What is the initial approach to managing non-tender joint swelling of the distal interphalangeal (DIP) joint?

Initial Management of Non-Tender DIP Joint Swelling

Non-tender swelling of the distal interphalangeal (DIP) joint most likely represents osteoarthritis with Heberden's nodes (bony enlargement), and initial management should focus on conservative measures including topical NSAIDs, exercises, and ergonomic modifications. 1, 2

Diagnostic Approach

Distinguish Bony vs Soft Tissue Swelling

• Palpate carefully to differentiate bony enlargement (suggesting osteoarthritis) from soft tissue swelling (suggesting inflammatory arthritis) 1
• Bony enlargement at the DIP joint represents Heberden's nodes, characteristic of osteoarthritis 1
• The absence of tenderness argues against active inflammatory arthritis 1
• Soft tissue swelling with minimal tenderness could indicate advanced structural disease from prior inflammation rather than active synovitis 1

Consider Alternative Diagnoses

• DIP involvement can occur in psoriatic arthritis, particularly if asymmetric or associated with nail changes (pitting, onycholysis) or dactylitis 3, 1
• Rheumatoid arthritis typically spares DIP joints, affecting MCP and PIP joints instead 3, 1
• Morning stiffness lasting >30 minutes suggests inflammatory rather than mechanical causes 1

Initial Laboratory Testing (If Inflammatory Arthritis Suspected)

• Order CBC, ESR or CRP, rheumatoid factor (RF), and anti-CCP antibodies if inflammatory arthritis is a consideration 4
• Plain radiographs of the affected joint are the initial imaging method of choice 2, 4

Conservative Management Strategy

First-Line Non-Pharmacological Interventions

• Provide education on ergonomic principles, activity pacing, and use of assistive devices 2
• Prescribe exercises to improve function and muscle strength for pain reduction 2
• Apply thermal modalities (heat or cold) for symptomatic relief 2

Pharmacological Treatment Hierarchy

• Start with topical NSAIDs as the first pharmacological treatment due to superior safety profile 2
• Consider oral NSAIDs (such as naproxen 500 mg twice daily) for limited duration if topical therapy insufficient, after evaluating gastrointestinal, renal, and cardiovascular status 2, 4
• Chondroitin sulfate may provide additional pain relief and functional improvement 2
• Intra-articular glucocorticoid injections may be considered specifically for painful interphalangeal joints 2

When to Escalate Care

Indications for Rheumatology Referral

• Refer within 6 weeks if multiple joints are involved with swelling not caused by trauma or bony enlargement 4
• Consider referral if inflammatory arthritis suspected based on soft tissue swelling, morning stiffness >30 minutes, or positive serologies 1, 4

Surgical Consideration

• Surgery should be considered only when conservative measures fail to provide adequate pain relief 2, 5
• Arthrodesis (joint fusion) is the procedure of choice for most symptomatic DIP joint arthritis refractory to conservative management 2, 5
• DIP arthroplasty may be considered in select cases where maintaining motion is critical, though it carries a 15% complication rate 6

Key Clinical Pitfalls

• Do not assume all DIP swelling is osteoarthritis—psoriatic arthritis can target DIP joints as a distinguishing feature 3, 1
• Osteoarthritis and inflammatory arthritis can coexist in the same patient 1
• Avoid starting DMARDs like methotrexate without rheumatology consultation, as these require specific monitoring protocols 4
• The absence of tenderness does not exclude pathology—it may indicate chronic structural changes rather than active inflammation 1