What are the red flags and treatment options for hand stiffness?

Red Flags and Treatment Options for Hand Stiffness

Hand stiffness requires a combination of non-pharmacological and pharmacological treatments tailored to the specific cause, with red flags including prolonged morning stiffness, structural abnormalities, and functional impairment requiring prompt evaluation. 1, 2

Red Flags for Hand Stiffness

Morning Stiffness Characteristics

• Duration: Prolonged morning stiffness (>60 minutes) is present in 17% of hand osteoarthritis (OA) patients and doesn't exclude an OA diagnosis 3
• Distribution: Hand OA typically presents with stiffness affecting one or a few joints at a time 2
• Severity: In hand OA patients, stiffness severity can be mild (30%), intermediate (37%), severe (18%), or extreme (4%) 3

Functional Impairment

• Reduced grip strength and pinch measurements strongly correlate with hand disability and should be assessed 4
• Patients with stiffness show poorer functional outcomes and lower grip strength at 12 months post-injury 5
• Tip-to-palm distance >1 cm for any finger may indicate significant stiffness 5

Structural Abnormalities

• Presence of Heberden's and Bouchard's nodes suggests nodal osteoarthritis 2
• Significant ulnar variance at injury predicts development of hand stiffness 5
• Radiographic evidence of carpometacarpal arthritis affects approximately 33% of postmenopausal women 6

Treatment Algorithm for Hand Stiffness

1. Non-Pharmacological Interventions (First-Line)

• Education and Self-Management (Level of Evidence 1b, Grade A)

  • Joint protection techniques
  • Ergonomic principles
  • Pacing of activities
  • Use of assistive devices 1, 2

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

  • Range of motion exercises
  • Strengthening exercises for hand muscles
  • Regular daily practice 1, 2

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

  • Particularly beneficial for thumb base OA
  • Recommended for long-term use 1, 2
  • Can prevent/correct lateral angulation and flexion deformity 1

• Heat Application

  • Local application of heat (e.g., paraffin wax, hot pack) especially before exercise 1

2. Pharmacological Interventions

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

  • Topical NSAIDs as first pharmacological choice
  • Capsaicin as alternative topical treatment 1, 2

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

  • Paracetamol (up to 4g/day) as first-line oral analgesic 1
  • NSAIDs at lowest effective dose for shortest duration if paracetamol inadequate 1, 2
  • Consider gastroprotective agents with NSAIDs in high-risk patients 1

• Other Options

  • Chondroitin sulfate may improve pain and function (Level of Evidence 1b, Grade A) 1, 2
  • Intra-articular corticosteroid injections for painful flares, especially in trapeziometacarpal joint OA 1

3. Surgical Interventions

• Consider when other treatments fail to relieve pain (Level of Evidence 5, Grade D) 1, 2
• Options include:
  • Trapeziectomy for thumb base OA
  • Arthrodesis or arthroplasty for interphalangeal OA 1, 2
  • Interposition arthroplasty or osteotomy in severe cases 1

Special Considerations

Dominant vs. Non-dominant Hand

• The dominant hand tends to be stiffer than the non-dominant hand 7
• Left-hand stiffness magnitude was 37% higher in left-handed males
• Right-hand stiffness magnitude was 11% higher in right-handed males and 40% higher in right-handed females 7

Comorbidities

• Patients with prolonged morning stiffness report more pain and lower quality of life 3
• Consider cardiovascular and gastrointestinal risk factors when prescribing NSAIDs 1
• Hand OA is more common in patients over 40 years 2

Treatment Pitfalls to Avoid

• Overreliance on oral NSAIDs while neglecting non-pharmacological approaches 2
• Failure to consider individual factors like joint location, severity, and comorbidities 1
• Delaying referral to specialists when symptoms persist despite appropriate management 2
• Not assessing grip strength and pinch measurements, which are strongly correlated with hand disability 4