Management of Hand Osteoarthritis
All patients with hand osteoarthritis should receive a combination of patient education, hand exercises, and hand orthoses (particularly for thumb base involvement), with topical NSAIDs as first-line pharmacological therapy when needed. 1, 2
Initial Non-Pharmacological Management (Required for All Patients)
Education and Joint Protection
Provide education on joint protection techniques and ergonomic principles to avoid adverse mechanical factors during daily activities. 2, 3 This is a first-line recommendation from the European League Against Rheumatism and should be offered to every patient regardless of disease severity.
Assess the patient's ability to perform activities of daily living and provide assistive devices as needed to maintain function and independence. 2, 3
Exercise Prescription
Prescribe a structured exercise regimen that includes both range-of-motion and strengthening exercises. 1, 2, 4 The number needed to treat (NNT) for improvement in patient global function is only 2, making this one of the most effective interventions. 2
Exercise reduces hand pain by approximately 5% on a 0-10 scale (NNT = 9) and improves function by 6% (NNT = 9). 4
Instruct patients to perform exercises 2-3 times weekly at minimum, though daily exercise may provide additional benefit. 4
Apply thermal modalities (paraffin wax or hot packs) before exercise sessions, which has strong expert support (77% recommendation). 5
Orthoses/Splinting
Provide hand orthoses for symptomatic relief, with particular emphasis on thumb base (first carpometacarpal joint) osteoarthritis. 1, 2 The NNT for symptomatic improvement is 4. 2
Long-term orthosis use is recommended, with evidence showing moderate effect size (0.64) for functional improvement. 2
For thumb base OA specifically, use a full splint covering both thumb and wrist for superior pain relief compared to partial splinting. 5
Pharmacological Management
First-Line: Topical Therapy
Topical NSAIDs should be the first-line pharmacological treatment choice due to their efficacy (effect size 0.77 for function) and superior safety profile compared to oral medications. 1, 2, 3 This is particularly appropriate when only a few joints are affected.
Topical capsaicin may be used as an alternative with an NNT of 3 for pain relief. 2, 5
Second-Line: Oral Medications
When topical treatments provide inadequate relief, use oral NSAIDs at the lowest effective dose for the shortest duration (effect size 0.40 for functional improvement, NNT = 3 for pain relief). 2, 5
Acetaminophen up to 4g/day can be considered, though evidence for efficacy in hand OA is limited. 5, 3
Chondroitin sulfate may be used for symptom relief in hand OA. 1, 2
Intra-articular Injections
Intra-articular corticosteroid injections are conditionally recommended for hand OA, particularly effective for trapeziometacarpal joint involvement during painful inflammatory flares. 1, 5
Generally not recommended for interphalangeal joints. 3
Surgical Management
Surgery should be considered only when conservative treatments (education, exercise, orthoses, and pharmacological management) have failed to provide adequate pain relief and the patient has marked disability. 2, 3
For thumb base OA, trapeziectomy should be considered. 2
For interphalangeal OA, arthrodesis or arthroplasty may be appropriate. 2
Treatment Algorithm Based on Number of Joints Affected
Few joints affected: Prioritize topical NSAIDs over oral medications. 5, 3
Multiple joints affected: Consider oral NSAIDs earlier in the treatment algorithm. 5
Common Pitfalls
Failing to provide splinting for trapeziometacarpal joint OA misses a significant opportunity for symptom relief (NNT = 4). 2, 3
The positive effects of exercise on pain, function, and joint stiffness may not be sustained at 6-12 month follow-up, requiring ongoing reinforcement and adherence support. 4
Adverse events from exercise (increased finger joint inflammation and hand pain) are uncommon but should be monitored. 4
Combining education with exercise provides significantly greater clinical benefit than either intervention alone. 2