What causes morning swelling in hands and feet?

Morning Hand and Foot Swelling: Causes and Clinical Approach

Morning swelling of hands and feet is most commonly physiological (normal overnight fluid redistribution), but requires systematic evaluation to exclude inflammatory arthritis, venous insufficiency, cardiac/renal disease, and medication effects.

Physiological Causes

Physiological nocturnal hand swelling occurs in healthy individuals without pathology. Hand volume increases significantly overnight (8 PM to 8 AM) and then decreases throughout the day, with the most significant reduction occurring between 8 AM and 2 PM 1. This normal phenomenon affects both hands symmetrically and is not influenced by age, sex, or body mass index 1.

Inflammatory Arthritis (Critical to Exclude)

Morning stiffness lasting >30 minutes with joint swelling suggests inflammatory arthritis and requires rheumatology referral within 6 weeks. 2

Key features suggesting inflammatory arthritis:

• Symmetrical involvement of small joints of hands and feet 2
• Morning stiffness >30 minutes 2
• Positive "squeeze test" of metacarpophalangeal/metatarsophalangeal joints 2
• Female gender and advanced age increase likelihood of rheumatoid arthritis 2

Essential Initial Laboratory Tests

When inflammatory arthritis is suspected, obtain 2:

• Complete blood count
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 2
• Rheumatoid factor and anti-citrullinated protein antibodies 2
• Antinuclear antibodies 2
• Urinalysis 2
• Transaminases 2

Clinical examination is the primary method for detecting synovitis; ultrasound or MRI can be helpful in doubtful cases 2.

Systemic Causes Requiring Evaluation

Cardiac and Renal Disease

Bilateral swelling suggests systemic causes including heart failure or renal disease. 3

• Assess for jugular venous distension and cardiac findings 3
• Check for dependent edema that improves with elevation
• Increased hydrostatic pressure from venous insufficiency or heart failure causes extremity swelling 3

Venous Thrombosis

Unilateral swelling requires exclusion of deep vein thrombosis (DVT). 3

• DVT accounts for 10% of upper extremity cases, presenting with ipsilateral arm edema, pain, and paresthesia 3
• Duplex ultrasound has >80% sensitivity and specificity for upper extremity DVT 3

Specific Conditions Causing Hand and Foot Swelling

Psoriatic Arthritis

Dactylitis ("sausage digit") with painful swollen joints in hands and feet suggests psoriatic arthritis. 3, 2

• Look for distal interphalangeal joint involvement 2
• Morning stiffness is common but differs from osteoarthritis where stiffness occurs with activity 2
• Requires 68/66 joint count including DIP joints of hands and feet 2

Erythromelalgia

Episodic burning pain with red, hot, swollen extremities triggered by heat or exercise suggests erythromelalgia. 2, 3

• Patients often immerse hands/feet in cold water for relief 2
• Avoid ice or water immersion as this may cause tissue damage, ulceration, and "immersion foot" 2
• Associated with small fiber neuropathy in 90% of cases 2

Drug-Induced Causes

Chemotherapy agents (capecitabine, 5-FU, doxorubicin) cause hand-foot syndrome with redness, swelling, and marked discomfort in 6-60% of patients. 4

• Buprenorphine IV misuse causes lymphatic destruction and "puffy hand syndrome" 5

Critical Pitfalls to Avoid

• Do not dismiss bilateral morning swelling as "just aging" without excluding inflammatory arthritis - early treatment within 6 weeks improves outcomes 2
• Do not wait for complete diagnostic criteria - refer to rheumatology with 2+ swollen joints and morning stiffness >30 minutes 2
• Distinguish unilateral from bilateral distribution - unilateral suggests local causes (DVT, infection), bilateral suggests systemic causes 3
• Avoid recommending ice water immersion for relief - this causes tissue damage in conditions like erythromelalgia 2

Diagnostic Algorithm

1. Determine distribution: Unilateral vs bilateral 3
2. Assess for inflammatory features: Morning stiffness >30 minutes, squeeze test positivity 2
3. Check for systemic signs: Jugular venous distension, cardiac findings, fever 3
4. Obtain baseline labs if inflammatory arthritis suspected: ESR, CRP, RF, anti-CCP, ANA, CBC, urinalysis 2
5. Consider imaging: Duplex ultrasound for suspected DVT 3; hands/feet X-rays for erosive changes 2
6. Refer to rheumatology within 6 weeks if inflammatory arthritis suspected 2