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Sunday, August 17, 2025

Thumb pain


Introduction

The thumb is an essential structure of the hand, responsible for gripping, pinching, and fine motor movements. Pain in the thumb can significantly affect daily activities such as writing, opening jars, typing, and using tools. Thumb pain can arise from overuse, injury, arthritis, nerve problems, or systemic disease. Because the thumb’s anatomy involves bones, joints, tendons, nerves, and soft tissues, identifying the precise cause is critical to guiding appropriate treatment.

Common Causes of Thumb Pain

1. Osteoarthritis of the Thumb (Carpometacarpal Joint Arthritis)

  • One of the most common causes of thumb pain, especially in people over 40.

  • Caused by cartilage breakdown in the base joint of the thumb (carpometacarpal or CMC joint).

  • Symptoms: pain at the base of the thumb, swelling, stiffness, difficulty with grip or pinching.

2. De Quervain’s Tenosynovitis

  • Inflammation of the tendons on the thumb side of the wrist (abductor pollicis longus and extensor pollicis brevis).

  • Symptoms: pain near the base of the thumb, swelling, and difficulty moving the thumb and wrist.

  • Often triggered by repetitive hand movements (typing, gaming, texting).

3. Trigger Thumb (Stenosing Tenosynovitis)

  • Narrowing of the sheath that surrounds the tendon in the thumb.

  • The thumb may lock, click, or catch when trying to straighten it.

  • Pain usually at the base of the thumb.

4. Sprains and Ligament Injuries

  • Sudden thumb injuries, such as “Skier’s thumb” (injury to the ulnar collateral ligament).

  • Symptoms: pain, swelling, weakness in grip.

5. Carpal Tunnel Syndrome

  • Compression of the median nerve in the wrist can cause pain, tingling, or numbness in the thumb and first three fingers.

6. Gout or Pseudogout

  • Crystal deposition in thumb joints may cause sudden severe pain, swelling, and redness.

7. Fractures or Dislocations

  • Trauma to the thumb may cause bone injury leading to sharp pain, swelling, and deformity.

8. Infections

  • Cellulitis or septic arthritis of the thumb joint can cause redness, warmth, and severe pain. Requires urgent treatment.

Clinical Presentation

  • Pain location: base of thumb (arthritis, De Quervain’s), middle joint (trigger thumb), entire thumb (nerve pain).

  • Pain type: aching (arthritis), sharp (fracture), burning/tingling (nerve).

  • Associated features: swelling, redness, stiffness, clicking, numbness.

Diagnostic Evaluation

History

  • Onset: sudden vs gradual.

  • Activities: repetitive thumb movements, trauma.

  • Past medical history: arthritis, gout, diabetes.

  • Medication history (e.g., fluoroquinolones increasing risk of tendon injuries).

Examination

  • Inspection: swelling, deformity, redness.

  • Palpation: tenderness at CMC joint or tendon sheath.

  • Movement: reduced range of motion, painful grip/pinch.

  • Special tests:

    • Finkelstein’s test: pain on ulnar deviation with thumb in palm suggests De Quervain’s.

    • Grind test: pain with axial compression and rotation of thumb indicates CMC arthritis.

Investigations

  • X-ray: arthritis, fracture, dislocation.

  • Ultrasound: tendon inflammation.

  • MRI: ligament injury or occult fracture.

  • Blood tests: uric acid (gout), inflammatory markers (rheumatoid arthritis).

Treatment Strategies

1. General Measures

  • Rest the thumb, avoid repetitive strain.

  • Ice packs for acute inflammation (15–20 minutes every 2–3 hours).

  • Splints or braces to immobilize thumb in painful conditions like arthritis or De Quervain’s.

  • Physiotherapy exercises for strengthening and flexibility.

2. Pharmacological Treatment

Pain Relief

  • Paracetamol (acetaminophen): 500–1000 mg every 6 hours as needed (max 4 g/day).

  • NSAIDs:

    • Ibuprofen: 200–400 mg every 6–8 hours as needed.

    • Naproxen: 250–500 mg twice daily.

    • Diclofenac: 50 mg twice to three times daily.

Local Treatments

  • Topical NSAIDs (diclofenac gel 1% applied 2–4 times daily).

  • Lidocaine patches or gel for localized pain.

Corticosteroid Injections

  • Intra-articular injection for thumb arthritis or tendon sheath injection for De Quervain’s and trigger thumb.

  • Triamcinolone acetonide: 10–40 mg injection into affected site.

  • Provides pain relief lasting weeks to months.

3. Condition-Specific Treatments

De Quervain’s Tenosynovitis

  • Splinting the thumb and wrist for 2–6 weeks.

  • NSAIDs for pain.

  • Corticosteroid injections highly effective.

  • Surgery (tendon release) in severe or refractory cases.

Trigger Thumb

  • NSAIDs and splinting initially.

  • Corticosteroid injection into tendon sheath.

  • Surgical release if symptoms persist.

Thumb Osteoarthritis

  • Activity modification and splints.

  • NSAIDs (oral or topical).

  • Corticosteroid injection into CMC joint.

  • In advanced cases: surgery (arthroplasty, joint fusion).

Carpal Tunnel Syndrome

  • Wrist splints (night-time).

  • NSAIDs for pain.

  • Corticosteroid injection into carpal tunnel.

  • Surgery (carpal tunnel release) for severe cases.

Gout/Pseudogout

  • Acute gout flare:

    • Colchicine: 1.2 mg initially, then 0.6 mg after 1 hour, followed by 0.6 mg once or twice daily.

    • Indomethacin: 50 mg three times daily.

    • Prednisone: 30–40 mg orally daily for 5–7 days if NSAIDs contraindicated.

  • Chronic gout prevention:

    • Allopurinol: start at 100 mg daily, titrate to uric acid control.

Fractures or Dislocations

  • Immobilization with a thumb spica cast or splint.

  • Pain control with NSAIDs.

  • Surgery if unstable or displaced fracture.

Infections

  • Antibiotics:

    • Flucloxacillin: 500 mg orally every 6 hours (for staphylococcal cellulitis).

    • Clindamycin: 300 mg orally every 8 hours (if penicillin-allergic).

  • Surgical drainage if abscess or septic arthritis suspected.

4. Non-Drug Therapies

  • Physiotherapy: strengthening exercises, range-of-motion therapy.

  • Occupational therapy: activity modification, ergonomic adaptations.

  • Assistive devices: jar openers, padded grips.

Red Flags (Need Urgent Referral)

  • Severe thumb pain with deformity (possible fracture or dislocation).

  • Rapidly progressive swelling, redness, warmth (infection).

  • Persistent pain unresponsive to conservative treatment.

  • Thumb weakness, numbness, or tingling (possible nerve compression).

Prognosis

  • Most thumb pain from overuse or mild arthritis responds well to rest, splinting, and NSAIDs.

  • Tendon and ligament injuries may require corticosteroid injections or surgery if severe.

  • Chronic conditions like arthritis may require long-term management or surgical intervention.

  • Early recognition of infections or fractures ensures better outcomes.

Summary of Key Treatments with Doses

  • Paracetamol: 500–1000 mg every 6 hours (max 4 g/day).

  • Ibuprofen: 200–400 mg every 6–8 hours.

  • Naproxen: 250–500 mg twice daily.

  • Diclofenac: 50 mg two–three times daily (oral) or 1% gel applied 2–4 times daily.

  • Triamcinolone injection: 10–40 mg intra-articular/tendon sheath.

  • Colchicine: 1.2 mg initially, then 0.6 mg after 1 hour, followed by 0.6 mg once or twice daily.

  • Indomethacin: 50 mg TID during gout flare.

  • Prednisone: 30–40 mg daily × 5–7 days for gout/inflammation.

  • Allopurinol: start at 100 mg daily, titrate as needed.

  • Flucloxacillin: 500 mg PO every 6 hours (infection).

  • Clindamycin: 300 mg PO every 8 hours (penicillin-allergic).




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