What is the treatment for inflammatory knuckle swelling?

Treatment for Inflammatory Knuckle Swelling

Optimal management of inflammatory knuckle swelling requires a combination of non-pharmacological and pharmacological treatments, with topical NSAIDs being the first-line pharmacological treatment due to their favorable safety profile compared to oral medications. 1

Initial Assessment and Treatment Approach

• Treatment should be individualized according to the location, severity, presence of inflammation, level of pain, and functional limitations 1
• Management typically requires a multidisciplinary approach combining non-pharmacological modalities, pharmacological options, and sometimes surgery 1

Non-Pharmacological Interventions (First-Line)

• Education about joint protection and ergonomic principles should be offered to every patient to prevent further joint damage 1
• Regular exercises to improve function and muscle strength should be considered for all patients with hand joint inflammation 1
• Orthoses (splints) should be considered for symptom relief, particularly for thumb base involvement, with long-term use recommended 1
• Heat application before exercise can provide symptomatic relief for inflamed joints 1

Pharmacological Management

First-Line Pharmacological Treatment

• Topical NSAIDs are the first pharmacological treatment of choice due to their favorable safety profile compared to oral medications 1
• Topical diclofenac gel has shown small improvements in pain and function after 8 weeks compared to placebo 1
• Topical NSAIDs can provide similar pain relief as oral NSAIDs with fewer systemic side effects 1

Second-Line Pharmacological Treatment

• Oral analgesics, particularly NSAIDs, should be considered for a limited duration when topical treatments are insufficient 1
• NSAIDs should be used at the lowest effective dose and for the shortest duration to minimize adverse effects 1
• In patients with increased gastrointestinal risk, non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor should be used 1
• Naproxen has been shown to be effective in reducing joint swelling and improving mobility in patients with inflammatory joint conditions 2

Corticosteroid Injections

• Intra-articular injections of long-acting corticosteroids may be considered for painful flares of inflammatory joint conditions 1
• For interphalangeal joint inflammation, intra-articular corticosteroid injections may be considered when other treatments have failed 1
• Direct injection into the tendon substance should be avoided as it may inhibit healing and reduce tensile strength 3

Treatment Algorithm

1. Initial Management:

   • Start with education, joint protection, and appropriate exercises 1
   • Apply topical NSAIDs (e.g., diclofenac gel) to affected joints 1
   • Consider orthoses/splints for symptom relief 1

2. If inadequate response after 2-4 weeks:

   • Add oral NSAIDs at the lowest effective dose for a limited duration 1
   • For patients with gastrointestinal risk factors, use gastroprotective agents or COX-2 selective inhibitors 1

3. For persistent symptoms or acute flares:

   • Consider intra-articular corticosteroid injection 1
   • Limit injections to avoid potential long-term adverse effects on joint tissues 1

4. For refractory cases:

   • Consider surgical consultation if structural abnormalities are present and other treatments have failed 1

Common Pitfalls and Caveats

• Paracetamol (acetaminophen), once considered first-line therapy, may have limited efficacy in hand osteoarthritis based on recent evidence 1
• Long-term use of oral NSAIDs increases risk of gastrointestinal, cardiovascular, and renal complications 4
• Complete immobilization for extended periods should be avoided as it may lead to muscle atrophy and deconditioning 3
• Habitual knuckle cracking has been associated with hand swelling and lower grip strength, and should be discouraged 5

Special Considerations

• When multiple joints are affected, systemic pharmacological treatment may be preferred over topical treatments 1
• For elderly patients or those with comorbidities, topical treatments should be prioritized due to their superior safety profile 1
• Patients should be periodically reassessed to evaluate treatment response and adjust management accordingly 1