What are the management options for osteoarthritis affecting the interphalangeal joints?

Management of Interphalangeal Joint Osteoarthritis

For interphalangeal joint osteoarthritis, begin with education, exercises, and topical NSAIDs as first-line therapy, reserving intra-articular glucocorticoid injections for persistently painful joints and surgery (arthroplasty for PIP joints, arthrodesis for DIP joints) only when conservative measures fail. 1

Core Non-Pharmacological Management

Every patient with interphalangeal joint OA should receive the following foundational interventions:

• Education and ergonomic training in pacing activities and proper use of assistive devices (tap turners, jar openers) to reduce joint stress 1, 2
• Therapeutic exercises targeting joint mobility, muscle strength, and grip function, with small but meaningful benefits on pain and function 1
  • Exercise regimens for interphalangeal joints differ from thumb base protocols 1
  • Benefits require ongoing adherence; effects diminish when exercises are discontinued 1

Important caveat: Night-time DIP joint orthoses have been studied but showed no efficacy and are not recommended 1. Orthoses are primarily beneficial for thumb base OA, not interphalangeal joints.

Pharmacological Treatment Algorithm

First-Line: Topical Therapy

• Topical NSAIDs (particularly diclofenac gel) are the preferred initial pharmacological treatment due to superior safety profile compared to oral agents 1
  • Provides similar pain relief to oral NSAIDs with minimal systemic adverse effects 1
  • Particularly appropriate when few joints are affected 1
• Topical capsaicin can be considered, though local burning/stinging sensations limit tolerability 1

Second-Line: Oral Analgesics

When topical treatments prove insufficient:

• Oral NSAIDs should be used at the lowest effective dose for the shortest duration 1
  • Prescribe with proton pump inhibitor for gastroprotection 1
  • Consider cardiovascular, renal, and hepatic risk factors before prescribing 1
• Paracetamol (acetaminophen) for pain relief, though less effective than NSAIDs 1
• Tramadol as an alternative analgesic option 1

Adjunctive Considerations

• Chondroitin sulfate may provide symptomatic relief in hand OA, though evidence is limited and NICE guidelines discourage its use 1
• Glucosamine lacks placebo-controlled trial evidence specifically in hand OA 1

Intra-Articular Glucocorticoid Injections

Critical distinction: Glucocorticoid injections should NOT generally be used in hand OA, but may be considered specifically for painful interphalangeal joints 1, 2

• Evidence supports efficacy for pain during joint movement and joint swelling in interphalangeal OA 1
• Contrasts with thumb base OA where injections showed no benefit over placebo 1
• Reserve for cases with clear joint inflammation 1

Surgical Management

Surgery is indicated when conservative treatments fail to adequately relieve pain 1, 2:

Joint-Specific Surgical Approaches

• PIP joints: Arthroplasty (typically silicone implants) is the preferred technique for most PIP joints 1, 2
  • Exception: PIP-2 may be treated with arthrodesis 1, 2
• DIP joints: Arthrodesis (joint fusion) is the recommended approach 1, 2
  • Alternative: Cheilectomy with debridement preserves motion and provides significant pain relief (mean VAS improvement from 8 to 1) with improved range of motion 3

Postoperative Care

• Rehabilitation is essential following surgical intervention 1, 2
• Potential complications include pain, instability, nerve dysfunction, superficial infection, wound healing issues, and chronic regional pain syndrome 1, 2

Treatments NOT Recommended

• Electroacupuncture should not be used 1
• Glucosamine and chondroitin products are not recommended by NICE guidelines 1
• Intra-articular hyaluronan lacks evidence for hand OA 1
• DIP joint orthoses (night-time splinting) showed no efficacy 1

Follow-Up Strategy

Long-term monitoring should be adapted based on disease severity, functional impact, and treatment response 1. Hand OA is heterogeneous, requiring individualized follow-up intervals rather than standardized protocols 1.