Key Points

• Multiple exercises and techniques can help improve thumb pain.

• Using various products designed to protect the thumbs can help limit or prevent injuries such as CMC.

Many pathologies can affect us as massage therapists, including carpal tunnel syndrome, repetitive strain injuries, and De Quervain’s tenosynovitis, among others. Another pathology that can affect MTs is hand osteoarthritis, particularly carpometacarpal (CMC) arthritis, also referred to as basal joint arthritis, carpalmetacarpal joint arthritis, or trapezio-metacarpal arthritis. 

Anatomy

The CMC joint of the thumb is a biconcave-convex saddle joint, where the first metacarpal of the thumb and the trapezium carpal bone articulate.¹ It is known as a saddle joint because of its shape—the articular surface is concave in one direction and convex in the other. 

There are 16 ligaments that support the CMC joint of the thumb. The two that provide the most support are the dorsoradial and the volar beak ligaments. The volar beak ligaments were once thought to be the most prominent stabilizers of the CMC joint; however, the dorsoradial ligaments are now thought be the most important in providing stability to the CMC joint.² 

The thumb is an extremely mobile joint, as demonstrated by movements of opposition and reposition (combinations of actions), flexion and extension (which occur in the frontal plane), and abduction/adduction (which occur in the sagittal plane). The extrinsic muscles that control the movements and support the thumb, in which the proximal part of the muscle attaches on the forearm and the distal part attaches to the thumb, are the extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus, and flexor pollicis longus. The intrinsic muscles, where the entire muscle and its attachments are on the hand and attach to the thumb, include the abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and adductor pollicis. The intrinsics and extrinsics work together to produce efficient motion.³ An additional hand muscle—thefirst dorsal interossei—helps stabilize the thumb and works in conjunction with the opponens pollicis to stabilize it during pinching. 

Pathology

CMC joint arthritis is described as the erosion of cartilage between the first metacarpal and the trapezium. There can be different mechanisms that cause CMC arthritis, such as ligament laxity, previous injury, and overuse.⁴ As massage therapists, we continually use our hands and, on many occasions, our thumbs during treatment sessions. However, we may not always be mindful of proper body mechanics and the stacking of our joints, thus inadvertently contributing to the wear and tear of our CMC joint.An adduction contracture of the thumb causes difficulty in its ability to abduct and rotate and, in some cases, may also limit the flexion of the fingers.⁵ Daily activities that may be affected by CMC arthritis include holding and turning a key, lifting a pot or pan, holding a toothbrush, and turning a door handle, among others where pinch and grasp are required. 

Joint Protection and Ergonomics

As massage therapists, we need to preserve our most important commodities: our bodies and hands. We often read about proper positioning of the table for maximum force and using our core to generate enough force for massage techniques, stacking our joints, leg stance, and standing over the client, to name a few. We can also focus on using our stronger joints and muscles, such as our forearms and elbows. During pinpoint work, such as on the neck, hand, and/or areas with specific trigger points that need to be addressed, we tend to rely more on our hands, especially our thumbs. 

What can we do to keep our fingers, especially our thumbs, protected from injury? As noted, one technique is to keep our thumbs in alignment with our forearms and avoid hyperextending them. Another technique is to use our other fingers instead of our thumbs. Or we can alternate using our thumbs with using our fingers. Again, with all these techniques, we want to use proper posture, changing our body positions as needed (changing table height, rolling chair position, etc.). The benefit of using our hands is that our fingertips supply a lot of feedback as to the different tone and texture in our clients’ tissues that our elbows or forearms may not. 

There are other ways to protect our thumbs too. We can use various tools designed for that, though we may lose the feedback that occurs through fingertips. We can also try and protect our thumbs and wrists during our daily activities, for example using our stacked fingers to press buttons/timers on an oven, using two hands to lift a pot, etc. Consider using adaptive equipment in our everyday lives, not just during our massage techniques. Some examples include using an electric toothbrush (to avoid pinching when you are holding the toothbrush) or putting your toothbrush in a foam/rubber sleeve for more gross grasp versus more pinching; kitchen tools with larger handles/ergonomic knives; mounted jar opener/bottle cap opener; spring-loaded scissors; electric can opener; adapted key holder; larger barrel pens for writing/adapted pens; and using a microphone for texting/messaging.⁶ 

Of course, self-massage on the forearms and thumbs as well as stretching the wrists is invaluable. But it’s also important to protect yourself by getting enough rest between clients. Avoid taking on too many clients so you don’t get fatigued and, in turn, sacrifice your body mechanics. You may also consider alternating your caseload, if possible, so that you don’t have as many deep-tissue sessions in one day. 

I Have Pain, Now What? 

Here’s where to start if you do have pain at your CMC joint:

• Determine pain—Do you have pain in your thumb in and around the CMC joint? 

• Evaluate stiffness—Do you have any inflammation in the base of the thumb at the CMC joint? Do you feel stiffness in your thumb?

• Check range of motion—Start by checking the active range of motion of both thumbs. Can you see differences in the range of motion between each side? 

If there is inflammation or swelling at the CMC joint, you can apply ice to your hand. If you have some joint stiffness in only the thumb and hand, you can use moist heat/warm compress to increase the elasticity of your tissues and decrease stiffness.

You can also try a prefabricated, over-the-counter orthosis. If you have only thumb pain, you can wear a hand-based thumb orthosis. If you have discomfort in your wrist and thumb, you can get a forearm-based thumb orthosis. Decreasing inflammation and increasing range of motion are also key to recovery. 

Exercises to Address CMC Pain 

The following techniques will increase extensibility and help with inflammation around the CMC joint. The most important thing when doing these exercises is to stop if you have pain at the CMC joint. 

Exercise: Release Tightness

If your thumb feels stiff, you can release tight muscles around the CMC joint to increase active motion of the thumb. You should do this before joint mobilization. First, check the motion of the thumbs before beginning; you’ll recheck them again after stretching. To massage/decrease tightness of thenar muscles, use the golf-ball techniques on page 65. Release the adductor pollicis muscle by supporting the hand and using a dowel/eraser part of a pencil (Image 1). Hold for 30–60 seconds. Another option is to use a chip clip for tight adductor muscles of the thumb (Image 2). Hold in place for 2–5 minutes. 

A third option is to place your palm down, flat under your thigh to stretch the hand. Do this for 2–5 minutes (Image 3). 

Exercise: Joint Mobilization⁷

This exercise will stretch the metacarpals and is easily done during a break.

1. Grasp your thumb behind your back with the opposite hand and let your arms relax to gently distract the affected thumb (Image 4).

2. Move your hands and arms to the front of your body. Grasp the first metacarpophalangeal joint with the non-affected hand. Gently turn the palm and place on your chest and gently rock your hand back and forth, stretching the metacarpal (Images 5 and 6).

Revisit the techniques for decreasing inflammation and/or increasing extensibility of the tissues using heat or ice, and depending on the situation, self-massage and release any tight muscles before beginning joint mobilizations. It is imperative you do not work through pain during these joint mobilizations. 

Stabilizing the CMC Joint

Just as poor body posture over time can cause pain and injury in the back and neck, the same can occur at our thumb joints as uneven wear can occur from tight, shortened muscles. The one muscle that has a strong pull on the CMC joint is the adductor muscle of the thumb, which can cause a muscular imbalance and subsequent wearing of the cartilage at the CMC joint. The two most stabilizing muscles of the thumb are the first dorsal interosseous muscle, which moves the second finger toward the thumb to pinch, and the opponens pollicis muscle, which moves the thumb into opposition. In conjunction with other muscles that hold the thumb away from the palm, these muscles turn the thumb to touch each fingertip and stabilize the thumb during pinching. 

To find the first dorsal interosseous muscle, with the palm placed flat on the table, abduct your index finger, and palpate just proximally and medially to the metacarpophalangeal joint of the index finger (Image 7).

Exercises: Stabilizing the CMC Joint⁸

1. Place the thumb in a “C,” as if you are holding a ball (Image 8). Hold this position for 5–10 seconds, repeating 10 times. Start with one set per day, then increase. 

2. Place and hold the thumb in a “C” position, using the opposite hand to stabilize, then lightly pinch (Image 9) and remove the supporting hand (Image 10) from this position without letting the metacarpophalangeal or interphalangeal of the thumb collapse for 10–12 reps. Start with one set per day, then increase. 

3. Place a thin rubber band around the hand and thumb and move the thumb out and away from the palm 10–12 times, ending with a rounded “C” position (Images 11 and 12). If you have pain, you can do this without a rubber band and just do the movement. Avoid flexion of the first metacarpophalangeal joint. Start with one set per day, then increase.

4. To work the first dorsal interossei muscle, place your hand on a table and your index finger away from your middle finger (Image 13). First do the movement, then resist the movement by placing your other hand/finger on the lateral side of the index finger (Image 14). Do this 10–12 times. Start with one set per day, then increase.

5. Add resistance to the first dorsal interossei muscle by placing a rubber band around the index finger at the proximal phalanx, then abduct and adduct the index finger (Images 15 and 16).

In Summary

As with any professional who uses their hands for precise work, we are at risk for pathologies of our hands. It is imperative we take care of our hands and protect them as much as we can. 

Getting a Diagnosis

If you do have pain in your thumb, you may want to see an orthopedic hand specialist to get a formal diagnosis, since there are other conditions that can mimic CMC joint arthritis. The orthopedist may refer you to see a hand therapist, occupational therapist, or physical therapist. The hand therapist may be able to make you a custom splint for more support and stability, as well as provide additional exercises, suggestions, and feedback.

Self-Care Between Clients

After each massage client, practitioners should do self-massage for the forearm and thumb, using a golf ball and either their hands (knuckles or stacked fingers) or a hard surface. This simple sequence offers trigger-point release to address the opponens pollicis, flexor pollicis brevis, abductor pollicis brevis, and adductor pollicis.

Notes

1. Joshua Gillis et al., “Review of Thumb Carpometacarpal Arthritis Classification, Treatment and Outcomes,” Canadian Journal of Plastic Surgery 19, no. 4 (2011): 134–38.  

2. Richard Kim and Robert Strauch, Musculoskeletalkey.com, “Ligament Stabilization of the Unstable Thumb Carpometacarpal Joint,” accessed March 2023, https://musculoskeletalkey.com/ligament-stabilization-of-the-unstable-thumb-carpometacarpal-joint.  

3. Virginia O’Brien et al., “Dynamic Stabilization of the Painful Thumb: A Historical and Evidence-Informed Synthesis,” Journal of Hand Therapy 35, no. 3 (2022): 388–99.

4. Gillis et al., “Review of Thumb Carpometacarpal Arthritis Classification, Treatment and Outcomes.”

5. J. Edward Flynn, “Adduction Contracture of the Thumb,” The New England Journal of Medicine 254 (1956): 677–86. 

6. The Mayo Clinic, “Joint Protection for People with Hand Arthritis,” last modified February 25, 2021, mayoclinic.org/diseases-conditions/arthritis/multimedia/joint-protection/sls-20076400.

7. Virgina O’Brien, Medbridgeeducation.com, “Evidence Based Intervention to Restore Dynamic Thumb Stability,” accessed March 2023, medbridgeeducation.com/course-catalog/details/evidence-based-intervention-to-restore-dynamic-thumb-stability-virginia-obrien-hand-therapy. 

8. Jan Albrecht, Caring for the Painful Thumb, (New Ulm, MN, Corporate Graphics, 2015); O’Brien, “Evidence Based Intervention to Restore Dynamic Thumb Stability.”