Evaluation and Treatment Approach for Bilateral Hand Cramping
Radiography (X-ray) should be the initial imaging study for patients presenting with bilateral hand cramping, followed by more advanced imaging only if symptoms persist after normal radiographic findings. 1
Initial Evaluation
Clinical Assessment
- Assess for characteristic symptoms:
- Episodic burning pain, erythema, and warmth of extremities
- Triggers: physical activity, warm temperatures
- Relief factors: cooling, rest
- Determine if cramps are task-specific (e.g., writing, typing, playing musical instruments)
- Evaluate for muscle wasting which may indicate a different pathology (cervical myelopathy)
Initial Imaging
- Standard radiographic evaluation with 3 views: posteroanterior, lateral, and oblique 2, 1
- X-rays can assess:
- Bone alignment
- Joint spaces
- Impaction syndromes
- Static instability
- Chronic healed and nonunited fractures
- Soft tissue mineralization
- Erosions
- Soft tissue swelling
Laboratory Studies
- If inflammatory or infectious etiology is suspected:
- Complete blood count
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Urinalysis
- Liver function tests
- Antinuclear antibodies 1
Advanced Imaging (if radiographs are normal/equivocal but symptoms persist)
MRI Without IV Contrast
- Appropriate for evaluating:
Ultrasound
- Equivalent alternative to MRI for evaluating:
- Synovitis and joint effusion
- Tenosynovitis and tendinopathy
- Tendon injuries
- Carpal tunnel syndrome
- Retained foreign bodies 1
- Advantages: allows dynamic assessment and comparison with contralateral side
Treatment Approach
First-Line Treatment
- Topical NSAIDs
- Rest, elevation, and ice for acute swelling 1
- If focal dystonia is suspected (task-specific cramping):
- Temporary cessation of the triggering activity 3
Second-Line Treatment
- Oral acetaminophen
- Oral NSAIDs at lowest effective dose 1
- For focal dystonia:
- Sensory discriminative retraining
- Stress-free hand use techniques
- Mirror imagery
- Mental rehearsal and practice techniques 3
Third-Line Treatment
- Intra-articular corticosteroid injections for painful joints with inflammation 1
- For refractory focal dystonia:
- Botulinum toxin injections have shown promising results 4
Therapeutic Exercises
- Home program should include:
- Sensory exercises
- Postural alignment exercises
- Neural tension reduction techniques
- Relaxation techniques
- Cardiopulmonary fitness exercises 3
Special Considerations
Focal Dystonia
- EMG studies may reveal co-contraction of agonist and antagonist muscles 5, 6
- Characterized by excessive muscle activity and defective fine motor control
- May be task-specific (writer's cramp, typist's cramp, musician's cramp) 5
- Treatment with sensory discriminative training has shown significant improvement in motor control, motor accuracy, and sensory discrimination 3
Cervical Myelopathy
- Consider if hand cramping is accompanied by muscle wasting
- May be due to cervical spondylosis with narrow anteroposterior canal diameter (<13mm)
- Surgical intervention (spondylectomy or laminoplasty) may be beneficial 7
Complications and Referral
- Normal radiographs do not exclude significant pathology
- Delayed diagnosis risks progression to chronic neuropathic pain and potential permanent hand dysfunction
- Persistent hand swelling requires urgent evaluation 1
- Consider referral to neurology for suspected focal dystonia
- Consider referral to hand specialist or orthopedic surgeon if structural abnormalities are identified
Remember that bilateral hand cramping can represent various underlying conditions, from focal dystonia to cervical myelopathy, and the treatment approach should be guided by the specific diagnosis established through appropriate imaging and clinical evaluation.