Thumb Arthritis or “Just Thumb Pain”: Achieving a

Pain Free Stable Thumb

Virginia O'Brien, OTD, OTR/L, CHT

Philadelphia 2017

Disclosures Virginia O’Brien, OTD, OTR/L, CHT

• No relevant personal financial relationships

• Editor, Caring for the Painful Thumb 2nd and 3rd ed.

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Conservative Management of the Painful Thumb is a CHALLENGE!

Teamwork is ImportantPerson –Therapist –Doctor – Family

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Finding the Source of Thumb Pain is like “Getting into the Weeds”

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Can You find the Deer?

Varieties of Thumb Pain• Trigger thumb

• Sprained thumb

• Ligament laxity of IP, MCP and CMC

• Hypermobility Syndrome vs. Ehler-Danlos Syndrome

• Fractures at each joint

• Neurologic injuries which cause pain: localized or referred

• Systemic Diseases which affect each joint: RA, OA, lupus, scleroderma

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3 Important Points for a Stable Thumb….

1. The thumb webspace: Keep it SUPPLE

2. Use of ALL thumb motors to Stabilize and Centralize the 1st metacarpal as it moves on the trapezium.

3. Educate the person to stabilize their own thumbs for a lifetime.

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Watch for these points throughout the presentation

Why is the human thumb at risk for pain?

Is it because there is only a 35 year warranty on the 1st CMC

joint ?

What is the mystery of dynamic stability for the CMC joint?

Can something be done about it ? YES!

Keep in mind……no two thumbs (painful or not)are alike.

It is our job as therapists to partner with our patients and the referring physicians to understand causes of thumb pain, and to design and teach effective interventional programs.

Loose capsule

Joint surfaces are not congruent

Stability from soft tissues

Ligamentous support

Muscular support

Carpometacarpal (CMC) joint

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• Controls the extent and direction of joint motion

• Helps maintain normal alignment of the joint

• Helps control and dissipate forces produced by activated muscles

• Extrinsic muscles• Intrinsic muscles

(Brand & Hollister, 1993) (Hagert, Lee, & Ladd, 2012) (Magnusson, Rosenstein, O’Brien, Nuckley, Adams, 2014)

Volar CMC Stabilizing LigamentsLeft Hand

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Intermetacarpal Ligament (not shown)Ulnar CollateralAnterior Oblique Ligament• Superficial• Deep (arrows)

(Ladd, Lee and Hagert, 2012, Figure 3)

Volar CMC Stabilizing Ligaments (L)

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IntermetacarpalLigamentAnterior Oblique Ligament• Superficial• DeepUlnar Collateral

Courtesy of Anatomy Softwear Gloves™ by Pat McKee

Dorsal CMC Stabilizing Ligaments Right hand

29Ladd, Lee and Hagert, 2012, Figure 4

(Posterior/Dorsal) Intermetacarpal ligamentFirst dorsal trapeziometarpalligamentDorsal deltoid ligament complex:1. Dorsal radial ligament2. Dorsal central/collateral

ligament3. Posterior oblique ligament

APL

(Hallilaj et al. 2015)

-Joint instability ALONE may not be the primary etiological factor in development of OA of CMC.-Dynamic proprioceptive function of the joint is subject of continuing studies

(Ladd et al. 2013) (Ladd et al. 2014) (Hagert et al. 2012)

Stout deltoid-like CMC dorsoradial ligament structure

Green: DorRadLig; Orange: DColLig;Magenta: PostOblLig; APL: red

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CMC Ligamentous Proprioception• Mechanoreceptors found

in CMC ligaments (as in shoulder, wrist, knee and ankle)

• Pacinian corpuscles: rapidly adapting, activated by joint compression and sudden perturbations*

• Ruffini end organs: slowly adapting and constantly active, sensitive to axial stress and tensile strains

32(Hagert & Ladd, 2012)

RUFFINI END ORGANS IN CMC DRL

• Avascular and aneural

• Nutrition from synovial fluid and from subchondral bone

• Movement necessary for joint nutrition

• Joint motion increases synovial blood flow, circulates synovial fluid, increases penetration of solutes

Articular Cartilage

(Brandt et al. 2008) (Wang et al. 2012)

The Thumb Column

(Kapandji, 1982)

Interphalangeal

Metacarpophalangeal

IP

MP

CMC

ST

Carpometacarpal

Scaphotrapezial

• Has 4 joints

• 60-80 degree angle between 1st and 2nd MCs

• wide arc of CMC motion

60-80⁰

The trapezium is like the saddle on a scoliotic horse.

The CMC joint is like a Universal Joint

(Brand & Hollister, 1993) (Kapandji, 1982)

Movement in 2 planes at right angles

Two theories to explain the “apparent” rotation of the thumb producing pronation and supination

Know Your Thumb Muscles: Extrinsics

• Extensor Pollicis Longus

• Extensor Pollicis Brevis

• Abductor Pollicis Longus

• Flexor Pollicis Longus

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Know your Thumb Muscles: Intrinsics

• Abductor Pollicis Brevis

• Flexor Pollicis Brevis – deep and superficial heads

• Opponens Pollicis (Deep)• AFO-acronym to remember the

Thenars

• Adductor Pollicis

•First Dorsal Interosseous!

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Muscles that influence the Thumb

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9 muscles influence the thumb

Thumb is 70% of the dominant

hand, 60% of the non-dominant

hand (Disability ratings)

Accessed at: militarydisabilitymadeeasy.com

We have a big job to help our patients with their thumbs!!!!

SO, Is the Position of Habit…… A cause of more than just Osteoarthritis?

• Could poor muscle motor patterns, tight web space structures, ligamentous hypo- or hypermobility be a cause of:

• Trigger thumb?

• Cascading OA from CMC to MP and IP?

• Ulnar Collateral Ligament strain/overstretching?

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Lax ligaments (and maybe

weak intrinsics) allow dorsal

translation of metacarpal on

trapezium, further stretching

the already lax ligaments

Chronic ligamentous instability alters proprioceptive input, decreasing awareness of thumb posture

Hypermobility

(Van Heest & Kallemeier, 2008)

Moulton showed MP flexion of 30°moves contact area on the trapezium more dorsally, unloading the volar articular surface

Achieving this position during functional activity is important

May require an orthosis with MCP ext. block temporarily

30º

Moulton’s research

(Moulton et al., 2001) (Mobargha et al. 2015)

Opponens

First Dorsal

Interosseous

Adductor

Abductor

Brevis

Flexor Brevis

Abductor LongusOpponens

Sesamoids

The multidirectional pull of these muscles:

Abductor

Pollicis

Longus

3/13/2017 79

Extensor Pollicis

Brevis

Potential De-Stabilizers Dynamic Stabilizers3/13/2017 80

First Dorsal Interosseous

Abductor Pollicis Brevis (Superficial)

Opponens (Deep)

Adductor Pollicis

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Effects of Exercise, Orthoses & Joint Protection Education

• Reduction in Pain & Improvement in Function

• No consensus for which orthosis is best

• No consensus (YET) for which exercises are best

• Little is known about dosage of exercise for the small muscles of the hand (ACSM 2011)

• EULAR and ACR recommend Exercises & Orthoses

• 1st Dorsal Interosseous is emerging as a key muscle for thumb stability

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Magnuson et al. 2016, McGee et al. 2015, Dziedzic et al. 2011, Boudreau 2010, Stamm et al. 2002, Wajon 2000, Swigart 1999.

Evidence Based/Informed

Practice

Evidence for 1st DI in Thumb Stability

• Radiological subluxation reduction in 2 cadaver studies, with 1st DI and OP together (O’Brien et al.2016)

• Radiological subluxation reduction with 1st DI maximal voluntary contraction in young subjects without CMC OA (McGee et al. 2015)

• 1stDI counteracts CMC dorsoradial imbalance and malalignment (Mobargha et al. 2015)

• In a population study, in persons > 50 yrs, the 1st DI strength was a strong predictor of thumb pain (Swan et al. 2015)

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Insert new CMC picture of 1st DI

Conclusions: 2 cadaver studies• Concomitant activation of 1st DI and OP and OP alone reduce radiographic

subluxation.

• OP as predominant reducing force

• OP and 1st DI+OP activation reduce subluxation in a dose dependent manner.

• Hand therapy may improve pain and function by reducing subluxation with activation of 1st DI and OP.

96(O’Brien et al. 2016)

Doesn’t the thumb deserve the same amount of attention therapists have given to shoulder problems?

It is time to Fine Tune Conservative Management to treat functional

impairment caused by Thumb Pain

THINK

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Dynamic Stability for the Painful Thumb

Conservative Management Program

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3 Important Points for a Stable Thumb….

1. The thumb webspace: Keep it SUPPLE

2. Use of ALL thumb motors to Stabilize and Centralize the 1st metacarpal as it moves on the trapezium.

3. Educate the person to stabilize their own thumbs for a lifetime.

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Watch for these points throughout the presentation

What is Different about Dynamic Thumb Stability Intervention?

Innovative techniques that go beyond Pinch strengthening -Orthotics - Joint Protection - Adaptive EquipmentExercises that first mobilize and then stabilize the thumb – which

do not involve painful pinching Re-education of specific muscles which assist in thumb stabilization is a key element Pain modification techniques Strategy to wean from an orthosis, if able

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How does Pain affect Learning in

Musculoskeletal Rehab?

Pain can hinder learning of new motor skills at the cortical level

Novel motor skill training should be presented at the first sign of pain to prevent poor motor patterns Can protect “pain associated cortical changes”

Strength training does not achieve the same effect as motor-skill training

Encourage a cognitive/conscious effort This is the first step to skill level performance

Quality vs. quantity when beginning skill development

104(Boudreau, Farina, & Falla, 2010) NeuroMuscular Science

OBSERVE: WHAT DO YOU SEE?

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What if the thumb appears NORMAL?

Palmar Abduction Radial Abduction

And in every area of the evaluation

Compare Hands

- Manual release of the adductor and any over-active, dominant

muscle

- Joint mobilization to reduce / realign the CMC

- Muscle re-education / strengthening

- Use of adaptive tools and joint protection techniques

- Orthosis/Orthoses as needed

- Strategy to wean from orthosis

With respect for pain at each step

Adductor: One of the strongest muscle per square measure in the body.

Manual release of this muscle increases the potential ROM of the thumb lost due to web space contracture.

Helps to “set the stage” to gain congruency of joint surfaces for the next portions of the exercise program.

Manual Release

Manual ReleaseAdductor Muscle Release is the KEY

VIDEO

Myo-Fascial or “Tender Point” release

Contract-Relaxrelease

Release of soft tissues in the web space

VIDEO

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Initiated after Manual Release (adductor release)

and soft tissue elongation .......

AND before muscle re-education*

Approximates the joint surfaces

(centralizes MC on Trapezium), helps improve motion and the production of nutritional substances in the joint.

Joint mobilization of the thumb column restores stable thumb biomechanics, and reduces pain.

* Must be done pain free!!!

Joint Mobilization

(Villafane, Silva, Diaz-Perreno & Fernandez-Carnero, 2011)

Distraction is the first level (grade I) of joint

mobilization

Opens joint spaces, relieves pain &

increases nutrition

Grasp the base of involved thumb, hold

arms behind back The weight of the arms

provides distraction

Hands behind body...

..or in front

If this position causes pain in shoulders,

bring arms in front of body, relax, and bring

elbows back to distract the CMC joint

In both photos, the subject’s RIGHT CMC is being distracted

Self-Joint Mobilization

Retropulsion

(Villafañe, Silva, Diaz-Perreno & Fernandez-Carnero, 2011)

VIDEOMust be PAIN-FREE: restores Retropulsion, improves CMC/STT glide

Joint MobilizationWith a “Skull Rock”

(Villafañe, Silva, Diaz-Perreno & Fernandez-Carnero, 2011)

METHOD ONE METHOD TWO

Place opposite

thumb in webspace

Roll hand

back and

forth

Then move arm

forward and back

Grasp thumb

Feels a little uncomfortable, but feels better later.

VIDEO

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Check Retropulsion: Better?

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Progress noted on opposite palmar MCP

joints(Kapandji, 1992)

1

2

3

4

Re-education of the thumb muscles to restore stable balance

Focus:

Abductor Pollicis Brevis

Opponens Pollicis

1st Dorsal Interosseous

Extensor Pollicis Brevis

Abductor Pollicis Longus

Flexor Pollicis Brevis

Muscle Re-education first before Strengthening

Isolate the Abductor and Opponens

Make the thumb

puppet sing

Closed Chain Exercise

VIDEO

The CMC joint is most

stable in the “C”

position

This exercise is done pain free

Note the rubber band placement on the metacarpal

Isometric and Isotonic Muscle Re-education of palmar abduction

Isolate the Extensor Pollicis Brevis

VIDEO1732/18/17

Keep the middle thumb knuckle lifted, making an arch!

EPB: Home Program

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VIDEO

1st Dorsal Interosseous Exercise

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Rubber Band Exercise: Abduct the Index away from theMiddle Finger

NEW GOAL: 100 repetitions per day???

1 2

3

Start with a thinner rubber band: First at P1 IF. Lift finger up and down slowly and smoothly. ISOKINETIC: Concentric/eccentric

To progress, advance RB distally on IF, toward P2 and P3: PAIN-

FREE ONLY.

Advance to thicker RB, and repeat the same progression.

Thumb Stability Exercises: Using a Rubber Band

GOAL: 100 x / day !!???!!??!!DOSE: 10 reps 2-3 sets/session183

Rubber-band Variations

to re-educate and strengthen stabilizing muscles

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VIDEO

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“Piano playing”

to strengthen

(isometric to isotonic)

Extensor Pollicis Brevis

Abductor Pollicis Longus

Abductor Pollicis Brevis

Opponens Pollicis

AND the 1st Dorsal Interosseous

Abduct without losing the MP flexion posture

Once you have been strengthening this most important muscle, the 1st

dorsal interosseous, then it is important you learn to “fire” it when you are using your hand to stabilize your thumb in daily tasks.

The thumb CMC joint is at risk!

For the patient who has a very unstable CMC, performing 1st DI strengthening may be painful initially.

External support with co-contraction of the “C” position, manual support of the metacarpal, or performing exercise with orthotic support at the CMC may be needed.

If the program is unsuccessful in stabilizing the CMC and

relieving pain, surgical options may be a consideration.

Practice Dynamic Thumb Stability Intervention

• Web Space release & Stretch: Palmar & Radial Abduction

• Achieve a C position, Isometric and Isotonic

• Perturbate that C position

• 1st Dorsal Interosseous: Feel the Stability of thumb when it is activated

• 1st DI: AROM, Isometric, Isotonic, and then during FUNCTION

• Feel the Opponens work with the 1st DI

• How will you begin using this for ALL your thumb patients?

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Equipment to “unload” thumbs

• Design or select according to need

• For activity or rest (may need both)

• Immobilize? Stabilize?

• Reduce deformity

• An uncomfortable orthosis is useless!

What about an Orthosis?

Plan to

wean

from an

orthosis

Manual release of the adductor and any over-

active, dominant muscle

Joint mobilization to reduce / realign the CMC

Muscle re-education / strengthening

Use of adaptive tools and joint protection

techniques

Orthosis/Orthoses as needed

Did you Learn 3 Important Points for Stable Thumb….

1. The thumb webspace: Keep it SUPPLE

2. Use of ALL thumb motors to Stabilize and Centralize the 1st

metacarpal as it moves on the trapezium.

3. Educate the person to stabilize their own thumbs for a lifetime.

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Keep up the Good Work for your thumbs and those of your patients.

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“No two thumbs are alike.” -Jan Albrecht

It’s NOT about an Orthosis(Splint)!

It is about Dynamic Stability!

In Remembrance: Jan Albrecht (1935-2016)OT & Hand Therapist Extraordinaire

• Jan Albrecht, OTR, CHT

• She discovered the power of dynamic thumb stability for her own painful thumb

• Used her passion and commitment to teach others: patients, therapists, and physicians

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(1991-2011)

Questions ?

Virginia O’Brien

vobrienotd@gmail.com

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