What is the treatment for right knuckle stiffness?

Treatment of Right Knuckle Stiffness

Begin with joint protection education and a structured exercise regimen combining range-of-motion and strengthening exercises, which forms the foundation of treatment for all patients with hand osteoarthritis. 1

Initial Non-Pharmacological Management

The optimal approach requires combining non-pharmacological and pharmacological treatments tailored to the specific joint involved, severity of structural changes, and degree of functional impairment. 1

First-Line Physical Interventions

• Implement range-of-motion and strengthening exercises immediately, as these are recommended for all patients with hand osteoarthritis regardless of severity. 1

• Apply local heat therapy (paraffin wax or hot packs) before exercise sessions to enhance effectiveness, with heat application showing strong support (77% expert agreement). 1

• Educate the patient on joint protection techniques to avoid adverse mechanical factors that perpetuate stiffness and pain. 1

• Consider orthoses or splints if there is lateral angulation or flexion deformity developing at the knuckle, particularly for thumb base involvement. 1

Important caveat: Ultrasound therapy has minimal supporting evidence (0% expert agreement) and should not be prioritized despite being mentioned in guidelines. 1

Pharmacological Treatment Algorithm

Step 1: Topical Therapy (Preferred Initial Approach)

• Start with topical NSAIDs or capsaicin as first-line pharmacological treatment, especially when only a few joints are affected with mild to moderate pain. 1

• Topical treatments are preferred over systemic agents due to superior safety profile and effectiveness for localized hand osteoarthritis. 1

Step 2: Oral Analgesics

• Prescribe acetaminophen (paracetamol) up to 4 g/day if topical treatments provide insufficient relief, as this is the oral analgesic of first choice based on efficacy and safety (87% strength of recommendation). 1

• Continue acetaminophen as the preferred long-term oral analgesic if successful. 1

Step 3: Oral NSAIDs (If Acetaminophen Fails)

• Use oral NSAIDs at the lowest effective dose for the shortest duration in patients responding inadequately to acetaminophen. 1

• Re-evaluate periodically to assess continued need and response. 1

• For patients with increased gastrointestinal risk: Add gastroprotective agent with non-selective NSAIDs, or use selective COX-2 inhibitor. 1

• For patients with increased cardiovascular risk: COX-2 inhibitors are contraindicated; use non-selective NSAIDs with extreme caution. 1

Interventional Options for Refractory Cases

Corticosteroid Injections

• Consider intra-articular long-acting corticosteroid injection for painful flares, particularly effective for trapeziometacarpal (thumb base) joint osteoarthritis. 1

• This option is moderately recommended (60% strength) for acute inflammatory exacerbations. 1

Critical warning: Use corticosteroid injections cautiously, as they may inhibit healing and reduce tensile strength of periarticular tissues, potentially predisposing to complications. 1

Symptomatic Slow-Acting Drugs

• Glucosamine, chondroitin sulfate, or other SYSADOAs may provide symptomatic benefit with low toxicity, but effect sizes are small and clinically relevant structure modification has not been established. 1

• These agents have moderate recommendation strength (63%) and should be considered adjunctive rather than primary therapy. 1

Surgical Referral Criteria

Refer for surgical evaluation (interposition arthroplasty, osteotomy, or arthrodesis) when:

• Marked pain and/or disability persist despite comprehensive conservative treatment failure. 1
• Severe thumb base osteoarthritis with functional limitations affecting quality of life. 1

Surgery is moderately recommended (68% strength) for appropriately selected patients with severe disease. 1

Common Pitfalls to Avoid

• Do not delay exercise therapy waiting for pain to fully resolve—exercise is therapeutic, not contraindicated, in stable hand osteoarthritis. 1

• Do not use systemic NSAIDs as first-line when topical options are appropriate for localized involvement. 1

• Do not continue ineffective treatments—reassess at 2-4 weeks and escalate therapy if no improvement occurs. 1

• Do not overlook inflammatory arthritis in the differential diagnosis, which may present with similar stiffness but requires different management including potential DMARDs or biologics. 1