Arm pain and thumb pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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There are a number of disorders that can cause arm pain and thumb pain. This is a rundown of some of them.
The first is Carpal Tunnel Syndrome (CTS). It presents with pain, numbness, or tingling in the hand, wrist, palm, thumb, or first three fingers. Patients may complain of numbness in the forearm, upper arm, and even the shoulder. Pain may wake the patient up at night. Patients often describe having to shake their hand or run hot water over their hand get relief.
On physical exam, a physician will do a few diagnostic maneuvers. The first is the Tinel’s sign. Here, tingling is reproduced by tapping the palmar side of the wrist with a reflex hammer. Phalen’s test is another maneuver where tingling is reproduced by having the patients press the top part (knuckle side) of their hands together with the wrists flexed at 90 degrees for 30 seconds.
Carpal tunnel syndrome often has an underlying condition causing it. Other diseases to look for that may be causing the carpal tunnel syndrome are thyroid disease, diabetes mellitus, or inflammatory arthritis. CTS may also occur in the 2nd or 3rd trimester of a pregnancy, due to fluid retention.
Nerve conduction tests are an important diagnostic test.
Treatment includes rest, ergonomic changes such as changing the position of a computer keyboard or modifying the work station. Anti inflammatory drugs can help. Light-weight wrist splints, designed to keep the wrist in a neutral position for night-time use can be useful. If all the above measures don’t work, corticosteroid injection into the carpal tunnel may be useful.
Conservative measures are effective in 80% of cases. If a patient continues to have symptoms, referral to a specialist for surgery is indicated. Surgery has a good outcome in most cases.
A new type of ultrasound guided needle release is very effective in treating carpal tunnel syndrome and avoids the need for surgery in many cases.
Pronator teres syndrome mimics carpal tunnel syndrome. It is a condition where the pronator muscle in the forearm applies pressure on the median nerve. Patients will develop numbness, tingling, and pain in the thumb and first two fingers.
This condition is found in people who use their arms for repetitive types of activities.
Sometimes there will be a positive Tinel’s sign over the pronator muscle. Electrical testing will sometimes help establish the diagnosis.
Rest, physical therapy, and specific exercises may be useful. Surgery is rarely required.
De Quervain’s Tenosynovitis is a type of tendonitis that affects the tendons that control the ability to abduct (move the thumb away from the hand). Pain is felt at the thumb side of the wrist with lifting. A patient will have problems with gripping.
On exam there will be local tenderness over the wrist at the base of the thumb. The pain will be maximum over the tendon responsible for moving the thumb away from the hand. (abductor pollicis longus tendon).
Pain is aggravated by resisting thumb abduction. Pain and difficulty moving the thumb when opening and closing the hand is also seen. Finkelstein’s maneuver which is reproduction of pain with stretching the patient’s fist towards the little finger side of the wrist while the patient wraps their fingers over the thumb with the thumb pointing towards the little finger, is a very good physical exam test.
A history of wrist pain and thumb side wrist tenderness coupled with pain aggravated by resisting thumb abduction is suggestive of active de Quervain’s tenosynovitis.
Treatment consists of ice, NSAIDs, splinting of the affected thumb, and corticosteroid injection. Surgery is rarely necessary,
Cervical Radiculopathy means “pinched nerve in the neck.” It presents with pain in shoulder, elbow, or forearm. A patients may have numbness in the elbow, forearm, or hand. Sometimes the pain is increased with straining (coughing, sneezing, bowel movement).
Physical exam will be aimed at demonstrating nerve root compression. Assessment of muscle strength and reflexes is also important.
Imaging procedures such as MRI or electrical tests may also be useful.
Treatment includes rest (sometimes using a soft cervical collar), anti inflammatory drugs, and physical therapy. Traction, transcutaneous nerve stimulation, and moist heat along with a stretching and strengthening exercise program are useful for patients with continuing discomfort.
Epidural injections of glucocorticoids may be helpful.Surgery is indicated if pain prevents patient from functioning, or if there is spinal cord compression, or weakness.
The thumb has the greatest range of motion of any joint in the body. It can swivel and pivot, and it enables a person to grasp. But this movement comes at a price. With age and overuse, the cartilage lining of the carpometacarpal joint (the base of the thumb- the joint closest to the wrist) becomes damaged and worn away leading to osteoarthritis. Eventually, everyday activities such as opening a jar or turning a key become painful.
Physical exam may reveal tenderness, “squaring of the joint”, and a grinding sensation.
Treatment involves making the diagnosis first. X-rays are helpful. Using a pen with a thicker grip may be useful. Moist heat, anti inflammatory drugs, splinting and glucocorticoid injection are also helpful. Sometimes arthroscopic joint debridement with injection of a lubricant afterwards may be suggested. In patients who do not respond to these measures a tendon transposition surgery is sometimes useful.
Another thumb problem is tendonitis of the flexor tendon- the tendon that allows the patient to bend the thumb. When this occurs, there may be sticking of the thumb with both bending and straightening. Sometimes the thumb will lock. This is also referred to as “trigger thumb.” Steroid injection is useful. Sometimes in severe cases, surgery is advised.
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