the arthritis.

And so the things that come to mind that are most common that we do is bracing, where we do a hand-based brace for the thumb to kind of support it from loading consistently in those types of movements that cause it to be painful. It's basically a rest thing. So if it hurts, then you rest it.

The other things that are commonly used are anti-inflammatory medications, as long as you don't have any other medical problems that would prohibit you from having them, such as kidney disease or issues with your stomach. But anti-inflammatories can be really helpful, both those that you take by mouth, as well as some topical anti-inflammatories.

I like to sell it to you straight. I'm not going to say this is a magical topical cream that's going make you feel 100% better, or take away your arthritis, or anything like that. But the goal with non-operative therapy is really to try to make you more comfortable to be able to do your normal activities of daily living, as well as your hobbies and things that you want to do without having pain that's limiting you.

Interviewer: When you do splinting to help relieve the pain, I thought I had read somewhere that that could relieve pain, but it could also cause weakness, which would be a concern to somebody who does use their hands for a living. Is that true?

Dr. Garcia: That's always a catch-22. Usually, my prescription, when I'm doing splinting with a patient, is I will try to have them wear that splint full time for about six to eight weeks to see if we can calm it down. So that includes daytime and nighttime with the exceptions of taking it off for showering and washing hands and hygiene and things like that.

Theoretically, there's a risk that, because you're not using those muscles, you get some weakening of that muscle. But I think if you can calm down the pain, then you're probably going to increase your function and gain that use back and bulk, so to speak, those muscles back up.

And the other thing is when you're having so much pain, you're probably not using it normally anyway. So there's probably some degree of deconditioning that people get just by having the pain and doing the splinting. But I think if you can get the pain under control by immobilizing that joint, then likely you bounce that back quite well.

And then the other thing I didn't mention, which is a nice non-operative option, is corticosteroid injections or steroid injections, which is commonly used in musculoskeletal conditions to help calm down the inflammation around the joint. So I sort of think of those as you're taking a dose of . . . it's sort of like putting ibuprofen right inside the joint to calm down inflammation.

"Itis," which is the end part of arthritis, is inflammation, so really this is an inflammatory process that's caused by the joint being overworked or overloaded. So putting steroid in that area can help calm down that inflammation and give people some pretty good relief.

Interviewer: Are there any downsides to the steroid injections?

Dr. Garcia: I like to use steroid injections for people who respond well to them and get a fairly long-lasting effect. It's really hard to predict exactly who's going to respond to them or who's not. And even if you've had an injection in the knee or the shoulder and it hasn't worked as well, it doesn't necessarily mean that it's not going to work in your hand. I've definitely had patients who've had injections in other places that haven't worked that well, and it's worked really well in the hand.

Interviewer: For surgical treatments, talk me through what considerations you have there. I think there are two different types of surgery, or is there just really kind of one that you tend to use most of the time? Help me understand that.

Dr. Garcia: There have actually been lots of different ways described to take care of arthritis here. Basically, they all culminate on taking out the trapezium bone, which is a small, little bone in the wrist that makes up the joint at the base of the thumb. And this is where most of your arthritis at the base of your thumb typically goes. So regardless of which type of procedure people choose to do, usually it all begins with taking out the trapezium.

And then there are a number of things that can be done to sort of stabilize or support the base of the thumb after you've taken out that little bone. That bone typically supports your metacarpal bone, which is the longer finger bone. It sits on that little bone.

So most people will take out the trapezium and then you can do a number of tendon-type procedures to support the base of the thumb. I like to do something called the suture suspensionplasty, which is where you take two of the tendons that are nearby and you suture them together underneath the metacarpal bone, which sort of acts as a soft tissue hammock or supportive structure for the base of the thumb now that that little arthritic bone is out. But people do a number of different iterations of that particular procedure.

Interviewer: And then after you get that procedure done, the goal is to reduce pain and improve functionality. How successful is that procedure at doing those two things?

Dr. Garcia: This CMC arthroplasty, which is what we call our surgery for this condition, is something that takes a long time to recover from, but people typically are very happy once they get recovered. So usually it involves some sort of immobilization like casting or splinting for about three months, exercises with our hand-specific occupational therapist to get the thumb back in good working condition and strong and get the range of motion back.

So people are sore for three to six months, but once they . . . They're slowly getting better, and once they get to kind of their maximum, I guess, potential of recovery, people are typically really happy with this surgery.

Interviewer: And that treatment, that pain relief will last for a while? The mobility will last for a while?

Dr. Garcia: Yeah, the goal is for that to kind of be one and done for people, that they get the surgery and then most people don't need any sort of revision surgeries or other procedures down the line for it. It typically takes care of it for the duration of their life, which is the goal of it.

Interviewer: And you've removed a bone, so is there going to be from a mobility standpoint anything different? Or when you go in and you make the other adjustments, it usually takes care of that?

Dr. Garcia: When we put the sort of supporting stuff at the base of the thumb, typically, people have pretty good motion. Obviously, after you come out of your splint or your cast after surgery, everybody is stiff. And any surgery around an area will make you stiff, particularly in the hand. But it doesn't necessarily take away motion.

Certainly, we have other options for different types of arthritis in your hand where we're actually fusing joints, and those are types of procedures we're definitely . . . you're very clear preoperatively with patients that they're going to lose motion at the joint that you're operating on. This is not one of those where we're talking to them about drastically decreasing motion.

Usually, people are using their thumb better because it no longer hurts. And so once we get them through that initial therapy period of getting the swelling down and the stiffness from surgery down, people's motion comes back pretty good.

And then the other thing I wanted to bring up, because we see it not infrequently, is carpal tunnel. People who have arthritis at the base of the thumb, we see in about 30% of patients, they also have carpal tunnel symptoms when they present to clinic. So that's always something that we're looking for at the same time because we don't want to miss that and not release their carpal tunnel if it's surgically something that makes sense based on their exam.

So any time they're coming to clinic, we're always teasing out, "Is your pain due to arthritis at your thumb? Is it due to the carpal tunnel? Is it due to both? And how much is contributing to what's going on?"

Interviewer: Oh, so you can get both of those done kind of at the same time.

Dr. Garcia: Exactly.

Interviewer: Dr. Garcia, that is some great information. I hope that it helps some people find some relief from their thumb pain and thumb arthritis. Before we go, though, do you have a takeaway, something we should take away from the conversation today?

Dr. Garcia: The most important thing is to know that we've got lots of options, both non-operative stuff that works really well and can get many people through without needing surgery, and then we have a good surgical option. It's just important to know that with the surgical option, there's a reasonable amount of recovery that goes along with it.

Interviewer: If you have carpal tunnel syndrome, it might seem like surgery is the only means of relief from your symptoms. But what about simple splinting? Could that be an effective, non-invasive alternative? Dr. Douglas Hutchinson is a hand surgeon. Does splinting work for carpal tunnel syndrome?

Dr. Hutchinson: You know, it's very effective actually, and splints alone are the mainstay of our treatment. And if a person can sleep at night and not wake up with numb fingers, they're going to feel a lot better, they're going to do better during the day, their hands are not going to hurt them, and/or go to sleep on them as much during the day as well, and they're going to get several years out of that type of treatment before they may get to the point where despite splinting they're still getting numbness, and that's when they probably should talk about surgery.

updated: November 23, 2020
originally published: March 28, 2018

Interviewer: Starting to get some wrist pain. Maybe it's carpal tunnel. Well, maybe not. Dr. Douglass Hutchinson, what is carpal tunnel syndrome, and what are the symptoms?

Dr. Hutchinson: Carpal tunnel syndrome is a common diagnosis, and, frankly it's commonly misdiagnosed. Carpal tunnel syndrome, primarily, is numbness in your fingers. Carpal tunnel syndrome is not primarily wrist pain, so if you have wrist pain, it's a different story. Carpal tunnel syndrome is numbness in most your fingers. Sometimes they feel as though it's all their fingers. Usually, it's the thumb, index, and third finger primarily. It usually comes at night because of the way we sleep, and that is part of the treatment right there is to change the way we sleep with our wrists bent.

Interviewer: So if you have numbness in your hand like that, visit your primary care provider for treatment options.

updated: January 8, 2021
originally published: March 6, 2019

Dr. Miller: Are there surgical solutions for your painful hand arthritis? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Doug Hutchinson. He's a Professor of Orthopedic Surgery here at the University of Utah. Doug, I have a lot of patients that come to see me with arthritis in their hands as they get older. They're asking me from time to time if there are any surgical solutions for their pain.

Dr. Hutchinson: Everyone gets arthritis in the hand at some point in time as long as we last long enough. Most arthritis in the hand is something that people live with and I think that's appropriate. Surgery is not going to solve everything that comes down the road, but there's no question that some people have certain fingers that get arthritic changes that hurt them on a daily basis and really get in their way of doing certain things in the kitchen, doing certain things in the garden, doing certain sports activities, and those we probably in some situations can help a lot.

Dr. Miller: How do we do that?

Dr. Hutchinson: For example, in the fingers the most common place to get arthritis is near the tips in the last joint, called the distal interphalangeal joint, right underneath your nail. Some people get cysts that grow out of those that become a problem on the nail and they're painful. Those can be taken care of if we get rid of some of the arthritis there.

Primarily, if the joint of the finger is stiff and painful and has arthritis on x-ray, which is common, one of the things we'll do the most commonly is fuse that joint. That just means putting a screw across the one bone into the other bone and making that joint effectively go away. You can't bend it at the end, but it stays straight the whole time.

Dr. Miller: And that eliminates the pain?

Dr. Hutchinson: That totally eliminates the pain, and the other joints still make you use your hand very well. Functionally, you're normal without that last joint working.

Dr. Miller: Are there any particular joints in the hand that are more amenable to surgery than others?

Dr. Hutchinson: Yeah, other than the DIP joint of the fingers, which is the last joint near the nail, the base of the thumb, which is all the way back closer to your wrist. Some people even think that they have wrist pain but in fact it's the base of the thumb that's hurting them. Typically a patient will really have a hard time with certain grips. They won't want to shake hands as much. They really hate the fact that they can't open a jar at home. They've got to give it to their wife or their husband to figure that out. It's generally a thumb pain problem that is really, in the world of humans the thumb is overwhelmed by what we do with our hands, and there are more forces put through our thumb joint than was originally intended.

Dr. Miller: Do you perform a similar stabilizing surgery where you put a pin or screw in the joint?

Dr. Hutchinson: Yeah. For a thumb arthritis, the most common solution is to remove a bone at the base of the thumb, which means the two ends of the bone that were grinding on each other causing pain, now one of them is gone. There's no longer a bone grinding on a bone. The word arthritis means "arth" which is joint, and "itis" which is inflammation. I tell my patients that if you don't have an "arth" you can't have arthritis. The getting rid of the "arth" is either a fusion, like we do in the distal joint of the finger, or a resection of the bone which means it can still move very well as opposed to a fusion. The pain is gone and we use a tendon to help stabilize the joint.

Dr. Miller: Would you recommend conservative therapy prior to considering surgery for either a distal interphalangeal arthritis or base of the thumb arthritis?

Dr. Hutchinson: Yes. We always recommend conservative care first, and most times that usually works for a lot of people for a good bit of time. A thumb arthritis, the mainstay for treatment is to get them a splint. The splint is something no one wants on their hand and no one wants on their thumb in particular, but it's worn at night when no one theoretically is using their thumb in the middle of the night. It allows the thumb to rest. That may make it better during the day when you take the splint off and use your thumb for normal activities.

We always want them to avoid certain activities. You don't want to open a can with a hand crank if you have thumb arthritis. You want to go out and buy an automatic can opener. That's something our hand therapists insist on. They think that should be done; at age 20 we should all get automatic can openers.

Dr. Miller: In your opinion, what would be the best conservative therapy? What do you advise patients to take?

Dr. Hutchinson: We generally tell them to wear a splint during the night that's fairly rigid that holds their thumb. We give them a strap type of a splint that's easy to wear during the day that they can wear when they want. When they don't want to they can not wear it at all. It sometimes helps when they're gripping things and gives them a little bit more support and decreases their pain.

If they get to the point where it's worse, we'll often inject them which helps them for two to three months at a time and really makes their pain go away, again, can delay the surgery if they want to have the surgery. Some people come back to me every six months and say, "Give me another injection. I don't want that surgery. I ain't got time for that. Let me just have three, five, six months of peace, please."

Dr. Miller: What is the durability of the surgery? Is it long-lasting?

Dr. Hutchinson: Yes. The surgery for base of the thumb arthritis is actually one of the best we have in our armamentarium. It works well in most any surgeon's hands. There are different procedures that can be done, all of which work about the same or as well as the others. I would caution a patient that it takes three months of being good and wearing a splint, and therefore it's a longer rehabilitation than they would like.

Other than that being a negative, the rest of it is positive. They maintain their motion. They actually increase their grip strength a little bit. Their pain is effectively 100% resolved at that particular joint. Again, a person with a lot of arthritis in their hand is not going to get the rest of their arthritis to go away, but that one is usually the one that is causing the most problem.

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updated: May 16, 2019
originally published: January 19, 2016