What are the differential diagnoses and initial management for a patient with bilateral hand stiffness and pain?

Differential Diagnoses for Bilateral Hand Stiffness and Pain

The most common differential diagnoses to consider are hand osteoarthritis (targeting DIP, PIP, and thumb base joints), rheumatoid arthritis (primarily affecting MCP, PIP joints and wrists), psoriatic arthritis (which may target DIPs or affect single rays), gout (often superimposing on pre-existing osteoarthritis), and haemochromatosis (mainly targeting MCPs and wrists). 1

Primary Diagnostic Approach

Key Clinical Features to Distinguish Conditions

Joint Distribution Pattern:

• Hand osteoarthritis: Targets DIP joints, PIP joints, and thumb base (CMC-1), with index and middle MCP joints occasionally involved 1
• Rheumatoid arthritis: Primarily affects MCP joints, PIP joints, and wrists, typically sparing DIP joints 1
• Psoriatic arthritis: May target DIP joints or affect just one ray in an asymmetric pattern 1
• Gout: Can superimpose on pre-existing osteoarthritis, often with acute flares 1
• Haemochromatosis: Mainly targets MCP joints and wrists 1

Symptom Characteristics:

• Osteoarthritis: Pain on usage with only mild morning stiffness (typically <30 minutes), symptoms often intermittent and affecting one or few joints at a time 1
• Inflammatory arthritis (RA, psoriatic): Prolonged morning stiffness (>1 hour), symmetrical involvement, systemic symptoms possible 1
• Erosive hand OA: Abrupt onset, marked pain, inflammatory symptoms (stiffness, soft tissue swelling, erythema), worse functional impairment than non-erosive OA 1

Physical Examination Findings:

• Osteoarthritis: Heberden nodes (DIP), Bouchard nodes (PIP), bony enlargement (not soft tissue swelling), lateral deviation of IP joints, thumb base subluxation 1
• Rheumatoid arthritis: Soft tissue synovitis, warmth, boggy swelling, ulnar deviation at MCPs 1
• Crystal arthropathy: Acute inflammatory signs, tophi in chronic gout 1

Additional Differential Considerations

Less Common but Important Diagnoses:

• Calcium pyrophosphate deposition disease (CPPD): Radiographic changes extremely similar to osteoarthritis, may coexist with hand OA 1
• Polymyalgia rheumatica-like syndrome: Severe myalgia in proximal extremities with fatigue, highly elevated inflammatory markers, normal CK levels (distinguishes from myositis) 1
• Cervical myelopathy: "Myelopathy hand" with muscle wasting and motor dysfunction, requires attention to narrow AP canal diameter (<13mm) and multisegmental cervical spondylosis 2
• Carpal tunnel syndrome: Numbness and tingling in thumb, index, middle, and radial ring fingers, weakness of thumb opposition when severe 3

Initial Diagnostic Workup

Imaging Strategy

First-Line Imaging:

• Plain radiographs (posteroanterior view of both hands on single film) are the gold standard for morphological assessment 1
• Classical radiographic features include joint space narrowing, osteophytes, subchondral sclerosis, and subchondral cysts 1
• Subchondral erosion indicates erosive hand OA 1
• Standard views should include posteroanterior, lateral, and oblique projections 1

Advanced Imaging (when radiographs are normal or nonspecific):

• Ultrasound or MRI without IV contrast for suspected tendon injury, tenosynovitis, or soft tissue pathology 4, 5
• Ultrasound particularly useful for carpal tunnel syndrome (measuring median nerve cross-sectional area) 4, 6

Laboratory Testing

Blood tests are not required for diagnosis of hand osteoarthritis but should be obtained when marked inflammatory symptoms are present, especially involving atypical sites 1

Recommended Laboratory Panel:

• Inflammatory markers (ESR, CRP): Mildly elevated in erosive OA; strongly elevated in RA and polymyalgia-like syndromes 1
• Rheumatoid factor (RF) and anti-CCP antibodies: Strongly positive RF supports RA diagnosis 1
• Serum urate: Elevated levels support gout diagnosis 1
• HLA-B27: Consider if symptoms suggest reactive arthritis or spinal involvement 1
• Creatine kinase (CK): To differentiate polymyalgia-like syndrome (normal CK) from myositis (elevated CK) 1

Initial Management Algorithm

Non-Pharmacological First-Line Treatment

All patients should receive:

• Education and ergonomic training on joint protection, activity pacing, and assistive device use 1, 4, 5
• Exercise program to improve function and muscle strength while reducing pain 1, 4, 5
• Orthoses (splints) for symptom relief, particularly for thumb base involvement, with long-term use when beneficial 1, 4, 5

Pharmacological Management

Topical NSAIDs are the first pharmacological treatment of choice due to superior safety profile over systemic medications 1, 4, 5

Escalation pathway:

• Oral NSAIDs for limited duration when topical agents provide insufficient relief 1, 4
• Chondroitin sulfate may be used for pain relief and functional improvement in hand OA 1, 4

Treatments to AVOID:

• Do NOT use conventional or biological disease-modifying antirheumatic drugs for hand osteoarthritis 1, 4, 5
• Intra-articular glucocorticoid injections should not generally be used in hand OA, though may be considered for painful interphalangeal joints in select cases 1, 4, 5

Critical Diagnostic Pitfalls

Composite assessment is essential: A single clinical or radiographic feature has limited sensitivity and specificity; diagnosis depends on combining multiple features including age, gender, joint distribution, examination findings, and radiographic changes 1

Coexistent conditions are common: Hand OA may coexist with CPPD, gout, or RA, requiring careful evaluation for additional inflammatory arthritides when atypical features are present 1

Erosive OA mimics inflammatory arthritis: Presents with inflammatory symptoms, soft tissue swelling, elevated CRP, but targets IP joints specifically and shows characteristic subchondral erosions on radiographs 1

Functional impairment in hand OA may be as severe as in rheumatoid arthritis, requiring careful assessment using validated outcome measures 1