What is the appropriate management plan for a patient presenting with morning hand stiffness?

Management of Morning Hand Stiffness

For patients presenting with morning hand stiffness, a comprehensive treatment approach should begin with non-pharmacological interventions including education, exercises, and assistive devices, followed by topical NSAIDs as first-line pharmacological treatment if needed, with oral NSAIDs reserved for limited duration use when symptoms are inadequately controlled. 1

Initial Assessment

When evaluating morning hand stiffness, consider:

• Duration of stiffness (mild morning stiffness of <60 minutes is typical of hand osteoarthritis, while prolonged stiffness >60 minutes may suggest inflammatory arthritis) 2, 3
• Distribution of affected joints (DIP, PIP, and thumb base joints are characteristic of hand OA) 1
• Presence of other symptoms (pain on usage, functional limitations) 1
• Age (hand OA is more common in patients over 40) 1

Key Diagnostic Considerations

• Hand osteoarthritis typically presents with mild morning stiffness affecting one or a few joints at a time 1
• Presence of Heberden's and Bouchard's nodes suggests nodal osteoarthritis 1
• Prolonged morning stiffness (>60 minutes) is present in approximately 17% of hand OA patients and does not rule out OA 2
• Consider inflammatory arthritis (such as rheumatoid arthritis) if stiffness is prolonged, affects multiple joints, or is associated with systemic symptoms 3

Treatment Algorithm

1. Non-Pharmacological Interventions (First-Line)

• Education and self-management strategies (Level of Evidence: 1b, Grade A) 1

  • Joint protection techniques
  • Ergonomic principles
  • Pacing of activities
  • Use of assistive devices

• Exercise program (Level of Evidence: 1a, Grade A) 1

  • Range of motion exercises
  • Strengthening exercises for hand muscles
  • Regular daily practice

• Orthoses/Splints (Level of Evidence: 1b, Grade A) 1

  • Particularly beneficial for thumb base OA
  • Long-term use is recommended

2. Pharmacological Interventions

• Topical treatments (Level of Evidence: 1b, Grade A) 1

  • Topical NSAIDs are first-line pharmacological treatment
  • Preferred over systemic treatments for safety reasons
  • Apply to affected joints

• Oral analgesics (Level of Evidence: 1a, Grade A) 1

  • NSAIDs for limited duration when topical treatments are insufficient
  • Use lowest effective dose
  • Consider patient's cardiovascular and gastrointestinal risk factors

• Chondroitin sulfate may be considered (Level of Evidence: 1b, Grade A) 1

  • Can improve pain and function in hand OA

3. Advanced Interventions

• Intra-articular glucocorticoid injections (Level of Evidence: 1a-1b, Grade A) 1

  • Not generally recommended for hand OA
  • May be considered for painful interphalangeal joints in specific cases

• Surgery (Level of Evidence: 5, Grade D) 1

  • Consider only when other treatments have failed to relieve pain
  • Options include trapeziectomy for thumb base OA or arthrodesis/arthroplasty for interphalangeal OA

Special Considerations

• Severity assessment: Evaluate not just duration but also severity of morning stiffness, as severity correlates better with underlying inflammation 4

• Individualized approach: Treatment should be tailored based on 1:

  • Joint location affected
  • Severity of symptoms
  • Presence of inflammation
  • Functional impairment
  • Comorbidities

• Regular follow-up: Monitor response to treatment and adjust as needed 1

Common Pitfalls to Avoid

1. Assuming prolonged morning stiffness rules out OA: Recent evidence shows that up to 17% of hand OA patients experience prolonged morning stiffness (>60 minutes) 2

2. Overreliance on oral NSAIDs: These should be used at the lowest effective dose and for the shortest duration due to potential side effects 1

3. Neglecting non-pharmacological approaches: Education, exercises, and orthoses have strong evidence supporting their use and should be implemented before or alongside pharmacological treatments 1

4. Delayed referral: If symptoms persist despite appropriate management or if inflammatory arthritis is suspected, timely referral to a rheumatologist is recommended, ideally within 6 weeks of symptom onset 1