When should a patient with hand stiffness be referred to rheumatology?

When to Refer to Rheumatology for Hand Stiffness

Patients with hand stiffness should be referred to a rheumatologist when they present with arthritis affecting more than one joint, ideally within six weeks after symptom onset, to prevent joint damage and disability. 1

Key Clinical Features Warranting Referral

Symptoms Suggesting Inflammatory Arthritis

• Morning stiffness lasting ≥60 minutes (strongly suggestive of inflammatory arthritis) 2
• Joint swelling in multiple joints 1, 3
• Pain that worsens after periods of inactivity 2
• Symptoms that are most severe after midnight 4
• Difficulty making a fist 4

Physical Examination Findings

• Presence of ≥3 swollen joints 3
• Metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joint involvement 1, 3
• Positive "squeeze test" of MCP or MTP joints (pain on lateral compression) 1
• Joint swelling not caused by trauma or bony enlargement 1

Differential Diagnosis Considerations

Rheumatoid Arthritis

• Symmetrical joint involvement 2, 5
• Morning stiffness lasting >60 minutes 2, 5
• Involvement of MCP and PIP joints 2
• Presence of rheumatoid factor (RF) and/or anti-citrullinated protein antibodies (ACPA) 2, 5

Hand Osteoarthritis

• Typically affects people over 40 years 1
• Morning stiffness usually brief (<30 minutes), though can be prolonged in some cases 6
• Characteristic involvement of DIP, PIP, and thumb base joints 1
• Presence of Heberden's and Bouchard's nodes 1
• Bony enlargement with or without deformity 1

Psoriatic Arthritis

• Often asymmetric joint involvement 2
• May affect distal interphalangeal joints 1
• Presence of dactylitis ("sausage digit") 1
• Enthesitis (inflammation at tendon/ligament insertion sites) 1
• Associated nail changes and skin psoriasis 1

Laboratory and Imaging Workup Before Referral

Basic Laboratory Tests

• Complete blood count 1, 2
• Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) 1, 2
• Rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) 2
• Antinuclear antibodies (ANA) 1, 2
• Liver function tests 1, 2
• Urinalysis 1, 2

Imaging

• Plain radiographs of hands and feet to assess for erosions or joint space narrowing 2
• In doubtful cases, ultrasound or MRI may help detect synovitis 1

Urgency of Referral

• Ideally within 6 weeks of symptom onset for suspected inflammatory arthritis 1
• Early referral and treatment significantly improve long-term outcomes 1, 3
• Structural damage occurs early in active rheumatoid arthritis 3

Common Pitfalls to Avoid

• Relying solely on morning stiffness duration to differentiate inflammatory from non-inflammatory conditions (this has poor discriminative ability) 6, 7
• Assuming that hand stiffness in older adults is always due to osteoarthritis 1
• Delaying referral while waiting for laboratory confirmation, as early treatment is crucial for preventing joint damage 1, 3
• Overlooking psoriatic arthritis in patients with skin or nail changes 1
• Failing to recognize that prolonged morning stiffness can occur in hand osteoarthritis and does not rule out this diagnosis 6

Remember that early diagnosis and treatment of inflammatory arthritis significantly improve long-term outcomes and can prevent irreversible joint damage. When in doubt about the diagnosis, prompt referral to a rheumatologist is warranted.