What are the treatment options for hand pain and swelling?

Treatment Options for Hand Pain and Swelling

Begin with topical NSAIDs as first-line pharmacological treatment for mild to moderate hand pain and swelling, combined with patient education about joint protection and a structured exercise program. 1

Initial Assessment and Diagnostic Approach

Start with plain radiographs to evaluate for structural abnormalities, arthritis, or fractures. 1

• If radiographs are normal or show only nonspecific arthritis and diagnosis remains unclear, ultrasound is the preferred next imaging study as it identifies synovitis, joint effusion, tenosynovitis, tendinopathy, and soft tissue pathology in 76% of cases, contributing to clinical management. 1
• MRI without contrast changes clinical management in 69.5% of cases but is reserved for when ultrasound is inconclusive or surgical planning is needed. 1

Non-Pharmacological Treatment (Foundation of Management)

All patients should receive education about joint protection techniques and avoiding adverse mechanical factors, combined with range of motion and strengthening exercises. 1

• Local heat application (paraffin wax, hot packs) before exercise provides symptomatic benefit. 1
• For thumb base involvement, splints are recommended; for lateral angulation or flexion deformities of fingers, orthoses should be used. 1

Pharmacological Treatment Algorithm

First-Line: Topical Therapy

Topical NSAIDs are preferred over systemic treatments, especially when only a few joints are affected. 1

• Topical NSAIDs (such as diclofenac gel) provide effective pain relief with minimal systemic side effects. 1, 2
• Topical capsaicin is an alternative effective and safe option. 1

Second-Line: Oral Analgesics

If topical treatments are insufficient, acetaminophen (paracetamol) up to 4 g/day is the oral analgesic of first choice due to its efficacy and safety profile. 1, 3

• Acetaminophen should be the preferred long-term oral analgesic if successful. 1
• Stop use and consult a physician if pain worsens or lasts more than 10 days, or if new symptoms or swelling develop. 3

Third-Line: Oral NSAIDs

Oral NSAIDs should be used at the lowest effective dose and for the shortest duration (typically 7-14 days) in patients who respond inadequately to acetaminophen. 1, 2, 4

• Ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily are appropriate choices. 2, 4
• In patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor. 1, 2
• In patients with increased cardiovascular risk, COX-2 inhibitors are contraindicated and non-selective NSAIDs should be used with extreme caution. 1, 2, 4
• Critical caveat: NSAIDs increase risk of heart attack, stroke, bleeding, and ulcers; avoid in patients with recent heart attack, heart surgery, kidney/liver problems, or bleeding disorders. 4

Fourth-Line: Adjunctive Therapies

Chondroitin sulfate may provide symptomatic relief with low toxicity, though effect sizes are small. 1

• Evidence is limited and this should be considered a suggestion rather than a strong recommendation. 1
• Glucosamine has not been studied in hand conditions specifically. 1

Invasive Treatment Options

Intra-articular Corticosteroid Injection

Intra-articular corticosteroid injections should NOT generally be used in hand osteoarthritis, but may be considered specifically for painful interphalangeal joints with clear inflammation. 1

• For thumb base (trapeziometacarpal) osteoarthritis, evidence does not support routine corticosteroid injection. 1
• For trigger finger, corticosteroid injection is effective first-line invasive therapy. 5, 6

Surgical Intervention

Surgery should be considered when conservative treatments have failed and patients have marked pain and/or disability with structural abnormalities. 1

• For thumb base osteoarthritis: Trapeziectomy (with or without interposition arthroplasty) is the procedure of choice. 1, 7, 6
• For interphalangeal osteoarthritis: Arthroplasty (typically silicone implants) for proximal interphalangeal joints (except PIP-2), or arthrodesis for distal interphalangeal joints. 1
• For trigger finger: Surgical release when conservative treatments fail, particularly in patients with diabetes who respond poorly to injections. 5, 6

Common Pitfalls to Avoid

• Do not overlook red flags: If hand swelling is bilateral, painless, and non-pitting with fixed erythema, consider alternative diagnoses such as red puffy hand syndrome from intravenous drug use, which mimics inflammatory arthritis but requires completely different management. 8
• Do not assume all erosive changes on imaging indicate inflammatory arthritis: Erosive osteoarthritis can present with inflammatory features including soft tissue swelling, erythema, and elevated inflammatory markers. 9
• Do not prescribe NSAIDs without assessing cardiovascular, gastrointestinal, and renal risk, particularly in elderly patients. 1, 2, 4
• Do not continue NSAIDs beyond the acute phase (7-14 days) without reassessment, as prolonged use increases serious adverse events. 2, 4
• Do not routinely inject corticosteroids into the thumb base joint, as evidence does not support efficacy in this location. 1

Follow-Up Strategy

Long-term follow-up should be adapted to individual patient needs, considering disease severity, functional impairment, treatment response, and presence of comorbidities. 1