Transcription:

Scott Webb: Hello and welcome to Check-Up Chat with EvergreenHealth. I'm Scott Webb. And there are several types of arthritis that involve the hands, wrists, and fingers leading to pain, swelling, and a loss of function. And today, I'm joined by Dr. Avi Goodman. He's an orthopedic surgeon at EvergreenHealth Orthopedic and Sports Care, and he's here to discuss arthritis of the thumb, also known as CMC arthritis. And doctor, before we get to CMC arthritis, welcome to Check-Up Chat.

Dr. Avi Goodman: Thank you very much for having me.

Scott Webb: So as we get going here on this topic of thumb arthritis, let's just have a basic baseline question, if you will. What is arthritis?

Dr. Avi Goodman: Arthritis is a breakdown of the cartilage of the joint surface. So instead of gliding smoothly over one another, the joints start to become ground down, and that's when you can develop the bone-on-bone. And that's really that grinding sensation, which can lead to a lot of pain, particularly with motion. And so in the thumbs, it usually comes out as pain with gripping or opening jars or twisting. There are a lot of those fine motor activities that can be pretty aggravating.

Scott Webb: Yeah, that's a perfect word, aggravating. Yeah, when you're trying to open a jar that, you know, 20, 30 years ago, you could have done with like two fingers and now you struggle with your whole hand because your thumb hurts and you just don't feel like you have the strength in your thumb. So then, what is CMC arthritis and what area of the hand does it affect?

Dr. Avi Goodman: So when we think of thumb CMC arthritis, that CMC stands for carpometacarpal, which is really the fancy word for the base of the thumb. And so, that's the base of the thumb, really where the thumb meets the hand and the wrist. And so, people will be feeling the base of their thumb, and that's where they'll have soreness as well as some tenderness. And again, it affects it with not only pinching, opening jars, but it can really just be this deep ache because it's very uncomfortable and can affect people during the night as well as during the day, and it's usually worse with activity.

Scott Webb: Yeah. That definitely checks out. And when we think about diagnosis, is it patient history, you know, kind of hearing their story in a physical exam? Or is there possibly any imaging or anything like that involved? How do you diagnose?

Dr. Avi Goodman: Well, we start with the physical exam as well as a history, and we take a look and we hear what people are coming in and what their issues really are. And then on examination, usually they have some pain around the base of their thumb. Sometimes there'll be a level of deformity, so the joint above it can sometimes hyperextend and that can lead to compensate, and their thumb can actually move closer to their other fingers. So, we'll look for that on exam and we can try grinding those two joints together. And if that hurts, that's generally a positive sign for arthritis, or at least it shows us that it's there. But usually, the definitive diagnosis is on x-rays. So, we'll get x-rays of the hand in a few different positions, and that will let us look at that joint really well and will let us see if there's any remaining joint space, if there's extra bone that's formed, or if any of the joints that are next to it have also become afflicted with arthritis.

Scott Webb: Yeah. I was looking at my hand listening to you talking, thinking "Is my thumb closer to my index finger?" Trying to self-diagnose myself, which I guess would be better if we came into the office and saw you, of course. And I think I know the answer to this because when we think about, at least in my experience with osteoarthritis and just the wear and tear of just being a human living a life, that a lot of these things just really aren't preventable. But in the case of CMC arthritis, is it preventable in any way?

Dr. Avi Goodman: I wish, but unfortunately not. And so, it affects people much more commonly as they get older. And women are also more commonly affected than men, but we certainly see this in men as well. And when we start thinking about treatment, usually we will think about doing things like wearing braces, particularly when the patients are going to do anything heavy. So, that could be yard work, it can be gardening, home renovation, or even just lifting or opening jars.

Scott Webb: So, you mentioned briefly there just sort of the treatment options and generally what you do and that it's not preventable. Is there ever a time where surgery is indicated?

Dr. Avi Goodman: Yes, absolutely. So before we think about surgery, we do some pretty good attempt at non-operative treatment. So, we start with the braces. If the brace is ineffective, then the next step we'll usually do is a steroid injection, and it can provide some fairly durable relief. Some people will get just a few weeks, but some people get six or eight months out of it, which is quite helpful when trying to avoid surgery.

But there is a very effective surgery, and this surgery is best at eliminating the pain. People still have pretty good strength after the surgery, but it's really good for pain control. And what we do during the surgery is we remove one of the bones in the hand. And so instead of bone grinding on bone, it's actually bone grinding on nothing. And then, we hold that thumb suspended in a way that still maintains the shape of the hand and, in doing so, maintains the strength of the hand.

Scott Webb: Wondering then when we think about surgery, if that's the best option, you know, if that's the last thing in everything that you can try and you get to that after steroids and braces and all of that, what's the recovery like? How long does it take people to recover? And is there a chance of this coming back after you've removed that piece of bone?

Dr. Avi Goodman: That's a great question. So the recovery afterwards, so it's a day-surgery, the surgery itself will take about an hour to an hour and a half or so. The patients generally do get anesthesia for it. But the recovery process usually takes about three months, which is a little bit faster than it used to be. We're just using newer techniques now that have a faster recovery than before. The patients work with the occupational and hand therapist along the way to regain first their motion and then their strength afterwards. But people are doing generally pretty well by about three months after the surgery and have gotten essentially to where they're going to be by four to six months after. Surgeons over the years have tried everything from implanting ivory to metal and plastic, and really nothing has seemed to do a better job than simply taking out the bone and then holding the thumb out in the right spot. And so, it's really a tried and true method that's been around for about 70 or 80 years. And so, we've had really good results and there have been little tweaks here and there, but very, very tried and true.

Scott Webb: Yeah, that's very cool. It always gets me thinking. I'm like, "I must have needed that at some point." But it's why we have surgeons and experts who say, "Nah, you're going to be fine." And sort of in that context of you're going to be fine, because you said that they kind of within three months and then maybe four to six months will be like, you know, all the way healed and all the way back after PT or OT or all the T's, you know, will people's thumbs perform as they did before? Are there going to be limitations if they played sports or did things where they really needed to be able to close that hand and hold on tight? Is that ever going to be an issue?

Dr. Avi Goodman: Occasionally, it can. We try to be very mindful of that, and so we try to strike this balance between having a nice, stable hand as opposed to one that's too stiff and one that has lots of strength. So once the thumb is in a better position, which it usually is after the surgery, then that actually enables the strength to increase. And then, the therapy will really make sure that that happens. So people, they should be able to close their hands. They should be able to do things like grips ski poles and do really all of their day-to-day activities. There's a little bit loss of strength, but people have mostly lost that ahead of time anyway, just because it hurts so much to use the thumb before having the surgery, and that's why they're having the surgery ultimately.

Scott Webb: Just wondering your final thoughts, if people are suffering, if they're having the pain, the stiffness, the inability to open jars or ski or whatever it might be, what would be your advice?

Dr. Avi Goodman: I would say to come in and talk with us and we'll be happy to evaluate you. And again, it'll start off with examination and x-rays, but really we try not to move too quickly. And we try to maximize all of the non-operative options before going to surgery. And generally, people are pretty happy with the outcome. And really, once we make the decision for surgery, it's because they've reached that point and we're always on the same page.

Scott Webb: Yeah. In hosting a lot of these, it's always music to my ears that surgery's the last option, but it is an option and people generally have good outcomes and are happy when they're confronted with or make that decision. So, good stuff today, doctor. Thanks so much. You stay well.

Dr. Avi Goodman: Absolutely. Thank you so much.

Scott Webb: And if you're experiencing thumb pain and would like to get it checked out by an expert, you can make an appointment by calling 425-899-4810 or visit evergreenhealth.com/ortho-sports-medicine.

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