Kategoria: Hand and Wrist (EN)

Pain at the base of the thumb that becomes worse when opening a jar, turning a key, pinching, squeezing or using a strong grip is commonly caused by osteoarthritis of the thumb carpometacarpal joint. This is the first CMC joint, between the first metacarpal and the trapezium. Pain location alone is not enough to make the diagnosis, however: de Quervain tenosynovitis, scaphoid injury, disease in adjacent joints and nerve irritation can produce similar symptoms. Most patients start with non-operative treatment.

Polish version: Ból u podstawy kciuka — czy to zwyrodnienie stawu siodełkowego?

What is the thumb CMC joint?

The joint at the base of the thumb has a saddle-shaped geometry that allows a large range of motion. It lets the thumb move away from the palm, oppose the fingers and perform precise pinch. That mobility comes at the cost of substantial loading across a relatively small articular surface.

Over time, cartilage may deteriorate and the joint can become less stable. Imaging may show joint-space narrowing, osteophytes, subchondral sclerosis and sometimes subluxation of the base of the first metacarpal. An important point is that radiographic severity does not always match pain or functional limitation. Treatment decisions should be based on the patient and the symptoms, not on the X-ray alone.

What symptoms are typical?

• pain around the base of the thumb, usually on the palmar or radial side,
• pain when opening jars, turning keys, fastening buttons, opening packaging or using tools that require pinch,
• reduced grip and pinch strength,
• tenderness directly over the joint,
• sometimes crepitus or clicking with movement,
• in more advanced cases, visible widening or deformity at the base of the thumb.

Symptoms often develop gradually. Activities requiring forceful grip or loaded pinch typically provoke more pain than moving the hand freely without resistance.

How is this different from de Quervain tenosynovitis?

Both problems may be described simply as “pain on the thumb side,” but the area of greatest tenderness is usually different. With first CMC osteoarthritis, pain is centred at the base of the thumb around the joint. With de Quervain tenosynovitis, pain is typically higher at the radial styloid on the wrist and relates to the tendons of the first extensor compartment.

After a fall onto the hand, the diagnostic situation is different again. New pain on the radial side can result from a scaphoid fracture and should not automatically be attributed to osteoarthritis.

How is thumb CMC osteoarthritis diagnosed?

History and examination

The pattern of symptoms and the clinical examination are central. Assessment includes the exact pain location, range of motion, thumb stability, grip and pinch strength, and neighbouring joints and tendons. The grind test — axial loading with rotation of the first metacarpal — can support the diagnosis, but it is not a perfect test. A negative result does not exclude thumb-base osteoarthritis.

X-ray

Radiographs are useful when bony changes need confirmation, their extent matters, adjacent-joint disease must be considered or surgery is being planned. An X-ray is not necessarily required for every first mild episode with a typical presentation. Even marked radiographic osteoarthritis can coexist with limited symptoms, and the reverse can also occur.

Ultrasound

Ultrasound can demonstrate osteophytes, joint fluid and synovial changes while also assessing the soft tissues around the painful region. It can be particularly useful when differentiating joint disease from de Quervain tenosynovitis or another tendon problem. It can also guide a planned injection accurately. Ultrasound is not mandatory in every patient with a typical clinical presentation.

MRI

MRI is rarely the first-line test for typical first CMC osteoarthritis. It is more useful when symptoms are atypical, previous tests do not explain the pain, or another bone, ligament or cartilage abnormality is suspected.

How is thumb-base osteoarthritis treated without surgery?

Current British Society for Surgery of the Hand guidance supports a stepwise approach. Initial management is multimodal and non-operative, with additional options introduced if symptoms continue to cause meaningful functional limitation.

Load modification and exercise

The aim is not to stop using the thumb completely, but to reduce the most provocative loads and improve how everyday tasks are performed. Wider handles, jar-opening aids, using two hands instead of one and limiting prolonged forceful pinch can be helpful.

Exercises directed at thumb stability, range of motion and hand strength may reduce pain and improve function. Their intensity should be adjusted so that they do not provoke a prolonged flare of symptoms.

Brace

A brace that stabilises the base of the thumb can reduce pain during gripping activities. It does not necessarily need to be worn continuously. Some people benefit most during demanding tasks, while others use it for selected periods at rest as well. The type and schedule should match the symptoms and the functional demands on the hand.

Pain and anti-inflammatory medication

Medication can reduce pain temporarily but does not restore cartilage. Topical anti-inflammatory preparations are often considered for local symptoms. Oral medication needs individual assessment, particularly in people with gastrointestinal, kidney or cardiovascular disease or those taking anticoagulants.

Joint injection

If non-invasive treatment has not provided enough relief, an intra-articular corticosteroid injection may be considered. BSSH guidance places injection at this stage in the pathway. The goal should be realistic: an injection may reduce pain for a period, but it does not regenerate cartilage or remove the mechanical cause of osteoarthritis.

The evidence for injection efficacy is less consistent than its widespread use might suggest. Systematic reviews have found heterogeneous results, so the decision should take symptom severity, previous treatment and alternatives into account.

When does an orthopaedic surgeon consider surgery?

Surgery is considered when pain and functional limitation remain substantial despite appropriate non-operative treatment and continue to interfere with daily life, work or activity. A “bad X-ray” alone is not an indication for surgery.

One of the most commonly used operations is trapeziectomy, which removes the trapezium. Numerous modifications add ligament reconstruction, suspension of the first metacarpal or tissue interposition. Current BSSH guidance notes that available evidence has not demonstrated an advantage of adding interposition or ligament reconstruction over trapeziectomy alone.

This does not mean every patient should have the same operation. Procedure selection depends on age, deformity, neighbouring joints, functional demands and surgeon experience. More complex reconstruction should have a specific rationale rather than being performed automatically.

When should thumb pain be assessed more urgently?

• severe pain after a fall or other injury, especially with deformity, bruising or inability to use the thumb,
• rapidly increasing swelling, redness and marked warmth, particularly with fever,
• new or pronounced numbness or weakness in the hand,
• a thumb that becomes blue, pale or cold, or other signs of impaired circulation,
• rapidly progressive unexplained symptoms or involvement of several joints suggesting inflammatory disease.

Common questions

Can osteoarthritis be reversed?

Structural changes in cartilage and bone cannot simply be reversed by exercise, a brace or an injection. Pain and function can nevertheless improve substantially, which is why imaging severity does not determine how well the hand can function.

Do severe X-ray changes mean I need surgery?

No. The relationship between radiographic severity and symptoms is limited. Surgical decisions are based mainly on pain, loss of function and failure of appropriate previous treatment, with imaging as one part of the decision.

Is ultrasound always needed before an injection?

Not in every straightforward case. Ultrasound guidance allows the operator to visualise the needle and adjacent structures and confirm that medication reaches the intended location. It may be particularly useful with atypical anatomy, previous unsuccessful injections or diagnostic uncertainty.

References

1. Gangopadhyay S, Jansen V, Khor WS, Gardiner MD, Burchette D, McKenna H. Guideline on managing thumb base osteoarthritis: The British Society for Surgery of the Hand Evidence for Surgical Treatment (BEST) findings and recommendations. J Hand Surg Eur Vol. 2025;50(5):576–586. DOI: 10.1177/17531934241313206.
2. Hamasaki T, Laprise S, Harris PG, et al. Efficacy of Nonsurgical Interventions for Trapeziometacarpal (Thumb Base) Osteoarthritis: A Systematic Review. Arthritis Care Res (Hoboken). 2020;72(12):1719–1735. DOI: 10.1002/acr.24084.
3. Merritt MM, Roddey TS, Costello C, Olson S. Diagnostic value of clinical grind test for carpometacarpal osteoarthritis of the thumb. J Hand Ther. 2010;23(3):261–267. PMID: 20452743.

This article is educational and does not replace a medical examination or individual treatment assessment.

← Osteoarthritis

Content prepared by: Tomasz Poboży - orthopaedic surgeon.

Polish version

Pain on the little-finger side of the wrist may come from the triangular fibrocartilage complex (TFCC), particularly when it begins after a fall onto the hand or a sudden twisting injury, or when it increases with forearm rotation and forceful gripping. TFCC injury is not the only possible cause. The extensor carpi ulnaris tendon, the distal radioulnar joint and other structures occupy the same region, so pain location alone is not enough to establish the diagnosis.

What is the TFCC?

The TFCC, or triangular fibrocartilage complex, is a group of fibrocartilaginous and ligamentous structures on the ulnar side of the wrist. It is an important stabiliser of the distal radioulnar joint, helps transmit load and acts as a cushion between the ulna and the carpal bones.

TFCC damage may be traumatic or degenerative. Traumatic tears can follow a fall onto an outstretched hand, sudden wrist rotation, sport or work involving strong forearm rotation. Degenerative changes more often develop gradually, particularly when the ulnar side of the wrist is subjected to chronic overload.

Which symptoms fit a TFCC injury?

Typical pain is felt on the ulnar side of the wrist, between the ulnar head and the carpal bones. It may be provoked by opening a jar, using a screwdriver, turning a door handle, gripping firmly, pushing up from the hand or using the hands to rise from a chair.

• pain with pronation and supination of the forearm,
• tenderness in the ulnar fovea region,
• clicking, catching or a sense that the wrist momentarily jams,
• reduced grip strength,
• a feeling of instability during forearm rotation.

Not every click represents clinically important damage. TFCC abnormalities can also be visible on imaging in people without symptoms, so MRI findings must always be interpreted together with the clinical examination.

What else can cause ulnar-sided wrist pain?

This is one of the more demanding areas of wrist diagnosis. Similar symptoms may arise from irritation or instability of the extensor carpi ulnaris (ECU) tendon, distal radioulnar joint instability, ulnocarpal impaction, lunotriquetral ligament injury, fracture of the ulnar styloid or hook of the hamate, and sometimes a ganglion.

How is TFCC injury diagnosed?

Clinical examination

The mechanism of injury and a careful examination are central. The clinician assesses the point of maximal tenderness, wrist motion, grip strength and distal radioulnar joint stability. Provocative tests that load the TFCC may also be used. No single manoeuvre is completely diagnostic, so findings must be considered together.

X-ray

After trauma, radiographs are often the first imaging test. They do not show the TFCC itself, but they can identify fractures, assess alignment and provide information such as ulnar variance, which can influence loading on the ulnar side of the wrist.

Ultrasound

Ultrasound can be valuable in the assessment of ulnar-sided wrist pain. It allows dynamic examination of the ECU tendon, parts of the TFCC and the distal radioulnar joint. It also has important limitations: a central TFCC disc tear cannot be reliably excluded with ultrasound. A normal scan therefore does not necessarily end the diagnostic process when symptoms continue to suggest an intra-articular lesion.

MRI

MRI provides detailed soft-tissue imaging and is commonly used when symptoms persist. It is not a perfect test. A diagnostic meta-analysis showed that conventional MRI can miss some TFCC tears and that accuracy varies with lesion location; peripheral tears can be particularly difficult to define unequivocally.

MR arthrography or CT arthrography may be used in selected situations, but they are not required for every patient with ulnar-sided wrist pain.

Arthroscopy

Arthroscopy allows direct inspection of the TFCC and other structures inside the wrist. It is the most direct method of assessing the lesion itself, but because it is an operative procedure it is not a routine first-line diagnostic test. It is most relevant when symptoms are substantial, non-operative treatment has failed, or a lesion is suspected that can be treated during the same procedure.

Does every TFCC tear require surgery?

No. Stable traumatic TFCC tears without distal radioulnar joint instability can often be treated non-operatively first. A 2024 systematic review including 425 patients and 427 wrists found that appropriately selected non-operative management can produce good functional outcomes. Distal radioulnar joint instability or subluxation and complete foveal detachment were associated with a greater risk of failure of conservative treatment.

The studies included in that review used different treatment protocols, so they do not support one universal immobilisation regimen. The type and duration of bracing should reflect the injury pattern and joint stability rather than the MRI report alone.

What does non-operative treatment involve?

Initially, activities that reproduce pain are usually reduced, particularly forceful gripping, rotation and weight bearing through the hand. Depending on the injury, temporary immobilisation or a brace may be used, followed by progressive restoration of movement and loading.

Analgesic or anti-inflammatory medication can be used in selected patients when appropriate. Hand therapy may then help restore motion, strength and control without repeatedly overloading the injured region.

An injection may occasionally be considered to reduce associated pain or inflammation, but an injection does not repair or “suture” a torn TFCC. When accurate needle placement matters, image guidance can be useful. See: Injection Treatments.

When does an orthopaedic surgeon consider surgery?

Surgery is considered more often when pain continues to limit function despite appropriate non-operative treatment or when clinically important distal radioulnar joint instability is present from the outset. The type and location of the lesion are important.

Peripheral and foveal tears, particularly those associated with instability, may be suitable for repair. The central disc has a much poorer blood supply, so some symptomatic central tears are treated by arthroscopic debridement of unstable tissue rather than suturing. When ulnocarpal impaction is also present, treatment may need to address the underlying bony anatomy.

Can the TFCC heal on its own?

Healing potential depends partly on lesion location. The peripheral TFCC has a better blood supply than the central portion and therefore greater biological healing potential. Clinically, however, the more important question is whether the wrist regains stable, painless function rather than whether the structural tear disappears on imaging. Symptoms can improve without surgery even when structural changes remain visible.

When should assessment not be delayed?

Earlier assessment is required after a more substantial injury when there is deformity, rapidly increasing swelling, marked inability to rotate the forearm or move the wrist, major loss of strength or concern about a fracture. Urgent assessment is also needed if the hand becomes pale or cold, new sensory loss develops, there is an open wound, or signs of infection such as increasing redness, fever and marked warmth appear.

For less acute symptoms, review is appropriate when ulnar-sided wrist pain persists despite reducing load, repeatedly returns during ordinary activities, or is accompanied by catching or a sense of instability.

Key points

Ulnar-sided wrist pain can result from a TFCC injury, but diagnosis requires the history, an assessment of wrist and distal radioulnar joint stability, and appropriately selected imaging. Ultrasound and MRI answer somewhat different questions, and neither replaces the clinical examination. Stable traumatic injuries can often be managed without surgery initially, whereas persistent pain combined with distal radioulnar joint instability requires more detailed assessment and more often leads to consideration of repair.

Back to: Hand Surgery

References

1. Choi SI, Malik S, MacLean S. The Natural History of Non-operatively Treated Traumatic Triangular Fibrocartilage Complex Tears: A Systematic Review. J Wrist Surg. 2024;13(6):550-558. DOI: 10.1055/s-0044-1786164.
2. Zhou JY, Tuyishime H, Yao J. Arthroscopic-Assisted Repair of the Triangular Fibrocartilage Complex. J Hand Surg Glob Online. 2024;6(4):445-457. DOI: 10.1016/j.jhsg.2024.03.011.
3. Treiser MD, Crawford K, Iorio ML. TFCC Injuries: Meta-Analysis and Comparison of Diagnostic Imaging Modalities. J Wrist Surg. 2018;7(3):267-272. DOI: 10.1055/s-0038-1629911.
4. Winnett M, et al. Sonographic Anatomy and Imaging of the Triangular Fibrocartilage Complex and the Distal Radio-Ulnar Joint. Australas J Ultrasound Med. 2025. DOI: 10.1002/ajum.70012.

Content prepared by: Tomasz Poboży - orthopaedic surgeon.