Differential Diagnosis for Hand Stiffness Worse in the Morning with Normal X-ray

• Single Most Likely Diagnosis
  • Rheumatoid Arthritis (RA): Morning stiffness is a hallmark symptom of RA, and early in the disease, X-rays may still appear normal. The stiffness typically lasts for more than an hour and improves with activity.
• Other Likely Diagnoses
  • Osteoarthritis (OA): Although OA is more commonly associated with afternoon stiffness, some patients may experience morning stiffness, especially in more advanced cases. Normal X-rays might be seen in early OA.
  • Psoriatic Arthritis (PsA): Similar to RA, PsA can cause morning stiffness. The presence of psoriasis or a family history can support this diagnosis.
  • Fibromyalgia: Characterized by widespread musculoskeletal pain, fatigue, and morning stiffness. Normal X-rays are expected in fibromyalgia.
• Do Not Miss Diagnoses
  • Septic Arthritis: Although less common in the hands, septic arthritis can cause severe stiffness and pain. Normal X-rays do not rule out this diagnosis, and it requires immediate medical attention.
  • Gout: Acute gouty arthritis can cause intense pain and stiffness, often starting at night. X-rays may be normal, especially early in the disease.
  • Neuropathic Conditions (e.g., Carpal Tunnel Syndrome): Can cause stiffness, numbness, and pain, particularly in the morning. Normal X-rays are expected.
• Rare Diagnoses
  • Scleroderma/Systemic Sclerosis: Can cause hand stiffness due to skin thickening and fibrosis. Other systemic symptoms are usually present.
  • Mixed Connective Tissue Disease (MCTD): Overlaps with RA, lupus, scleroderma, and polymyositis, and can cause hand stiffness. Normal X-rays might be seen early in the disease.
  • Eosinophilic Fasciitis: A rare condition characterized by inflammation of the fascia, leading to stiffness and swelling of the hands. X-rays are typically normal.