Arm pain and thumb pain

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit



There are a number of disorders that can cause arm pain and thumb pain. This is a synopsis 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 diffuse numbness in the forearm, upper arm, and shoulder. The top part of the hand is spared. Pain may wake the patient up at night. Patients often describe shaking the hand or running their hand under water to obtain relief.

On physical exam, a physician will be able to do a few maneuvers that may suggest the diagnosis. 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 his/her hands together with the wrists flexed at 90 degrees for 1 minute.

Carpal tunnel syndrome is a symptom, not a disease. It 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 2nd or 3rd trimester of a pregnancy.

Electrodiagnostic testing (nerve conduction tests) are also 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 are helpful. Splinting consisting of light-weight wrist splints, designed to maintain the wrist in a neutral position for night-time use, also are useful. If all the above measures don’t work, corticosteroid injection into the carpal tunnel may be useful.

Conservative measures effective in 80% of cases. If a patient remains symptomatic, referral to a specialist for surgery is indicated. Surgery has an excellent outcome in most cases, provided risk factors (such as overuse activities at work) are addressed.

Pronator teres syndrome mimics carpal tunnel syndrome. It is a condition where the pronator muscle in the forearm causes 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 occasionally required.

De Quervain’s Tenosynovitis is a type of tendonitis that affects the tendons that allow the patient to abduct (move the thumb away from the hand). Pain is felt at the radial side (thumb side) of the wrist with lifting. A patient will have problems with gripping. Often the condition occurs as the result of lifting infants with the second metacarpals (web between the thumb and the index finger) under the baby’s arm pits.On exam there will be local tenderness over the distal part of 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 aggravation 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.

In the absence of trauma to the distal radius (thumb side lower forearm bone), a history of wrist pain and thumb side wrist tenderness coupled with pain aggravated by resisting thumb abduction is highly suggestive of active de Quervain’s tenosynovitis.

Treatment consists of ice, NSAIDs, splinting of the affected thumb, and corticosteroid injection. Surgery is rarely necessary,

A condition known as RSI, (repetitive stress syndrome) or CTD, (cumulative trauma disorder) develops from continuous low level stress on any muscle or joint. It is becoming more common in the wrist and arm from the increased use of computers and other motions involving the arms such as working with an espresso machine.

RSI / CTD is difficult to treat. It often involves tendonitis of all the wrist muscles, mild carpal tunnel syndrome, as well as problems at the wrist, shoulder and neck.

RSI /CDT is preventable if caught early. This condition affects members of both genders, usually between the ages 20 and 40.

Pain, deep ache, numbness or burning of the hand, wrist, arm or shoulder are the major symptoms. On exam there will be limited range of motion (less than normal movement) of fingers, wrist or shoulder. Stiffness or soreness of the muscles at the hand, elbow, or shoulder will also be seen.

Repeated use of the arm or wrist in an awkward position is the major cause. Examples include bending the wrist with typing, using the phone, operating a machine, playing sports, working with the arm held away from your body (reaching forward or to the side and keeping the arm in this position), postural strain ( improper position when sitting - reaching ), falling and landing on an out stretched arm. This is also a common cause of a wrist fracture.

Any condition that causes swelling of the wrist can compress the median nerve as it passes through the carpal tunnel. This is a cause of carpal tunnel syndrome which is a major part of RSI.

Risk factors include working at a desk for long periods, repeated bending the wrist or reaching out with the arm, participation in sports without proper training, rapid increase in athletic activity (weekend athlete), and playing musical instruments.

RSI may be prevented by proper training and following a program where you gradually increase the amount of time you play.

It is helpful to remember to keep the elbow close to the body with the wrist straight. The elbow, forearm, and wrist should be supported.

Other tips are: rest the arm in a comfortable position when using the arm and wrist; take frequent breaks at work; when learning a new sport or instrument, stretch the arms; get proper training when taking up a new sport or learning a new instrument; use proper equipment on the job or with sports; learn how to sit properly.

A physician will do a medical history and exam. Electrical testing may be done to determine if there is any nerve damage.

Treatment will depend on severity of the pain and discomfort. Rest, instruction in body mechanics, splinting, anti inflammatory drugs, and physical therapy are all helpful.

Thoracic Outlet Syndrome (TOS) is a condition that affects the shoulder, arm and hand. It is characterized by pain, weakness and numbness in these areas. TOS occurs when the 5 major nerves and 2 main arteries that leave the neck become compressed between the two scalene muscles in the front of the neck and the first rib. TOS is caused by repetitive actions with the arms held overhead or extended forward, which can result in irritation and compression in this area. In addition, Forward Head Posture, slouching or dropping the shoulders forward can cause tension in the muscles at the side of the neck, which constricts arteries and nerves and contributes to TOS. Other causes of TOS include an extra first rib or an old collarbone fracture, since these both limit space in this region. Injuries that tear the scalene muscles of the neck, such as whiplash, can lead to a buildup of scar tissue, which also restricts space around the nerves and arteries, leading to TOS.

Symptoms of TOS can include pain, weakness, numbness, tingling, swelling, fatigue, or coldness in arms and hands. Waking up with a "dead arm" is also characteristic of TOS. TOS is often difficult to diagnose since its symptoms mimic those of other conditions, such as Herniated Cervical Disk, Carpal Tunnel Syndrome, or bursitis of the shoulder.

People at risk for developing TOS include people whose occupations involve repetitive actions with the arms extended, such as computer users, waiters and painters.

Prevention of TOS includes taking frequent breaks from repetitive tasks, doing stretching and strengthening exercises for the back, neck and shoulders, adopting an ergonomic workstation arrangement, practicing proper posture at the computer, and by limiting the amount of time spent with arms extended or doing repetitive tasks.

Treatment for TOS includes rest, doing stretching and strengthening exercises for the back, neck and shoulders, adopting an ergonomic workstation arrangement, and using proper posture at the computer. Depending on the cause, physical therapy, chiropractic care, or medication may be useful.

Cervical Radiculopathy means “pinched nerve.” It presents with pain in shoulder, elbow, or forearm. The pain often has a burning quality. 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. Many different maneuvers may be done by physicians. 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 supplemented by a stretching and strengthening exercise program are warranted for people with continuing discomfort.

Surgery is indicated if pain prevents patient from functioning, or if there is spinal cord compression, or weakness.

Of all the fingers, the thumb has the greatest range of motion- 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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