What could be causing swelling of my hands and feet?

Swelling of Hands and Feet: Diagnostic Approach and Management

When you present with swelling of both hands and feet, the most critical first step is determining whether this represents inflammatory arthritis requiring urgent rheumatology referral within 6 weeks, or a systemic condition like heart failure or kidney disease that needs immediate medical attention. 1

Immediate Assessment: Bilateral vs. Unilateral Distribution

Bilateral swelling suggests systemic causes including heart failure, renal disease, or inflammatory arthritis, and requires assessment for jugular venous distension and cardiac findings. 1 In contrast, unilateral swelling points to local causes such as deep vein thrombosis (accounting for 10% of upper extremity cases) or infection, necessitating duplex ultrasound which has >80% sensitivity and specificity for DVT. 1

Key Clinical Features Indicating Inflammatory Arthritis

If you have morning stiffness lasting >30 minutes with joint swelling, this indicates inflammatory arthritis and requires rheumatology referral within 6 weeks. 1 Critical diagnostic features include:

• Symmetrical involvement of small joints in hands and feet 1
• Positive "squeeze test" of metacarpophalangeal/metatarsophalangeal joints causing pain 1
• Morning stiffness exceeding 30 minutes that improves with activity 1
• Female gender and advanced age increase likelihood of rheumatoid arthritis 1

Do not dismiss bilateral morning swelling as "just aging" without excluding inflammatory arthritis—early treatment within 6 weeks dramatically improves outcomes. 1

Essential Laboratory Workup for Inflammatory Arthritis

When inflammatory arthritis is suspected, obtain these tests immediately: 1

• Complete blood count
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
• Rheumatoid factor and anti-citrullinated protein antibodies
• Antinuclear antibodies
• Urinalysis
• Transaminases

Refer to rheumatology with 2+ swollen joints and morning stiffness >30 minutes—do not wait for complete diagnostic criteria to be met. 1

Specific Conditions to Consider

Psoriatic Arthritis with Dactylitis

"Sausage digit" appearance (dactylitis) with painful swollen joints in hands and feet indicates psoriatic arthritis. 1 Look specifically for:

• Distal interphalangeal joint involvement 1
• Morning stiffness pattern 1
• Associated skin psoriasis or nail changes 2

The diagnosis requires a 68/66 joint count including DIP joints of hands and feet. 1

Erythrodermic Psoriasis

Generalized erythematous patches and plaques with superficial exfoliation of palms and soles, accompanied by pitting edema of lower extremities, suggests erythrodermic psoriasis. 2 Toe swelling in this context is typically related to lower leg edema rather than true arthritis. 2

Erythromelalgia

Episodic burning pain with red, hot, swollen extremities triggered by heat or exercise indicates erythromelalgia. 1 Critical management point: Never recommend ice water immersion for relief—this causes tissue damage, ulceration, and "immersion foot" despite providing temporary symptom relief. 1

Lyme Disease (Acrodermatitis Chronica Atrophicans)

Swelling of hands and feet with bluish-red discoloration and doughy consistency, occurring months to years after initial infection, suggests late-stage Lyme disease. 2, 3 This manifestation:

• Occurs most often on extensor surfaces 2
• May be initially unilateral, later becoming bilateral 2
• Associated with peripheral neuropathy in two-thirds of patients 2
• Requires elevated B. burgdorferi antibody titer for diagnosis 3

Treatment consists of ceftriaxone 2g IV daily for 2-4 weeks, with complete symptom regression expected. 2, 3

Peripheral Arthropathy in Inflammatory Bowel Disease

Type I peripheral arthropathy affects large weight-bearing joints including ankles, knees, wrists, and sometimes elbows, presenting as acute, self-limiting, asymmetric arthritis in 4-17% of ulcerative colitis patients. 2 Diagnosis requires:

• Clinical finding of painful swollen joints (synovitis) 2
• Exclusion of osteoarthritis, rheumatoid arthritis, and connective tissue diseases 2
• Differentiation from arthralgia related to corticosteroid withdrawal 2

Treatment of underlying inflammatory bowel disease is normally effective in relieving peripheral arthritis symptoms. 2

Systemic Causes Requiring Urgent Evaluation

For bilateral swelling without inflammatory features, assess for: 1

• Heart failure: Check for jugular venous distension, peripheral edema, dyspnea
• Renal disease: Obtain urinalysis, creatinine, albumin levels
• Hepatic disease: Check transaminases, albumin, coagulation studies

Critical Pitfalls to Avoid

Do not attribute all bilateral swelling to systemic causes without examining individual joints for synovitis—inflammatory arthritis can present with generalized swelling. 1 Clinical examination remains the primary method for detecting synovitis; ultrasound or MRI can help in doubtful cases. 2

Distinguish unilateral from bilateral distribution immediately, as this fundamentally changes your diagnostic approach and urgency. 1 Unilateral suggests local causes (DVT, infection) requiring immediate imaging, while bilateral suggests systemic or inflammatory causes. 1

For any hot, swollen foot in a diabetic patient with neuropathy, always suspect active Charcot neuro-osteoarthropathy and initiate knee-high immobilization/offloading promptly while performing diagnostic studies. 2 Untreated Charcot presents high risk of fractures, dislocations, deformity, ulceration, and amputation. 2