Nancy McRay was just three years old when she sat down at her family's piano and began to play, naturally and easily and with great joy. She also had a knack for sight-reading, looking at the printed notes set before her and immediately playing them, as if she'd already practiced them many times before. By the time she was 14, word had gotten around about that skill and she became the official accompanist for a regional musical theater company.

McRay kept playing, earning an undergraduate degree in music performance, and then a master's degree. She taught piano, she directed musical productions and she never stopped accompanying, sometimes playing for hours on end in the course of a rehearsal.

Then, one day about 15 years ago, McRay felt something different when she spread her left hand out wide to cover a big distance between one note and another−it was a little pain between her thumb and her fingers. "I knew my mother had had arthritis, and I wondered if it could be that," she said.

Use, time and genetics

She was exactly right. McRay, like two in three post-menopausal women, was experiencing the first signals from a basal thumb joint beginning to lose its protective buffer of cartilage. With each pivot of the thumb, each outreach, each grasp, the cartilage between the thumb joint and its partner bone, the trapezium, grew thinner and thinner, more and more painful. After years of medication, splints and acupuncture, McRay finally found her way to Stanford Hospital & Clinics orthopaedic hand surgeon Amy Ladd. Also a pianist, Ladd understood McRay's dilemma better than most.

Ladd borrowed from one part of McRay's body to repair the thumb joint's worn edge. Carefully picking her way through the network of nerves and muscles to reach a tendon in McRay's forearm, Ladd removed a small piece of it, coiling it into a plate-like shape and placing it as a new padding between the thumb joint and the trapezium.

"I can't sing Stanford's praises high enough," McRay said. She had thought about having the surgery for more than two years, and knew it would mean a year of carefully-paced recovery before she could venture another try on a piano. But now, when she comes for a follow-up appointment, she and Dr. Ladd work hard to find a few minutes to sit down to play some simple duets. She's also learning jazz piano with a teacher who almost immediately identified how McRay could change her playing style to protect her repaired thumband its mate from further damage.

Architectural challenge

The human hand is a tricky piece of engineering, especially the thumb joint. "We're looking for ways to better understand it," Ladd said. Anatomists call the thumb joint−the trapezial-metacarpal joint−a saddle joint. It is the only one of its kind in the body."

The saddle joint looks very much like its name, and it is the key to the thumb's ability to work in opposition to each of the fingers.

Essential and multipurpose

The motion of the basal thumb joint acts like a ball and socket, similar to the hip or shoulder joint.  However, Ladd said, "This saddle joint is much more complicated. It's more like two spoons loosely cupped together. Sometimes one rolls on the other like a snowboarder on a half-pipe, sometimes they grind like a mortar and pestle."  And compared to the hip, shoulder, or knee, she said, "It's a tiny little joint much harder to study with imaging techniques and motion studies."

Ladd and her Stanford colleagues at the Robert A. Chase Hand & Upper Limb Center take a collaborative and comprehensive approach to patient care, combining research and clinical practice of three fields of surgery−plastic, orthopaedic and general surgery− as first established by Chase, the Center's founder. An early pioneer in hand surgery, Chase established Yale University's Plastic Surgery section and then came to Stanford in 1963 to chair its surgery department. From 1977 to 1992, he was chief of the Division of Human Anatomy. He is the co-author of the Handbook of Hand Surgery and a founding member of the American Society of Hand Surgeons. He remains at Stanford as an active teacher and physician. His interest in the hand began when he served as a military doctor, treating soldiers wounded in the Korean conflict in the early '50s. Then, there were just two centers in the U.S. who offered specialized care of the hand.

Compared to other parts of the body, Chase said, the hand is a tightly-packed labyrinth of bone, muscle, tendon, ligament and nerve. Its ability to perform its tasks combines the need for brute force and minute manipulation. The muscles and joints are a pulley system with flexibility that enables an unmatched diversity of movement. The hand's architecture also can control an extreme range of intensity of motion and force–as fist or as coordinator of such fine motor skills as sewing, writing and playing musical instruments.

And then, there's the way the hand, and its skin, interacts with the brain. The brain devotes as much of its real estate to movements of the hand as it does to the arms, trunk and legs together. The hand's sensory function are also dense−that's how we can recognize an object just by holding it. Chase likes to tell the story of a patient whose badly injured thumb was replaced with a finger. A few months later, seeing the patient using the new digit just as he would have his thumb, Chase asked him about it. The patient was quite happy with the restoration of function. "It feels like a thumbger!" he told Chase."

Array of repair options

Ladd and others have ideas about what might work to prevent the kind of deterioration that, for someone like McRay, ends in surgery. The need will be great: millions of Baby Boomers are getting to that age when they will likely develop the same kind of osteoarthritis McRay has. The next generation will have grown up typing on keyboards for hours on end from an early age or texting hundreds of times daily on cell phones. That kind of heavy use could produce repetitive stress injury. It's already showing up in popular parlance as ailments like cell phone elbow and Guitar Hero wrist.

Implants are in development, Ladd said, as are studies to pinpoint the mechanisms at play in thumb joint breakdown. "This little saddle joint is a sloppy one, with built-in vulnerabilities," she said. "We think micromotion could be the key to why it fails."

The surgery that McRay had is not for everyone. Some patients may opt for another of the surgical approaches that stabilize the thumb joint. What finally made McRay decide to go forward was the degree of pain that had become constant and its impact on her ability to do the many small tasks required for daily life - to open jars, grasp a door knob, put away dishes or walk her dog.

The surgery and the months of postoperative hand therapy have made her far more selective about how she uses her hands. She definitely stays away from the kind of intense, rapid piano playing she once did so often. But play she does, and loves it as much as she ever did. "I'm a great believer in not expecting something like this is going to make everything perfect again. And I am trying to do everything I can to take care of it."