What is the approach to managing hand joints pain?

Approach to Hand Joint Pain

Begin with non-pharmacological interventions as first-line therapy: education on joint protection and ergonomic principles, hand exercises for range of motion and strengthening, and topical NSAIDs for symptomatic relief. 1

Initial Assessment

Identify the specific pattern and location of joint involvement to guide treatment:

• Thumb base (CMC-1) involvement: Most common site requiring specific orthotic management 1
• Interphalangeal joint involvement (DIP/PIP): Requires different exercise protocols than thumb base disease 1
• Presence of inflammatory signs: Swelling, warmth, morning stiffness lasting >1 hour suggests inflammatory arthritis rather than osteoarthritis 2
• Exclude dangerous conditions: Rule out fractures, septic arthritis, or systemic inflammatory disease requiring immediate intervention 3

Non-Pharmacological Management (First-Line for All Patients)

Education and Joint Protection

• Provide education on ergonomic principles, activity pacing, and use of assistive devices to every patient 1
• Joint protection training has proven efficacy and should replace the outdated concept of "protecting joints by avoiding use" 1
• This can be delivered by occupational therapists, physical therapists, or trained nurses 1

Exercise Therapy

• Implement exercises to improve function, muscle strength, and reduce pain for every patient 1
• Hand exercises provide small but significant benefits for pain, function, joint stiffness, and grip strength with minimal adverse effects 1
• Tailor exercise regimens specifically: CMC-1 joint exercises differ from interphalangeal joint protocols 1
• Focus on range of motion initially, then progress to strengthening exercises 1

Orthoses/Splinting

• For thumb base OA: Use neoprene or rigid orthoses with long-term application (minimum 3 months) for optimal symptom relief 1, 4
• Custom-made orthoses are preferred for proper fit and compliance 4
• Short-term use (<3 months) shows no significant benefit 1
• For other hand joints, orthoses may be considered but have weaker evidence 4

Heat Therapy

• Apply local heat (paraffin wax, hot packs) before exercise sessions 1, 4
• Heat therapy has stronger evidence (77% recommendation strength) compared to ultrasound (25% recommendation strength) 1

Pharmacological Management (Stepwise Approach)

First-Line Pharmacological Treatment

• Topical NSAIDs are the preferred initial pharmacological treatment due to superior safety profile 1, 4
• Topical treatments are especially appropriate when few joints are affected 4
• In patients ≥75 years old, use topical rather than oral NSAIDs 4

Second-Line: Oral Analgesics

• Acetaminophen (paracetamol) up to 4g/day is the oral analgesic of first choice 4
• Use as the lowest effective dose for efficacy and safety 4

Third-Line: Oral NSAIDs

• Oral NSAIDs (including COX-2 selective inhibitors) should be used at the lowest effective dose for the shortest duration 1, 4
• Reserve for patients with inadequate response to topical NSAIDs and acetaminophen 4
• For patients with increased gastrointestinal risk: Use non-selective NSAIDs plus gastroprotective agent OR selective COX-2 inhibitor 4

Intra-articular Corticosteroids

• Intra-articular long-acting corticosteroid injection is effective for painful flares, especially in the trapeziometacarpal (CMC-1) joint 4
• Use for acute exacerbations when conservative measures are insufficient 4

Surgical Interventions

• For severe thumb base OA with marked pain and/or disability unresponsive to conservative treatment: Consider surgical options (interposition arthroplasty, osteotomy, or arthrodesis) 4
• Surgery should only be considered after other treatment modalities have failed 4

Common Pitfalls and Caveats

• Avoid short-term splinting (<3 months): No significant benefit is demonstrated with brief orthotic use 1
• Do not use conventional or biological DMARDs: These have no role in hand osteoarthritis management 4
• Avoid long-term oral NSAIDs: Risk of gastrointestinal, cardiovascular, and renal adverse effects outweighs benefits 4
• Intra-articular therapies and opioid analgesics are conditionally recommended against in initial management 4
• Morning stiffness lasting >1 hour suggests inflammatory arthritis (e.g., rheumatoid arthritis) rather than osteoarthritis, requiring different management 2
• Distal interphalangeal (DIP) joint involvement is rare in rheumatoid arthritis; if present, consider psoriatic arthritis or osteoarthritis 2

Treatment Algorithm Summary

1. All patients: Education + joint protection + hand exercises + heat therapy before exercises 1, 4
2. Add for thumb base OA: Custom-made orthosis for ≥3 months 1, 4
3. Add topical NSAIDs for symptomatic relief 4
4. Add acetaminophen (up to 4g/day) if inadequate response 4
5. Add short-term oral NSAIDs at lowest effective dose if still inadequate 4
6. Consider intra-articular corticosteroid injection for painful flares, especially CMC-1 joint 4
7. Refer for surgery if severe symptoms persist despite conservative management 4