What treatment is recommended for pain, numbness, and inflammation in the hands?

Treatment for Hand Pain, Numbness, and Inflammation

For hand pain, numbness, and inflammation, begin with topical NSAIDs combined with physical activity and joint protection education, reserving oral NSAIDs for inadequate response, while simultaneously assessing for underlying causes such as carpal tunnel syndrome, hand osteoarthritis, or peripheral neuropathy to guide specific interventions.

Initial Assessment and Diagnosis

The first critical step is determining the underlying cause, as treatment differs substantially:

• Assess for carpal tunnel syndrome if numbness affects the thumb, index, middle, and radial half of the ring finger, using the Durkan maneuver (64% sensitive, 83% specific) which involves firm digital pressure across the carpal tunnel to reproduce symptoms 1
• Evaluate for peripheral neuropathy by asking specifically about numbness and tingling characteristics in both hands and feet, particularly if symptoms worsen at night or during rest 2
• Consider hand osteoarthritis if pain involves multiple joints with stiffness and decreased function, particularly in postmenopausal women (affects 33% radiographically) 2, 1
• Rule out occupational neuropathy in patients performing repetitive hand/arm labor, where sensory axonal polyneuropathy affects only upper extremity sensory nerves 3

First-Line Non-Pharmacological Treatment

All patients should receive education on joint protection and begin physical activity immediately, regardless of the underlying diagnosis:

• Implement range-of-motion and strengthening exercises as these improve pain across multiple conditions including osteoarthritis, neuropathy, and post-surgical pain 2, 4
• Apply local heat (paraffin wax or hot packs) before exercise sessions, which has strong expert support (77% recommendation) for hand conditions 4, 5
• Provide joint protection education focusing on avoiding adverse mechanical factors during daily activities 2, 4
• Consider splinting for carpal tunnel syndrome or thumb base osteoarthritis, with full splints covering both thumb and wrist providing superior pain relief (NNT=4 for functional improvement) 4, 1

First-Line Pharmacological Treatment

Topical NSAIDs are the preferred initial pharmacologic intervention for localized hand pain and inflammation:

• Start with topical NSAIDs or capsaicin as first-line therapy, which provide equivalent efficacy to oral NSAIDs (effect size 0.77 for pain relief) without gastrointestinal risk, particularly when few joints are affected 6, 4
• Use acetaminophen up to 4g/day as the oral analgesic of first choice if topical therapy is inadequate, due to superior safety profile (strength of recommendation 87/100) 2, 4

Second-Line Pharmacological Treatment

If topical NSAIDs and acetaminophen provide inadequate relief:

• Prescribe oral NSAIDs at the lowest effective dose for the shortest duration with mandatory cardiovascular and gastrointestinal risk stratification before initiating 2, 6, 7
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor 6, 7
• For patients with increased cardiovascular risk, COX-2 inhibitors are contraindicated and non-selective NSAIDs should be used with extreme caution 6, 7

Treatment for Neuropathic Symptoms

If numbness and tingling persist despite initial measures, indicating neuropathic pain:

• Offer duloxetine for patients with confirmed neuropathic pain, numbness, and tingling (Level IB evidence) 2
• Continue physical activity as it has Level IA evidence for improving neuropathy symptoms 2
• Consider acupuncture which has demonstrated statistically significant improvement in pain intensity through multiple RCTs and meta-analyses 2

Interventional Options

For persistent symptoms despite conservative management:

• Intra-articular corticosteroid injection may be considered for painful interphalangeal joints in hand osteoarthritis or for inflammatory flares, particularly effective for trapeziometacarpal joint 2, 4
• Steroid injection for carpal tunnel syndrome provides temporary symptom relief in approximately 72% of patients, particularly when combined with immobilization 1
• Refer for electrodiagnostic testing if carpal tunnel syndrome is suspected but diagnosis unclear, as it is >80% sensitive and 95% specific 1

Surgical Referral Criteria

Surgery should be considered when:

• Conservative treatments fail and the patient has marked pain and/or disability affecting quality of life 2, 1
• Carpal tunnel syndrome shows progressive weakness or muscle atrophy, warranting open or endoscopic carpal tunnel release 1
• Hand osteoarthritis with structural abnormalities causes persistent pain despite optimal medical management, with trapeziectomy for thumb base OA and arthrodesis or arthroplasty for interphalangeal OA 2

Critical Pitfalls to Avoid

• Never prescribe oral NSAIDs as first-line therapy when topical options have not been tried, especially in elderly patients or those with multiple comorbidities 6
• Do not continue oral NSAIDs indefinitely without periodic reassessment of efficacy, necessity, and emerging risk factors 6
• Avoid missing carpal tunnel syndrome in patients with diabetes, obesity, or occupational keyboard/vibrating tool use, as these are high-risk populations requiring lower threshold for electrodiagnostic testing 1, 8
• Do not overlook bilateral symptoms which suggest systemic causes like diabetes, hypothyroidism, or rheumatoid arthritis rather than isolated nerve entrapment 9
• Assess for secondary causes such as lymphedema or chest wall tightness in breast cancer survivors, referring to appropriate specialists 2