What are the causes and treatments of hand pain?

Hand Pain: Causes and Treatment

Begin with plain radiographs as the mandatory first imaging study for all hand pain presentations, then proceed to ultrasound for soft tissue evaluation or MRI without contrast for suspected occult fractures, tendon injuries, or inflammatory arthritis. 1, 2

Common Causes of Hand Pain

Osteoarthritis

• Thumb carpometacarpal (CMC) joint arthritis affects approximately 33% of postmenopausal women radiographically, with 20% requiring treatment for pain and disability. 3
• Nodal, erosive, and post-traumatic variants exist, each requiring individualized assessment based on inflammation presence and structural severity. 1

Tendon Disorders

• Trigger finger affects up to 20% of adults with diabetes and 2% of the general population, characterized by abnormal resistance to smooth finger flexion/extension. 3
• De Quervain tenosynovitis involves extensor tendon swelling at the wrist, more common in women (median onset 40-59 years), with increased risk from frequent mobile phone use. 3
• Repetitive forceful thumb movements cause or aggravate stenosing tenosynovitis and CMC arthritis. 4

Nerve Compression

• Carpal tunnel syndrome presents with numbness/tingling in thumb, index, middle, and radial ring fingers, plus thumb opposition weakness when severe. 3
• The Durkan maneuver (firm digital pressure across carpal tunnel) is 64% sensitive and 83% specific for diagnosis. 3
• Electrodiagnostic testing is >80% sensitive and 95% specific when proximal compression or other neuropathies are suspected. 3

Inflammatory Arthritis

• Rheumatoid arthritis may begin with finger pain, requiring assessment for synovitis, joint effusion, and bone marrow edema. 1, 5
• MRI bone edema is a strong independent predictor of subsequent radiographic progression in early rheumatoid arthritis. 2

Infectious Causes

• Cellulitis, tendinitis, paronychia, felon, and infectious emboli generally require antibiotics with or without drainage. 5
• Certain infections mandate hand surgeon referral. 5

Vascular/Ischemic Causes

• These represent true emergencies requiring prompt intervention to preserve tissue viability. 5

Diagnostic Algorithm

Step 1: Initial Imaging

• Always begin with plain radiographs to detect fractures, joint malalignment, and bony abnormalities. 1, 2
• Never order MRI as the initial study—radiographs must come first. 2

Step 2: Advanced Imaging Selection

For acute trauma with negative/equivocal radiographs:

• MRI without IV contrast or ultrasound are equivalent first-line options for suspected tendon/ligament injury. 2
• For suspected occult fracture, repeat radiographs in 10-14 days, MRI without contrast, or CT without contrast are equivalent alternatives. 2
• Do not repeat radiographs earlier than 10-14 days—earlier imaging has high risk of missing radiographically occult fractures. 2

For chronic hand pain with normal or nonspecific radiographs:

• Ultrasound is recommended as the first imaging modality after radiographs for hand swelling with elevated inflammatory markers. 6
• Ultrasound was contributory to clinical assessment in 76% of patients referred from hand surgeons (67% without trauma history). 1, 2
• MRI without IV contrast is appropriate when ultrasound is inconclusive or deeper structures need evaluation. 2, 6

For inflammatory arthritis assessment:

• MRI is superior to clinical examination for detecting synovitis and should be considered for accurate assessment. 2
• MRI can detect inflammation predicting subsequent joint damage even in clinical remission. 2
• Adding IV contrast improves detection of tenosynovitis and distinguishes synovitis from joint effusion and ganglion cysts. 2

Treatment Algorithm

Non-Pharmacological Management (First-Line for All Patients)

Education and exercise are foundational:

• Joint protection education (avoiding adverse mechanical factors) plus exercise regimen (range of motion and strengthening) are recommended for all hand osteoarthritis patients. 1
• Local heat application (paraffin wax, hot pack) especially before exercise is beneficial. 1

Splinting and orthoses:

• Splints for thumb base osteoarthritis and orthoses to prevent/correct lateral angulation and flexion deformity are recommended. 1

Pharmacological Management

Step 1: Topical agents (preferred for mild-moderate pain, few affected joints):

• Topical NSAIDs and capsaicin are effective and safe first-line treatments for hand osteoarthritis. 1
• Local treatments are preferred over systemic treatments for mild-moderate pain. 1

Step 2: Oral analgesics:

• Paracetamol (up to 4 g/day) is the oral analgesic of first choice and preferred long-term oral analgesic due to efficacy and safety. 1

Step 3: Oral NSAIDs (for inadequate response to paracetamol):

• Use at the lowest effective dose for the shortest duration. 1
• Re-evaluate patient requirements and response periodically. 1
• In patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agent, or selective COX-2 inhibitor. 1
• In patients with increased cardiovascular risk, COX-2 inhibitors are contraindicated and non-selective NSAIDs should be used with caution. 1
• Naproxen has been shown comparable to aspirin and indomethacin for rheumatoid arthritis and osteoarthritis, but with less frequent/severe gastrointestinal and nervous system adverse effects. 7
• Naproxen causes statistically significantly less gastric bleeding and erosion than aspirin in blood loss studies. 7

Condition-Specific Treatments

Carpal tunnel syndrome:

• Splinting or steroid injection may temporarily relieve symptoms. 3
• Patients not responding to conservative therapies should undergo open or endoscopic carpal tunnel release for definitive treatment. 3

Trigger finger:

• Steroid injection is first-line therapy but less efficacious in insulin-dependent diabetes. 3
• Patients with diabetes and those with recurrent symptoms may benefit from early surgical release. 3

De Quervain tenosynovitis:

• Steroid injections relieve symptoms in approximately 72% of patients, particularly when combined with immobilization. 3
• Patients with recurrent symptoms may be considered for surgical release of the first dorsal extensor compartment. 3

Thumb CMC arthritis:

• Intra-articular injection of long-acting corticosteroid is effective for painful flares, especially trapeziometacarpal joint osteoarthritis. 1
• Nonsurgical interventions (immobilization, steroid injection, pain medication) relieve pain but do not alter disease progression. 3
• Surgery (interposition arthroplasty, osteotomy, or arthrodesis) should be considered in patients with marked pain/disability when conservative treatments have failed. 1, 3

Critical Pitfalls to Avoid

• Never dismiss unilateral hand swelling—it indicates obstruction requiring urgent duplex ultrasound to exclude upper extremity deep vein thrombosis. 8
• Do not order MRI for foreign body detection—CT or ultrasound are superior. 2
• Eliminate aggravating factors including improper posture, inadequate workplace ergonomics, and contributory habits (jaw/hand clenching). 9
• Recognize that vascular and ischemic causes represent true emergencies requiring prompt intervention. 5
• Consider that occupational and psychosocial factors are linked with symptom reporting and disability, playing important roles in pathogenesis and management of recalcitrant cases. 10
• Pain relief must be achieved before patients can follow through with rehabilitation efforts. 9