What causes pain in the proximal phalanges and hand?

Causes of Pain in Proximal Phalanges and Hand

Pain in the proximal phalanges and hand most commonly results from osteoarthritis affecting the interphalangeal joints, traumatic injuries (fractures, ligament tears, tendon injuries), nerve compression (particularly carpal tunnel syndrome), inflammatory arthritis, or trigger finger with secondary joint involvement. 1, 2, 3

Primary Diagnostic Categories

Osteoarthritis (Most Common Non-Traumatic Cause)

• Proximal interphalangeal (PIP) joint arthritis is a leading cause of hand pain and impairment, occurring as either nonerosive (primary) or erosive osteoarthritis 1, 3
• Nonerosive osteoarthritis results from abnormal mechanical stress causing cartilage and subchondral bone damage, with subsequent cytokine and growth factor activation 3
• Erosive osteoarthritis exhibits an inflammatory component and represents a more aggressive form, though whether it is truly a separate entity remains controversial 3
• The wrists, knees, and ankles are most frequently affected, but involvement of proximal and distal interphalangeal joints, metacarpophalangeal joints, and temporomandibular joints is well-documented 1
• Plain radiographs are the initial imaging study and can show degenerative changes, alignment abnormalities, deformity, and soft tissue mineralization 4

Traumatic Injuries

• Fractures of the proximal phalanx cause significant pain, with moderate to high resting pain (≥4.5/10 on VAS) in the first post-operative week predicting persistent pain and reduced hand function at 12 weeks 5
• Soft tissue injuries include tendon tears, ligament injuries, and capsular damage affecting the metacarpophalangeal and interphalangeal joints 1
• MRI is ideal for evaluating tendon injuries and surgical planning, with sensitivity of 92-100% for flexor tendon injuries and 100% sensitivity for thumb ulnar collateral ligament tears 1
• Ultrasound allows dynamic assessment and can diagnose Stener lesions, pulley system injuries, and collateral ligament tears 1

Neurogenic Causes

• Carpal tunnel syndrome is the most frequent neurogenic cause, diagnosed by cramping, pain, and paresthesias in the median nerve distribution 2
• Bilateral carpal tunnel syndrome without obvious trauma or rheumatoid arthritis should raise suspicion for systemic conditions, particularly cardiac amyloidosis 2
• Ultrasound is first-line imaging, demonstrating median nerve enlargement, nerve flattening, and flexor retinaculum bowing 2
• MRI can detect carpal tunnel syndrome with high accuracy and identify associated tendon pathology, though ultrasound is preferred due to cost-effectiveness 2

Trigger Finger with Secondary Joint Pain

• Twenty-four percent of patients with trigger finger experience proximal interphalangeal joint pain, which results from prolonged symptom duration and consequent joint pathology 6
• This pain is incompletely resolved after A1 pulley release, particularly when joint tenderness is present on palpation 6
• Bone scan can identify joint lesions in these patients 6

Inflammatory and Systemic Causes

• Adult-onset Still's disease presents with arthritis affecting knees, wrists, ankles, and frequently the proximal and distal interphalangeal joints, metacarpophalangeal joints, and temporomandibular joints 1
• Sarcoidosis can present as painful bony swelling of the proximal phalanx with lytic lesions on imaging, though this is uncommon 7
• Intrinsic plus hand describes a rare painful contracture with excessive flexion at metacarpophalangeal joints and extension at interphalangeal joints, requiring evaluation for cerebrovascular injury, infection, compartment syndrome, and deep vein thrombosis 8

Diagnostic Algorithm

Initial Evaluation

• Begin with plain radiographs to assess alignment, joint spaces, fractures, soft tissue abnormalities, and degenerative changes 1, 2, 4
• Radiographs may be sufficient to establish diagnosis or confirm clinical suspicion in many cases 4
• Never order MRI before obtaining appropriate radiographs 2

When Radiographs Are Normal or Equivocal

• For suspected carpal tunnel syndrome: ultrasound is first-line, measuring median nerve cross-sectional area and identifying anatomic variants 2
• For hand swelling with elevated inflammatory markers: ultrasound identifies synovitis, joint effusion, tenosynovitis, tendinopathy, and soft tissue pathology 9
• For persistent symptoms with normal radiographs: MRI without IV contrast evaluates soft tissues, nerve compression, and tendon pathology 1, 2
• Ultrasound offers dynamic assessment, is more readily available and less expensive than MRI, and is better suited for detecting fluid collections 9

Advanced Imaging Considerations

• MRI without IV contrast is of limited benefit for nonspecific hand pain and should be reserved for cases where ultrasound is inconclusive or deeper structures require evaluation 9
• Intra-articular glucocorticoid injections should not generally be used in hand osteoarthritis, but may be considered for painful interphalangeal joints with clear joint inflammation 1

Critical Red Flags

• Bilateral carpal tunnel syndrome without trauma warrants evaluation for cardiac amyloidosis 2
• Moderate to high resting pain (≥4.5/10) following proximal phalangeal fracture surgery should be recognized as unusual and targeted in rehabilitation 5
• Lytic bone lesions require referral to a musculoskeletal tumor service for biopsy to exclude sarcoidosis or malignancy 7
• Intrinsic plus hand requires emergency evaluation for cerebrovascular injury, infection, compartment syndrome, and DVT 8

Common Pitfalls

• Radiographs can show only nonspecific arthritis that doesn't distinguish between degenerative osteoarthritis, inflammatory arthritis, and crystalline arthritis—clinical correlation is essential 4
• Trigger finger patients with PIP joint tenderness have worse surgical outcomes despite resolution of clicking, as the joint pathology persists 6
• MRI has shown no significant advantage over radiographs for assessing joint space narrowing, bone erosion, and malalignment in erosive osteoarthritis 9