What are the differential diagnoses for a patient experiencing morning wrist pain?

Differential Diagnoses for Morning Wrist Pain

Morning wrist pain that improves throughout the day most strongly suggests inflammatory arthritis, particularly rheumatoid arthritis, which characteristically causes morning stiffness lasting at least 1 hour before maximal improvement. 1, 2

Primary Differential Diagnoses

Inflammatory Arthritis (Most Likely)

• Rheumatoid arthritis (RA) is the leading consideration when wrist pain is worse in the morning with prolonged stiffness, as RA characteristically targets the wrists, MCPJs, and PIPJs with symmetric involvement 1, 2
• Morning stiffness duration >30 minutes is a predictor of persistent inflammatory arthritis and strongly suggests RA over osteoarthritis 1
• RA presents with symmetric swelling of small joints and wrist involvement in early disease, with morning stiffness being the hallmark clinical feature 2
• Psoriatic arthritis should be considered if there is single ray involvement or DIPJ targeting, which can mimic hand osteoarthritis 1

Hand Osteoarthritis (Less Likely Given Morning Predominance)

• Hand osteoarthritis typically causes only mild morning or inactivity stiffness affecting just one or a few joints, making prolonged morning-predominant pain less characteristic 1
• HOA pain is primarily on usage rather than at rest, with limited morning stiffness being more specific to HOA than inflammatory arthritis 1
• Confident clinical diagnosis can be made in adults over 40 with typical features including DIPJs, PIPJs, and thumb base involvement 1

Tendon Pathology

• Stenosing tenosynovitis or inflammatory tenosynovitis presents with morning pain worsened by gripping and twisting motions 3
• De Quervain's disease classically causes pain during gripping and twisting movements on the radial side 3, 4
• Radiographs are typically normal in tendon pathology, requiring advanced imaging for diagnosis 3

Other Inflammatory Conditions

• Gout may superimpose on pre-existing osteoarthritis and should be considered 1
• Haemochromatosis mainly targets MCPJs and wrists 1
• Adult-onset Still's disease can cause wrist arthritis with morning stiffness, though typically accompanied by fever and rash 1

Critical Diagnostic Approach

History and Physical Examination

• Duration of morning stiffness is the key discriminator: >30 minutes suggests inflammatory arthritis, while brief stiffness suggests osteoarthritis 1
• Assess the pattern of joint involvement: symmetric small joint involvement suggests RA, while DIPJs/PIPJs/thumb base suggests HOA 1
• Evaluate for systemic symptoms (fever, weight loss, malaise) that indicate inflammatory disease 1, 2
• Determine exact location of pain: radial-sided suggests De Quervain's or scapholunate pathology, ulnar-sided suggests TFCC issues 3

Initial Laboratory Testing

• ESR and CRP should be performed at baseline as these acute phase reactants are predictive of inflammatory arthritis 1
• RF and/or ACPA testing should be performed, as these are predictive of RA diagnosis and prognosis; negative tests do not exclude progression to RA 1
• If connective tissue disease is suspected, additional autoantibody tests should be considered 1

Imaging Strategy

• Plain radiographs are the appropriate initial study for chronic wrist pain 1
• X-rays of hands, wrists, and feet should be obtained at baseline as the presence of erosions is predictive for development of RA 1
• If radiographs are normal or nonspecific and inflammatory arthritis is suspected, MRI is the next study 1
• MRI with IV contrast can quantify active synovitis and detect bone marrow edema (osteitis), which is the best single predictor of future disease progression in early RA 1
• Ultrasound with power Doppler is an alternative that can identify active synovitis and erosions, useful for early RA diagnosis when patients don't meet formal criteria 1
• For suspected tendon pathology, ultrasound or MRI without IV contrast are equally appropriate after normal radiographs 3

Critical Clinical Pitfalls

• Normal radiographs do not exclude significant pathology in wrist pain, particularly early inflammatory arthritis or tendon disease 3
• Do not delay joint aspiration if septic arthritis is suspected; perform immediately without waiting for advanced imaging 1, 3
• Morning stiffness must be differentiated from pain—patients need careful education on this distinction 2
• Erosive hand OA can mimic inflammatory arthritis with abrupt onset, marked pain, inflammatory symptoms (stiffness, soft tissue swelling), and mildly elevated CRP 1
• Carpal tunnel syndrome should be considered as a neurological cause of morning wrist pain, particularly with hand muscle atrophy 5

Predictors of Persistent Disease

If inflammatory arthritis is suspected, document these predictors of chronicity: disease duration ≥6 weeks, morning stiffness >30 minutes, functional impairment, involvement of ≥3 joints, ACPA/RF positivity, and presence of radiographic erosion 1