Non-Surgical Alternatives for Thumb Osteoarthritis

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

Thumb Osteoarthritis Surgery Alternatives

In many patients we see with thumb pain and restricted motion, they have self-managed their thumb problems for as long as they could before pain and loss of mobility, and, especially grip strength and inability to sleep at night makes self-management difficult at best. At this time the patient will seek out their doctor who will likely refer them to the orthopedist for more specialized help.

As with other joints, many patients are often surprised that their doctor and orthopedist are making the same recommendations for treatment that they, the patient, was using to self manage: non-steroidal anti-inflammatory medications except in stronger doses or a better splint than the one the patient bought for themselves.

When these treatments were not helpful, after a short go-round, cortisone injections were recommended, physical therapy was prescribed, and then after a few weeks or months, the reality of this managed conservative program effectiveness set it. It was not working that well. So now, according to your clinician, you have reached the fork in the road. Surgery or “live with it.”

Surgery or live with it, is there no other way?

In this article, we will examine surgical and non-surgical options. The non-surgical options we will present here are likely new to you as they are not part of the well-accepted “conservative care,” option. In this article, we will talk about regenerative injection techniques that include Prolotherapy. In our clinic, we see and have seen many patients with thumb osteoarthritis. The reason that we see them is that these patients seek out an alternative to thumb surgery.

A patient comes into our office, they tell a familiar story

We have been hearing from thumb pain patients for more than 27 years now. Let’s see how familiar these patient’s stories sound to you:

I am being recommended to have surgery. My doctor sees no other way.

I already had surgery on my right thumb, I guess it went well.

 I need to do something different. My daily routine is to make sure that I have gel pads in the freezer so I can ice my thumb/wrist throughout the day.

When people reach the point that these people have, the pressure to have surgery becomes stronger and stronger. But is surgery the answer? For some people, it works great, for others, it does not work great. Let’s get to the research.

Conservative care options for someone whose thumb slips out of place

Doctors at the Royal North Shore Hospital and Institute of Bone and Joint Research, Kolling Institute at the University of Sydney, published these July 2021 findings in the journal Osteoarthritis and cartilage (1). Here the doctors of this study investigated the combined effects of variously applied conservative therapies.

The people in this study, suffering from radiographic and symptomatic thumb osteoarthritis, were divided into groups which compared a combination of education on self-management and ergonomic principles, a prefabricated neoprene splint, hand exercises, and diclofenac sodium gel (a topically applied pain medication), with patients who were given patient education alone (to see how they would self-manage their thumb pain).

In other words, it is hard to tell it splints, exercise, gels and creams help patients with thumb instability. The worse the instability, the worse these treatments work.

Patients are trying. But their thumb really hurts

Doctors often look at patients and try to assess the patient’s ability to adhere to a program. For some people, especially those in a lot of pain, adherence to conservative care options may be difficult. Again, the doctors at the Royal North Shore Hospital and Institute of Bone and Joint Research, Kolling Institute at the University of Sydney, published, this time in the Journal of hand therapy, (2) these May 2021 findings on adherence to conservative care options for thumb pain.

In this research the doctors examined adherence to prescribed conservative interventions in patients with thumb osteoarthritis to determine whether baseline pain and hand function is associated with treatment adherence over a 12 week period. Here the doctors suggested: “high baseline pain was associated with better adherence in participants with thumb base osteoarthritis. Higher baseline functional impairment was not associated with better adherence.”

If a patient had a lot of pain, they stayed with the conservative care program. If the patient had more of a functional issue, they did not. This is something we see in our patinets. Treatments are usually when a situation is becoming more painful or acute. When the pain lessens, less adherence even though function of the hand and thumb is less than needed. The researchers in this study found, in their group of patients treatments are dictated by pain over function.

However, the more positive the expectation of conservative care treatment, the better the outcomes for many

Doctors at the Department of Plastic, Reconstructive, and Hand Surgery, Erasmus Medical Center in the Netherlands offered this view point on conservative care outcomes. Writing in the journal Disability and rehabilitation, the doctors made these observations in their July 2021 study.(3)

“More positive outcome expectations and illness perceptions are associated with better outcomes for patients with several osteoarthritic orthopedic conditions.  . . We found that positive outcome expectations and a better illness understanding, were associated with a better outcome of non-operative treatment for first carpometacarpal osteoarthritis.  Non-operative treatment can often be successful for patients with arthritis of the thumb. . . .Improving the outcome expectations and illness perceptions of patients through better education could improve the outcome of non-operative treatment.”

But what if the patient does not succeed at conservative care options? Is surgery the only choice? In this segment we will explore research on surgery.

Surgeons express concern with thumb joint replacement implants. September 2019, The Journal of hand surgery. Research study: Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review. (4)

In this research, surgeons wrote: “Several implant designs (arthroplasties) had high rates of failure due to aseptic loosening, dislocation, and persisting pain. Furthermore, some implants had higher than anticipated failure rates than other implants within each class. Overall, the failure rates of non-implant techniques were lower than those of implant arthroplasty.”

In other words, several implants presented a lot of problems. Some implants being far more problematic than others. Surgery, or treatment without the implants, had lower complication rates.”

An August 2020 study in The Journal of Hand Surgery (5) simply suggests, “There is a lack of consensus on critical outcomes after surgery for thumb CMC joint osteoarthritis.

However a May 2021 study (6) from doctors at the Epsom & St Helier University Hospitals in the United Kingdom and published in the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) open review found, “In general, good results were demonstrated (in the thumb surgery), with improvements in (patient’s range of motion), pain scores and strength. Failure rates ranged from 2.6% to 19.9% depending upon implant studied. Comparative studies demonstrated promising results for replacement when compared to resection arthroplasty, with modest improvements in (patient’s range of motion) but at a cost of increased rates of complications. . . Failure, in terms of loosening and dislocation, remains a concern. . . ”

Four women who had Trapeziometacarpal joint replacement – their thumbs did not return to a more natural range of motion

When we discuss surgery, it is always best to listen to the surgeons and the challenges they are facing in providing joint replacement surgery.

An April 2018 study from a team of Belgium doctors that appeared in the American Journal of Hand Surgery (7) questioned whether or not a thumb joint replacement surgery provides a good benefit for the patient. Here are the highlights of that study.

So what happened after the surgery? How was the range of motion in the replaced thumbs?

So after thumb replacement, the thumb does not return to a more natural range of motion. This may not be an important factor for many people, especially people who have deformity from rheumatoid arthritis (see below), but it is certainly an important factor for people who rely on their hands for work or if they are an artisan. Tell a pianist or a carpenter that his/her thumbs won’t move that well after surgery. See how fast they look for an alternative to their thumb arthritis.

Pain on load and weakness remains to some extent 1 year after surgery for trapeziometacarpal joint arthritis

In a February 2020 study from Sweden, doctors reporting in the journal BioMed Central Musculoskeletal Disorders (8) wrote:

Thumb osteoarthritis is caused by joint instability due to ligaments that are weakened or damaged by overuse or by a traumatic injury. To restore a more natural movement to the thumb joint, you have to examine and explore the repair of the thumb’s ligaments.

To restore a more natural movement to the thumb joint, you have to examine and explore the repair of the thumb’s ligaments. Repairing the thumb ligaments should be the main objective of treatment. We are going to discuss this below.

Research: Thumb osteoarthritis is caused by joint instability due to ligaments that are weakened or damaged by overuse or by a traumatic injury. (9)

This according to researchers from Indiana University School of Medicine, Tufts University School of Medicine, University of Bristol, Bristol, and the Dutch university researchers who made this statement in their paper: “Yet more evidence that osteoarthritis is not a cartilage disease,” published in the British Medical Journal.

Trapeziometacarpal joint surgery causes wrist problems and wrist instability

In May 2020, surgeons at the Imperial College London writing in The Journal of Hand Surgery (10)  explored the effects of surgical treatments for trapeziometacarpal osteoarthritis on wrist biomechanics. What they found was “wrist biomechanics were significantly altered following trapeziectomy. . . Trapeziectomy, as a standalone procedure in the treatment of trapeziometacarpal osteoarthritis, may result in the formation of a potentially unfilled trapezial gap, leading to higher wrist muscle forces. This biomechanical alteration could be associated with clinically important outcomes, such as pain and/or joint instability.”

What do weakened ligaments in the thumb do? Cause pain, loss of motion, loss of grip strength, and cause osteoarthritis. “So I have no grip strength because of the thumb ligaments?”

Why occupational or physical therapy was only a little help and only delayed surgery

A team of researchers from Norway published their findings on the benefit or lack of benefits for occupational therapy in the November 2019 issue of Rheumatic & Musculoskeletal Diseases Open. (11)

The goal of the study was to determine “whether occupational therapy, provided in the period between referral and surgical consultation, might delay or reduce the need for surgery in thumb carpometacarpal joint osteoarthritis and to explore predictors for carpometacarpal joint surgery.”

The patients they looked at:

These are not robust results.

The conclusion of the research:

“In conclusion, we found a small non-significant tendency towards a delay and reduction in carpometacarpal joint surgery in patients that received occupational therapy, compared with a control group. Previous non-pharmacological treatment and motivation for surgery were significant predictors of surgery. These results may support the notion that patients with carpometacarpal joint osteoarthritis should be referred to occupational therapy before surgery is considered.”

In this x-ray image the arrow points to severe osteoarthritis in the carpometacarpal joint. This is evidenced by the lack of cartilage at the joint. Thumb arthritis often involves inflammation.

In this x-ray image, the arrow points to severe osteoarthritis in the carpometacarpal joint. This is evidenced by the lack of cartilage at the joint. Thumb arthritis often involves inflammation.

In the above study, physical or occupational therapy was seen as helpful for some, not all, and that many go on to surgery anyway. Why?

Patients are often very confused as to why a physical therapy program did not help their thumb and hand pain as much as they thought it would. This is very typical of the patients we see. They have been to physical therapy for months and nothing seems to have improved. How can this be? Many of these patients have been listening and reading about “great exercises” to strengthen their thumb. These people have been told that exercise will lead to greater pain relief and an increase in mobility. So why is it not working? And because it is not working, are you now equally concerned you are going to be escalated to a surgical candidate, or have your pain management prescriptions increased in strength?

Loss of strength, muscle power, and range of motion are clear indicators of impending thumb surgery. In patients with degenerative joint disease, where connective tissue such as the ligaments and tendons that attach bone to bone and muscle to bone are damaged. It is very difficult to derive benefit from strength training where resistance is needed because the ligaments and tendons that help provide that resistance are weak.

Weak Ligaments in the thumb anatomy explain why cartilage breaks down and why 

Thumb arthritis often involves inflammation of the basal joint (the base of the thumb), which is the joint that allows the thumb to swivel and pivot, it is also called the thumb carpometacarpal (CMC) joint or trapeziometacarpal (TMC) joint (as mentioned above), because the trapezium bone joins the metacarpal bone of the thumb.

The basal and metacarpophalangeal (MCP) (the knuckle joint of the thumb), are usually the first areas where the pain is experienced.

Surgery for osteoarthritis of the thumb often includes ligament reconstruction with a tendon and bone removal

Much of the research and attention of surgery for thumb osteoarthritis centers around the removal of the trapezium bone at the base of the thumb. The surgery is called a trapeziectomy.

The trapeziectomy can be performed with variations to the technique. First is the removal of the bone. Some procedures will include a ligament reconstruction to strengthen the compromised anatomy and filling the void left with a forearm tendon. For patients with thumb arthritis being recommended to surgery the term interpositional arthroplasty or commonly referred to as trapeziectomy with LRTI would likely be recommended as a surgical choice.

In addition to the research above, research from the University of Massachusetts Medical School examined various surgical procedures for thumb osteoarthritis. Here are their findings published in the medical journal Hand. (12)

A bone spur and a lengthened ligament

Loose or lax ligaments and bone spurs are the common dominate theme in degenerative joint disease. When the ligaments are loose, the bones wander and abnormal wear and tear in the joint will cause the formation of bone spurs. As we saw in the conservative care study above. The more subluxation and the more instability. The less conservative care options including splints work.

In an August 2021 study (13) from doctors at the Department of Trauma and Orthopaedics, King’s College Hospital, London and published in the Journal of wrist surgery examined problems of the thumb carpometacarpal joint with a focus on the failure of conservative care and the thumb ligaments. Here is what they wrote:

“The surrounding ligamentous structures (of the thumb carpometacarpal joint) are complex and important to maintain thumb carpometacarpal joint stability. Objectives The aim of this study was to review the normal and arthritic anatomy of the thumb carpometacarpal joint, focusing on morphology (the joint structure is broken and becoming abnormal) and position of osteophytes (bone spurs) and the gap between metacarpal bases, and the effect of these on intermetacarpal ligament integrity.”

The researchers of this study are exploring ways to avoid surgical failure. One way suggested is to make sure the joint is stable by examining damage and instituting repair of the liagments.

The researchers continue: “(The intermetacarpal ligament) may be the sole ligament suspending the first metacarpal following trapeziectomy and could determine the need for further stabilization during surgery, avoiding potential future failures.”

The intermetacarpal distance in trapeziectomy patients

A total of 55 patients, 30 normal controls and 25 arthritic patients who had trapeziectomy, were identified and studied. The most common anatomic position for osteophytes was the intermetacarpal ulnar aspect of the trapezium (a bone spur at the base of the thumb at the wrist). The intermetacarpal distance increased by an average of 2.1 mm in the presence of the arthritic process. (The thumb joint had become unstable and the bones of the joint began to wander and cause more problems. Bone spurs were forming to try to “bridge the gap” and keep the thumb in place.”

The researchers concluded: “The findings point to an increase in the intermetacarpal distance, and hence lengthening of the ligament with potential damage, possibly secondary to osteophyte formation and wear. Further prospective research is required to determine whether using preoperative CT scanning to define osteophyte position and measure the intermetacarpal distance would predict probable damage to the ligament, hence providing an indication for stabilization and reconstruction in trapeziectomy surgery.”

In other words, the intermetacarpal ligament should be examined before surgery to offer a better chance to understand post-surgical problems.

Thumb medicine can sometimes be very amazing in its desire to do the most complicated and invasive things

Joint replacement can be considered in selected patients who require greater strength and range of motion, although it has been associated with a higher complication rate.

Doctors at the Hand Surgery Unit, Department of Orthopedic Surgery, University Hospital, in Granada, Spain, wrote in the medical journal Orthopedics(14)

Trapeziectomy with or without ligament reconstruction is still considered the gold standard, but the challenges associated with treating its complications limit its indications.

Despite this and other evidence, doctors from the University of Michigan writing in the journal Plastic and Reconstructive Surgery(15) “With a consistent rise in health care spending, adherence to an evidence-based approach in medicine is more important than ever. Most surgeons continue to perform trapeziectomy with ligament reconstruction and tendon interposition, the most expensive surgical option.”

French doctors gave a thorough analysis of the challenges of surgical repair of trapeziometacarpal osteoarthritis. Writing in the journal Hand Surgery and Rehabilitation, (16) they write:

Medicine can sometimes be very amazing in its desire to do the most complicated and invasive things. Like performing two surgeries when one would have offered similar results with less trauma to the patient.

Here is a situation where an alternative surgical option is given. It failed. Now the doctors had to go back to the original choice surgery to fix the alternative surgery.

Another team of French doctors gave a thorough analysis of the challenges of Total trapeziometacarpal joint replacement. Also writing in the journal Hand Surgery and Rehabilitation, (17) they write:

This study examined the results of 12 cases of failed TMC joint replacement that were treated by trapeziectomy with ligament reconstruction and tendon interposition (LRTI) arthroplasty. The study found the Trapeziectomy with LRTI after TMC joint replacement appears to be an attractive salvage procedure.

Simply doctors had to go back to a surgery that could have been the first choice procedure, to repair the damage of an alternative choice surgery. Two surgeries when one would have offered similar results with less trauma to the patient.

Injections for thumb osteoarthritis

This is a brief introductory video on injections for thumb osteoarthritis that can help rebuild the soft tissue of the thumb and alleviate problems of degenerative arthritis and possibly help patients avoid thumb joint surgery.  The video is presented by Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida.

At 1:10 of the video 

Brief description of Prolotherapy

At 1:30 of the video.

Ultrasound showing joint instability in a patient with osteoarthritic fingers and thumb

In this video Ross Hauser, MD demonstrates an ultrasound examination showing joint instability in her thumb. (0:42) the ultrasound image and explanation by Dr. Hauser.

Non-surgical options for thumb arthritis: The research on Prolotherapy

Comparing Prolotherapy to cortisone in the first carpometacarpal joint

A study published in the Journal of orthopaedic science (18) compared dextrose Prolotherapy against corticosteroid local injection for the treatment of osteoarthritis in the first carpometacarpal joint. This was a double-blind randomized clinical trial.

These are the summary learning points:

The black dots in this image represent the places that Prolotherapy injections will be given during this treatment session.

The black dots in this image represent the places that Prolotherapy injections will be given during this treatment session.

Making your thumb function better and move naturally without surgery is certainly an appealing option. Can this be realistically done? In the many patients that we have seen over the years, Prolotherapy injection treatments into the thumb have provided excellent results. Will this treatment work for everyone? The answer is no. Will it work for you? That is something that is discussed after a physical examination of the thumb and a discussion with the patient of the goals of their treatment.

The goal of the Prolotherapy treatment is to bring stability to the thumb. Degenerative wear and tear arthritis occur because of hypermobility/loose ligaments. In other words, the bones of your thumbs are moving around too much. This hypermobility is causing thumb joint erosion due to unnatural wear patterns in the joint. To compensate and hold your thumb together as best as possible, your body starts to grow bone (bone spurs) in the joint. Prolotherapy injections would be best given in the earlier stages of the disease before bone spur formation became a problem.

In 2000, K. Dean Reeves, MD lead a study published in the  Journal of Alternative and Complementary Medicine (19). These were the findings of this research on Prolotherapy for finger and thumb degenerative disease:

The objective of the study was to determine the clinical benefit of dextrose prolotherapy (injection of growth factors or growth factor stimulators) in osteoarthritic finger joints.

The study participants were selected based on:

The findings: “Dextrose prolotherapy was clinically effective and safe in the treatment of pain with joint movement and range limitation in osteoarthritic finger joints.”

In our research published by Caring Medical in the Journal of Prolotherapy, (20we were able to document the beneficial use of Prolotherapy Injections. Prolotherapy was administered to 13 patients suffering from basal thumb arthritis in 17 thumbs. Here are our highlights:

Prolotherapy enables TMC joint arthritis sufferers to avoid surgery and its possible adverse effects. The substantial advantages and minimal drawbacks (e.g., aversion to needles), as well as the reduced risks and increased rewards of Prolotherapy over conventional treatments, suggest that this option for the second most common joint arthritis—that of the thumb—should be considered by doctors and patients.

Demonstration of Prolotherapy treatment for the thumb

The treatment starts at 1:15 of the video: Ross Hauser, MD comments, and narrates:

Thumb Joint boutonniere deformity

Thumb Joint boutonniere deformityAlso presented in the Journal of Prolotherapy, (21) our research and clinical team documented a case of a 57-year-old female afflicted with rheumatoid arthritis received treatment for a 35-degree interphalangeal (IP) thumb joint deviation.

The thumb deviation clinically described as a boutonniere deformity was treated with a combination of Prolotherapy and splinting. She wore a custom three-point splint for six weeks and received three separate Prolotherapy treatments within that six-week period. After treatment, the deviation decreased from 35 degrees to 10 degrees, and her thumb pain decreased from 7 to 1 on a pain scale of 10 as the highest level.

Platelet Rich Plasma (PRP)

Many people who are exploring non-surgical options for their thumb osteoarthritis may have come upon research surrounding the use of Platelet Rich Plasma (PRP).

In basic terms, PRP involves the application of concentrated platelets (harvested from your own blood), which release growth factors to stimulate recovery in non-healing injuries. These growth factors, such as platelet-derived growth factor, transforming growth factor, and others, proliferate fibroblasts which means they spark the production of new connective tissue and cartilage. Specifically, PRP enhances the fibroblastic events involved in tissue healing including chemotaxis (the chemical attraction of repair cells to the site of injury,  proliferation of cells, proteosynthesis (create of proteins), reparation, extra-cellular matrix deposition (this is a subject all in of itself, and the remodeling of tissues. The bottom line here is that PRP helps the healing process

The preparation of therapeutic doses of growth factors consists of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In other words, PRP is done just like any other Prolotherapy treatment, except the solution used for injection is plasma enriched with growth factors from your own blood.

We are going to explore the research on PRP first and then discuss the combined use of PRP and Prolotherapy.

The professional pianist returns to the piano

An October 2019 case review was written up in the journal Rheumatology International, (22) Here university doctors in Spain described a case of Platelet-rich plasma for thumb carpometacarpal joint osteoarthritis in a professional pianist. The hope of the researchers was: “Presenting this case, our aim is to draw the attention of healthcare providers dealing with thumb carpometacarpal joint osteoarthritis to PRP as a safe, beneficial therapy for this condition which needs further assessment in randomized controlled trials.”

Here is what they reported:

Let’s point out that this was a case to illustrate what Platelet Rich Plasma could do for one professional musician and to shed light on the potential of the treatment. The treatment while beneficial to many, may not help everyone.

PRP vs cortisone

In the October 2018 issue of the medical journal Cartilage (23), a team of researchers from Greece and the United Kingdom published their clinic observation in the use of PRP vs. Cortisone ion the treatment of thumb osteoarthritis

The combined use of PRP and Prolotherapy

When a patient presents a more advanced case of osteoarthritis we may suggest a more aggressive treatment to include the PRP preparation. Why? The PRP has been shown in many studies, including the one we just cited to be more effective in cartilage degeneration. More so even than the simple dextrose Prolotherapy injections. In our clinic, based on over 27 years of experience in treating patients with thumb osteoarthritis, we have found that injecting PRP to attack the cartilage breakdown and injecting Prolotherapy to tackle the instability of the joint by addressing and strengthen weaken ligaments provide the patients with superior results. In the right patient, PRP, and Prolotherapy as a combined treatment would be favored.

Stem Cell Therapy for thumb osteoarthritis

Another more aggressive treatment we may employ is Stem Cell Prolotherapy. This combined treatment of stem cells and Prolotherapy presents the same clinical benefits as PRP Prolotherapy except we are using, bone marrow aspirate concentration or bone marrow-derived stem cells. We want to make it clear that we perform stem cell therapy on very few patients. Why? Because we can usually achieve the patient’s goal of treatment with simpler procedures. Bone marrow stem cell therapy is usually reserved for the most advanced cases.

Stem cell therapy in an injection of your own harvested stem cells. Stem cell therapy is typically utilized when we need to “patch” holes in cartilage and stimulate the bone. We explore this option in patients when there is more advanced osteoarthritis and a recommendation for a joint replacement has been made or suggested.

Our published research in the journal Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders (24) demonstrates and documents clinical results in patients receiving bone marrow-derived stem cells and dextrose Prolotherapy.

If you have a question about Thumb Osteoarthritis Surgery Alternatives, get help and information from our Caring Medical staff

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This page was updated September 8, 2021

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Caring Medical Florida
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax Fort Myers, FL Office
We are an out-of-network provider. Treatments discussed on this site may or may not work for your specific condition.
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