What is the best treatment approach for a patient with moderate arthritis in the Proximal Interphalangeal Joint (PIPJ) and Distal Interphalangeal Joint (DIPJ)?

Treatment of Moderate Arthritis in PIPJ and DIPJ

For moderate arthritis affecting the proximal and distal interphalangeal joints, initiate topical NSAIDs (such as diclofenac gel) as first-line pharmacological treatment combined with hand exercises and education on joint protection, reserving surgery for patients with structural abnormalities who fail conservative management.

Initial Conservative Management

Patient Education and Joint Protection

• Provide education on ergonomic principles, activity pacing, and use of assistive devices to every patient, as this foundational approach improves self-management and has demonstrated efficacy 1, 2
• Teach patients to avoid repetitive gripping, pinching motions, and activities that stress the affected joints 1

Exercise Therapy

• Prescribe exercises specifically designed to improve joint function, muscle strength, and reduce pain 1
• Exercise regimens for interphalangeal joints should focus on range of motion and strengthening of intrinsic hand muscles 1, 2
• Emphasize that benefits are not sustained when patients stop exercising, requiring ongoing adherence 2
• Small but beneficial effects on pain, function, joint stiffness, and grip strength have been demonstrated in multiple trials 1, 2

Orthotic Management

• Consider orthoses for symptom relief, particularly for DIPJ involvement, with long-term use advocated 1
• Custom-fitted splints may provide better outcomes than off-the-shelf options for specific joint involvement 1

Pharmacological Interventions

First-Line Topical Treatment

• Apply topical NSAIDs (diclofenac gel) as the preferred initial pharmacological treatment due to favorable safety profile 1, 2
• Topical diclofenac shows small improvements in pain and function after 8 weeks compared to placebo, with similar pain relief to oral NSAIDs but significantly fewer gastrointestinal side effects 1, 2

Oral Analgesics

• Use oral NSAIDs (such as naproxen) for limited duration when topical treatments are insufficient 1, 3
• Naproxen has been shown to be comparable to aspirin and indomethacin in controlling disease activity measures, but with less frequent and severe gastrointestinal and nervous system adverse effects 3
• In patients with osteoarthritis, naproxen reduces joint pain or tenderness and increases range of motion 3

Alternative Oral Agents

• Consider chondroitin sulfate for pain relief and improvement in functioning, though evidence quality is moderate 1

Interventional Options

Intra-articular Injections

• Intra-articular glucocorticoid injections should not generally be used in hand OA, but may be considered in patients with painful interphalangeal joints experiencing acute flares 1
• The evidence for injections in PIPJ and DIPJ is limited compared to thumb base involvement 1

Surgical Intervention

Indications for Surgery

• Consider surgery for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain 1
• For interphalangeal OA, arthrodesis or arthroplasty should be considered 1

Surgical Options

• Arthrodesis: Remains the most common surgical intervention for DIPJ arthritis, providing reliable pain relief and joint stability 4, 5
• Arthrodesis of the DIPJ is an accepted procedure to treat osteoarthritis, instability, and joint deformity 5
• Arthroplasty: DIPJ arthroplasty may be a viable alternative to arthrodesis in select patients, providing high patient satisfaction (97.7%), improvements in range of motion (from 24° to 36°), and complete pain relief 4
• Arthroplasty preserves some joint motion, which may be advantageous for grip strength compared to arthrodesis 4

Treatment Algorithm

1. Weeks 0-12: Initiate topical NSAIDs, hand exercises, and patient education 1, 2
2. If inadequate response at 12 weeks: Add oral NSAIDs for limited duration and consider orthoses 1
3. If severe pain persists: Consider intra-articular glucocorticoid injection for acute flares 1
4. If symptoms remain severe after 3 months of appropriate conservative treatment: Escalate to surgical consultation 1, 2

Treatments to Avoid

• Do not use conventional or biological disease-modifying antirheumatic drugs for hand OA, as they have not demonstrated efficacy 1
• Do not rely on acetaminophen alone, as its efficacy is limited compared to NSAIDs 2
• Avoid viscosupplementation injections in interphalangeal joints, as evidence does not support their use 1

Common Pitfalls

• Do not prescribe oral NSAIDs without assessing cardiovascular, gastrointestinal, and renal risk factors, particularly in elderly patients 2
• Do not continue conservative management indefinitely without reassessment; if symptoms remain severe after 3 months, escalate treatment 2
• Recognize that exercise benefits require ongoing adherence and are not sustained when patients stop 2

Long-Term Management

• Adapt long-term follow-up to the patient's individual needs, monitoring for progression of structural changes and functional decline 1
• Reassess treatment efficacy at regular intervals, typically every 3-6 months 1