What are the causes and management of sudden onset finger stiffness in an adult with no prior medical history?

Sudden Onset Finger Stiffness: Causes and Management

In an adult with sudden onset finger stiffness and no prior medical history, the most critical immediate considerations are acute inflammatory arthropathies (particularly erosive hand osteoarthritis, psoriatic arthritis, rheumatoid arthritis, or gout), acute trauma (including occult fractures or tendon injuries), and stroke with spasticity—each requiring distinct urgent management pathways.

Primary Differential Diagnosis

Inflammatory Arthropathies

Erosive Hand Osteoarthritis (HOA) presents with abrupt onset finger stiffness and should be strongly considered in adults over 40, particularly women. 1 Key diagnostic features include:

• Abrupt onset with marked pain and functional impairment, inflammatory symptoms (stiffness, soft tissue swelling, erythema, paresthesias), and mildly elevated CRP levels 1
• Targets DIP and PIP joints specifically, with only mild morning or inactivity stiffness (unlike inflammatory arthritis which causes prolonged morning stiffness) 1
• Can be confidently diagnosed clinically in adults over 40 with characteristic joint distribution and Heberden/Bouchard nodes 1

Other inflammatory conditions to exclude include:

• Psoriatic arthritis (may target DIPJs or affect just one ray) 1
• Rheumatoid arthritis (mainly targets MCPJs, PIPJs, wrists—not typically sudden DIP/PIP stiffness) 1
• Gout (may superimpose on pre-existing HOA) 1

Acute Traumatic Causes

Even without recalled trauma, occult injuries must be excluded:

• Jersey finger injuries (flexor digitorum profundus avulsion) require urgent hand surgery referral within 7-10 days, as delayed repair beyond 2-3 weeks significantly compromises outcomes and may necessitate tendon grafting 2
• Occult phalangeal fractures require three-view radiographs (PA, lateral, oblique) to detect displacement and articular involvement 3
• Post-traumatic stiffness from unrecognized injury can develop rapidly, with finger stiffness being one of the most functionally disabling complications 1

Neurological Causes

Acute stroke with spasticity must be considered in sudden onset stiffness:

• Poststroke spasticity affects 25-43% of patients over the first year and may have dystonic features with involuntary muscle activity and limb positioning 1
• Spasticity is correlated with activity limitations in hygiene, dressing, and pain, significantly reducing quality of life 1
• Early recognition is critical as untreated spasticity leads to contractures that restrict movement and cause pain 1

Immediate Management Algorithm

Step 1: Rapid Assessment for Red Flags

Obtain three-view hand radiographs immediately (PA, lateral, oblique with internally rotated oblique projection) to exclude fractures or dislocations 3

Assess for stroke symptoms: facial droop, arm weakness, speech difficulty, sudden onset neurological deficits 1

Evaluate joint distribution pattern:

• DIP/PIP involvement → Consider HOA or psoriatic arthritis 1
• MCP/PIP/wrist involvement → Consider rheumatoid arthritis 1
• Single ray involvement → Consider psoriatic arthritis or trauma 1

Step 2: Prevent Catastrophic Stiffness

Initiate active finger motion exercises immediately for all unaffected joints, regardless of suspected etiology. 1, 3 This is critical because:

• Finger stiffness can be very difficult to treat after it develops, requiring multiple therapy visits and possibly surgical intervention 1
• Finger motion does not adversely affect adequately stabilized fractures and provides significant impact on patient outcome 1
• Isolated finger stiffness causes 26-47% reduction in total active motion of adjacent digits through the quadriga phenomenon 4
• Overprotectiveness is present in 82% of patients with more finger stiffness than expected, regardless of primary pathology 5

Step 3: Specific Management Based on Etiology

For Inflammatory Arthropathy (HOA, Psoriatic, RA):

• Obtain inflammatory markers (CRP, ESR) and consider rheumatology referral 1
• Plain radiographs provide gold standard for morphological assessment of HOA 1
• Functional impairment in hand OA may be as severe as rheumatoid arthritis and should be carefully assessed with validated outcome measures 1

For Suspected Trauma:

• If jersey finger suspected: Immediate splinting in flexion and urgent hand surgery referral within 7-10 days 2
• If fracture confirmed: Buddy taping for non-displaced fractures with immediate active motion of unaffected joints 3
• Rigid splinting only when absolutely necessary (displaced fractures), as over-immobilization leads to unnecessary stiffness 3

For Stroke-Related Spasticity:

• Targeted botulinum toxin injection into localized upper limb muscles is recommended to reduce spasticity, improve range of motion, and improve dressing, hygiene, and limb positioning 1
• Oral antispasticity agents (tizanidine, dantrolene, oral baclofen) can be useful for generalized spastic dystonia but may result in dose-limiting sedation 1
• Avoid benzodiazepines due to deleterious effects on recovery and sedation 1
• Positioning, passive stretching, and range-of-motion exercises should be done several times daily 1

Critical Pitfalls to Avoid

Never immobilize fingers rigidly without clear indication, as this is the most common cause of iatrogenic stiffness 3, 6, 7

Do not delay hand surgery referral if tendon injury suspected—repair beyond 2-3 weeks requires tendon grafting with worse outcomes 2

Recognize that unremitting pain during follow-up requires reevaluation for complications such as complex regional pain syndrome or occult injury 1

Initiate physical therapy within 7 days if surgical release is performed—patients starting therapy after 7 days lost an average of 19° of motion versus 59° improvement when started within 7 days 8

Address maladaptive coping strategies early, as overprotectiveness is present in 82% of patients with finger stiffness and limits recovery regardless of primary pathology 5