What is the appropriate treatment for a patient presenting with sudden stiffness of the fingers?

Treatment of Sudden Finger Stiffness

For a patient presenting with sudden finger stiffness, initiate topical NSAIDs as first-line pharmacological treatment, combined with hand exercises and education on joint protection techniques, while determining the underlying cause to guide definitive management. 1

Initial Assessment and Diagnosis

The most common causes of sudden finger stiffness requiring immediate consideration include:

• Hand osteoarthritis (OA) - characterized by pain, stiffness, and decreased function, particularly affecting interphalangeal joints 1
• Trigger finger (flexor tenosynovitis) - presents with catching, locking, or stiffness of finger flexion 2, 3
• Inflammatory arthritis - may present with morning stiffness lasting >30 minutes 4

The distinction matters because trigger finger responds excellently to corticosteroid injection (90% success rate), while hand OA requires a different treatment algorithm 3.

First-Line Treatment Approach

Non-Pharmacological Management (Start Immediately)

• Education and training in ergonomic principles, pacing of activity, and use of assistive devices should be offered to every patient 1
• Hand exercises to improve function and muscle strength, as well as reduce pain, should be considered for every patient 1
• Thermal modalities - local application of heat (paraffin wax, hot pack) especially before exercise provides benefit 1
• Splinting - if thumb base involvement is present, orthoses should be provided for symptom relief with long-term use advocated 1

Pharmacological Management

Topical treatments are preferred over systemic treatments because of safety reasons. 1

• Topical NSAIDs are the first pharmacological topical treatment of choice (Level 1b evidence, Grade A recommendation) 1
• Topical capsaicin can be used as an alternative or adjunct 1
• Oral NSAIDs should be considered for a limited duration for relief of symptoms if topical therapy is insufficient 1
  • Use at the lowest effective dose and shortest duration 1
  • In patients ≥75 years, use topical rather than oral NSAIDs 1
  • Cardiovascular, gastrointestinal, and renal risks must be assessed before prescribing 1

When Conservative Treatment Fails

For Trigger Finger Specifically

If the presentation is consistent with trigger finger (catching, locking sensation):

• Corticosteroid injection (triamcinolone 20 mg or methylprednisolone) is highly effective, with 61% resolution after single injection and nearly 90% success with repeat injections if needed 3
• This is far superior to NSAID injection, which shows no benefit over glucocorticoid injection 2

For Hand Osteoarthritis

If conservative measures fail after adequate trial (typically 4-12 weeks):

• Intra-articular glucocorticoid injections may be considered for painful interphalangeal joints, though not generally recommended for hand OA 1
• Chondroitin sulfate may be used for pain relief and improvement in functioning (Level 1b evidence) 1
• Surgery should be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective 1

Critical Pitfalls to Avoid

• Do not use conventional or biological disease-modifying antirheumatic drugs for hand OA - they are ineffective 1
• Do not prescribe opioid analgesics for hand conditions - they are conditionally recommended against 1
• Do not use intra-articular therapies routinely for hand OA (except painful interphalangeal joints in select cases) 1
• Avoid prolonged NSAID use - evidence supports only short-duration therapy (7-14 days for acute symptoms) 1
• Do not overlook cardiovascular risk when prescribing NSAIDs - coxibs are contraindicated in patients with increased cardiovascular risk 1

Follow-Up Strategy

• Monitor response to treatment at 2-4 weeks initially 1
• Long-term follow-up should be adapted to individual patient needs rather than following rigid protocols 1
• Re-evaluate if symptoms persist beyond 4 weeks and consider alternative diagnoses or specialist referral 1