Background & Etiology
Ligaments are fibrous bands of connective tissue made of collagen, which join bone to bone. Ligaments provide stability and limit excessive motion of the joint. Gamekeeper’s thumb is an injury to the ulnar collateral ligament (UCL) in the thumb. In the thumb, the joint is the hinge that allows the finger to bend.
The thumb is an important part of the hand that allows us to grip objects, and perform many daily tasks. An injury to the UCL can cause instability that significantly impairs the thumb’s function on the involved hand. A UCL injury can range from a tear, to a more severe complete rupture.
The term Gamekeeper’s thumb dates back to the early 1950’s, when the condition was first observed among “gamekeeper’s” hunters in the United Kingdom and Scotland that put excess pressure on their thumb through the motions of the hand required to participate in hunting small game.
Gamekeeper’s thumb refers to a condition that develops as a result of chronic, or repeated, overuse or injury. When an acute (sudden) injury occurs to the UCL, it is sometimes referred to as skiers thumb. Several factors can cause Gamekeeper’s thumb including:
- Fall on an outstretched hand, particularly when the thumb is in an abducted position, separated away from the palm position
- Overuse or repetitive motion of the thumb and hand
- Athletic activities (like skiing) where a fall will put pressure on the thumb
- Instability in the thumb
- Pain and weakness that impedes the ability to make grasping or pinching motions
- Swelling and ecchymosis (severe bruising) of the thumb
- Difficulty completing everyday tasks that require the use of the thumb, like tying your shoes or buttoning a shirt.
- Loss of motion of the thumb
If an individual suspects they have Gamekeeper’s thumb, the initial treatment should consist of avoiding the positions and activities that produce the pain. A physician will need to evaluate the injury to determine if it is a partial tear (sprain) or a complete tear (rupture) as this will affect the course of treatment. X-rays will be taken to evaluate the injury.
A course of conservative treatment is usually recommended for a partial tear that would include rest and immobilization (with a splint or wrist brace,) ice, as well as hand therapy and non-steroidal medications to reduce inflammation. If symptoms persist, treatment by your physician may be necessary. This may include steroidal medication or injections, in conjunction with therapy.
In severe cases of a total rupture, surgical intervention may be needed to correct the condition. A complete tear can be complicated by the development of a Steiner lesion, a loss of blood to the adductor pollicis muscle in the thumb that comes between the UCL and the place where it attaches to the bone. When this occurs the UCL will not heal and surgery may be indicated.
Hand Therapists are occupational or physical therapists, educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and goal of the patient or client. Common interventions in the treatment of Gamekeeper’s thumb include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage and joint mobilization by a hand therapist to regain mobility and range of motion of the thumb and hand.
- Splinting to support or rest affected area
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the hand and effected muscle.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the upper extremity, and improve movement technique and mechanics (for example, throwing or lifting activities) in daily use of the involved upper extremity.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation at the hand.
- Home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Procedures that your physician may recommend and perform in addition to physical therapy that include:
- REST and ICE
- Splint or brace to support the affected area
- The use of NSAIDS (Non Steroidal Anti-Inflammatory Drugs)
- Steroidal injections to reduce inflammation
- Pain medication to reduce the discomfort and allow the patient to perform the recommended exercises
- Surgery to correct underlying pathology or the cause of the condition
Prognosis
Some patients recover full function following a course of conservative care that includes hand therapy, medication and/or injections. If surgery is required, it can take longer for full motor function of the hand to return. It is important that once the pain and inflammation is reduced, and motion and strength are restored, the patient gradually returns to full activities. Instruction in daily activities or sport performance is helpful for reducing a reoccurrence of Gamekeeper’s thumb.
