What is the cause and treatment of knots in the knuckles, considering age, medical history, and lifestyle?

Knots in Knuckles: Diagnosis and Management

Most Likely Diagnosis

The "knots" you're describing are most likely Heberden nodes (at the distal knuckles) or Bouchard nodes (at the middle knuckles), which are bony enlargements characteristic of hand osteoarthritis (HOA), particularly in adults over age 40. 1

Clinical Diagnosis

Key Diagnostic Features

• Bony enlargements at characteristic sites: Heberden nodes affect the distal interphalangeal joints (DIPJs), while Bouchard nodes affect the proximal interphalangeal joints (PIPJs) 1
• Pain pattern: Typically pain occurs with usage, with only mild morning stiffness (less than 30 minutes), affecting one or a few joints intermittently 1
• Age and demographics: Most common in adults over 40, particularly women, especially post-menopausal 1
• A confident clinical diagnosis can be made without imaging in adults over 40 with these typical features 1

Risk Factors to Consider

• Female sex, age over 40, menopausal status 1
• Family history of hand arthritis 1
• Obesity, prior hand injury 1
• Occupation or recreation involving repetitive hand use 1

Important Differential Diagnoses

The EULAR guidelines emphasize considering these alternatives 1:

• Psoriatic arthritis: May target DIPJs or affect just one finger ray 1
• Rheumatoid arthritis: Primarily affects MCPJs and PIPJs, typically with prolonged morning stiffness 1
• Gout: Can superimpose on pre-existing osteoarthritis 1
• Knuckle pads: Benign skin thickening (epidermis) over PIPJs in children, which can resolve spontaneously 2

When Imaging Is Needed

Plain radiographs are the gold standard for morphological assessment but are NOT required for diagnosis when clinical features are typical. 1 A single posteroanterior view of both hands is adequate if imaging is pursued 1. Classical radiographic features include joint space narrowing, osteophytes, subchondral sclerosis, and cysts 1.

Treatment Approach

First-Line Conservative Management

Begin with topical NSAIDs as they provide similar pain relief to oral NSAIDs with fewer systemic side effects for localized hand involvement. 3, 4

• Topical NSAIDs: Preferred for localized hand osteoarthritis 3, 4
• Paracetamol up to 4g/day: First-choice oral analgesic due to favorable safety profile 3, 4
• Relative rest: Reduce repetitive loading activities but avoid complete immobilization which causes muscle atrophy 3, 4
• Ice application: Through a wet towel for 10-minute periods for short-term pain relief 3, 4
• Heat therapy: Paraffin wax or hot packs before exercise can be beneficial 4

Rehabilitation Protocol

• Eccentric strengthening exercises: Proven to reduce symptoms, increase strength, and reverse degenerative changes 3, 4
• Deep transverse friction massage: Can reduce pain 3, 4
• Technique modification: For those with occupational hand use to minimize repetitive stresses 3, 4

Advanced Interventions (If Conservative Measures Fail)

• Corticosteroid injections: Provide better acute pain relief than oral NSAIDs but do not alter long-term outcomes and may inhibit healing 3, 4
• Extracorporeal shock wave therapy (ESWT): Safe noninvasive option for chronic cases, though expensive 3, 4

Surgical Consideration

Surgery is indicated only after 3-6 months of failed conservative management in carefully selected patients. 3, 4

Important Clinical Pearls

What NOT to Worry About

• Knuckle cracking does NOT cause osteoarthritis: Multiple observational studies show no association between habitual knuckle cracking and development of hand osteoarthritis 5, 6, 7
• However, one study found habitual knuckle crackers may have hand swelling and lower grip strength, though without increased arthritis 8

Red Flags Requiring Different Management

• Joint effusions are uncommon with osteoarthritis: Their presence suggests intra-articular pathology requiring different evaluation 3
• Erosive hand OA: Abrupt onset with marked pain, inflammatory signs (soft tissue swelling, erythema), and mildly elevated CRP indicates a more aggressive subset requiring closer monitoring 1
• Prolonged morning stiffness (>30 minutes): Suggests inflammatory arthritis rather than osteoarthritis 1

Systemic Considerations

Patients with polyarticular hand OA are at increased risk for knee OA, hip OA, and generalized OA—examine other common sites accordingly. 1

Prognosis and Follow-Up

• Approximately 80% of patients with overuse tendinopathies recover within 3-6 months with appropriate conservative treatment 3
• Functional impairment in hand OA can be as severe as rheumatoid arthritis: Function should be carefully assessed using validated outcome measures 1
• If symptoms persist beyond 6 months despite well-managed conservative therapy, surgical consultation is warranted 3, 4