Differential Diagnosis for Hand Joint Pain
The differential diagnosis for hand joint pain should be systematically approached by first distinguishing inflammatory from non-inflammatory causes, then identifying the specific joint distribution pattern and associated features to narrow the diagnosis.
Primary Diagnostic Categories
Inflammatory Arthropathies
Rheumatoid Arthritis (RA) is characterized by symmetric involvement of metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints, and wrists, with morning stiffness lasting >1 hour and soft tissue swelling 1, 2. The distal interphalangeal (DIP) joints are characteristically spared in RA 2. Look for positive rheumatoid factor, anti-citrullinated protein antibodies, and elevated ESR/CRP 3, 2.
Psoriatic Arthritis can target DIP joints or affect just one ray (single digit involvement), distinguishing it from RA 1. Examine for nail pitting, psoriatic skin lesions, and dactylitis ("sausage digits") 1.
Crystalline Arthropathies including gout may superimpose on pre-existing osteoarthritis and present with acute inflammatory flares 1. Gout can affect any joint but consider it particularly when there is acute monoarticular or oligoarticular involvement 1.
Non-Inflammatory Arthropathies
Osteoarthritis (OA) presents with pain on usage, minimal morning stiffness (<30 minutes), and targets DIP joints (Heberden nodes), PIP joints (Bouchard nodes), thumb base (carpometacarpal joint), and index/middle MCP joints 1. Radiographs show joint space narrowing, osteophytes, subchondral sclerosis, and cysts 1.
Erosive Hand OA is a distinct subset with abrupt onset, marked pain, inflammatory symptoms (stiffness, soft tissue swelling, erythema), mildly elevated CRP, and radiographic subchondral erosions targeting interphalangeal joints 1.
Mechanical and Overuse Syndromes
Carpal Tunnel Syndrome causes numbness and tingling in the thumb, index, middle, and radial ring fingers with weakness of thumb opposition when severe 4. The Durkan maneuver (firm digital pressure across the carpal tunnel) is 64% sensitive and 83% specific 4.
De Quervain Tenosynovitis involves swelling of extensor tendons at the wrist, more common in women aged 40-59 years and those with frequent mobile phone use 4.
Trigger Finger presents with abnormal resistance to smooth flexion/extension ("triggering"), affecting up to 20% of adults with diabetes 4.
Other Important Differentials
Hemochromatosis mainly targets MCP joints and wrists, distinguishing it from typical OA patterns 1.
Systemic Lupus Erythematosus should be considered with polyarticular involvement and positive antinuclear antibodies 1.
Infectious causes including atypical mycobacterial infection must be excluded with appropriate history and examination 5.
Initial Clinical Assessment Algorithm
Step 1: Determine Inflammatory vs Non-Inflammatory
- Inflammatory features: Palpable synovitis, morning stiffness >30-60 minutes, soft tissue swelling, warmth, fever, weight loss, fatigue 1, 6
- Non-inflammatory features: Bony hypertrophy, crepitus, pain primarily with use, minimal morning stiffness 6
Step 2: Identify Joint Distribution Pattern
- MCP + PIP + wrists (DIP spared): Think RA 2
- DIP + PIP + thumb base: Think OA 1
- DIP or single ray involvement: Think psoriatic arthritis 1
- MCP + wrists: Consider hemochromatosis 1
Step 3: Look for Extra-Articular Manifestations
- Rheumatoid nodules, vasculitis, Felty's syndrome suggest RA 2
- Psoriatic skin/nail changes suggest psoriatic arthritis 1
- Heberden/Bouchard nodes suggest OA 1
Initial Diagnostic Workup
Laboratory Testing
For suspected inflammatory arthritis, obtain: complete blood count, urinalysis, transaminases, antinuclear antibodies, ESR, CRP, rheumatoid factor, and anti-citrullinated protein antibodies 1, 3. These tests are more diagnostically useful than classic rheumatologic tests which are often nonspecific 6.
Blood tests are NOT required for OA diagnosis but may be needed to exclude coexistent inflammatory disease, particularly when there are marked inflammatory symptoms involving atypical sites 1.
Imaging Strategy
Plain radiographs (posteroanterior, lateral, and oblique views) are the initial imaging study of choice for chronic hand pain, providing gold standard morphological assessment 1, 7, 3.
Ultrasound or MRI without IV contrast are appropriate for suspected tendon injury, tenosynovitis, carpal tunnel syndrome, or when radiographs are normal but clinical suspicion remains high 1, 8, 7.
Electrodiagnostic testing (>80% sensitive, 95% specific) should be performed for suspected carpal tunnel syndrome, especially when considering proximal compression or other compressive neuropathies 4.
Initial Management Framework
Non-Pharmacological First-Line (All Patients)
Education and ergonomic training regarding joint protection, proper workstation setup, activity pacing, and assistive devices should be provided to every patient 1, 8, 7.
Exercise regimen involving range of motion and strengthening exercises provides symptomatic relief and functional improvement 1, 8, 3.
Splinting is particularly beneficial for thumb base (trapeziometacarpal) involvement and to prevent deformities 1, 8.
Local heat application especially before exercise is recommended 8.
Pharmacological First-Line
Topical NSAIDs are the first pharmacological choice due to superior safety profile, especially for mild-to-moderate pain affecting few joints 1, 8, 7, 3. In patients ≥75 years, use topical rather than oral NSAIDs 1.
Oral NSAIDs (including COX-2 selective inhibitors) or tramadol may be used for limited duration when topical agents provide insufficient relief 1, 9.
Topical capsaicin is a conditional recommendation for hand OA 1.
Critical Management Pitfalls
Do NOT use conventional or biological disease-modifying antirheumatic drugs for hand osteoarthritis or overuse syndromes 8, 7.
Avoid intra-articular glucocorticoid injections generally in hand OA, though they may be considered for painful interphalangeal joints in select cases 8, 7.
For carpal tunnel syndrome, trigger finger, and de Quervain tenosynovitis: Steroid injection or immobilization are first-line treatments; surgical release is reserved for patients unresponsive to conservative therapy 4.
Referral Criteria
Refer to rheumatology within 6 weeks for patients with arthritis involving >1 joint, particularly with joint swelling, morning stiffness >30 minutes, or involvement of MCP/metatarsophalangeal joints 1.
Refer to hand surgery for severe structural abnormalities, persistent ganglion cysts, severe thumb base OA, or when conservative treatments have failed 8, 3.
Refer to neurology for suspected focal dystonia, progressive weakness, or signs of motor neuron disease 3.
Reassessment Timeline
Review the management plan within 6 months and develop an individualized pain management plan with ongoing assessment if no improvement is seen 8.