I have persistent pain and swelling in my left hand; what should I do?

Persistent Pain and Swelling in Left Hand: Diagnostic and Management Approach

Start with plain radiographs of the left hand (3 views: posteroanterior, lateral, and oblique) as the essential first imaging study, followed by targeted clinical assessment to differentiate between inflammatory arthritis, tendon pathology, and infection. 1, 2

Immediate Clinical Assessment

Determine the exact location and character of symptoms:

• Identify whether pain is localized to specific joints (suggesting arthritis) versus along tendon paths (suggesting tenosynovitis) 3
• Assess for morning stiffness duration—prolonged morning stiffness suggests inflammatory arthritis 2, 3
• Evaluate whether pain worsens with gripping/twisting motions, which strongly indicates tendon involvement like De Quervain's tenosynovitis 3, 4
• Check for radial-sided pain (De Quervain's or scaphoid pathology) versus ulnar-sided pain (TFCC or lunotriquetral issues) 3

Examine for inflammatory versus mechanical features:

• Look for soft tissue swelling, joint tenderness, and reduced range of motion 1, 2
• Critically, the absence of redness makes infection highly unlikely 2
• Note that inflammatory hand osteoarthritis can present with significant swelling and pain even when CRP, ESR, and CBC are completely normal 2
• Assess for psoriatic features: nail dystrophy, dactylitis, asymmetric joint involvement, or personal/family history of psoriasis 2

Diagnostic Imaging Strategy

Plain radiographs are the mandatory first imaging study and may be the only examination needed to establish diagnosis 1, 2:

• Standard 3-view hand radiographs assess alignment, joint spaces, erosions, soft tissue swelling, and chronic fractures 1
• In many cases, radiographs alone confirm the clinically suspected diagnosis 1

If radiographs show mild arthritis but symptoms persist:

• Ultrasound is the preferred next imaging modality to detect synovitis, joint effusion, tenosynovitis, or erosions not visible on plain films 2, 5
• Ultrasound contributes to clinical assessment in 76% of patients and is more readily available, less expensive, and allows dynamic assessment 5

MRI without IV contrast is reserved for:

• Cases where ultrasound is inconclusive or diagnosis remains unclear 2, 5
• Detection of bone marrow edema, early erosive changes, or deeper structural pathology 2, 3
• MRI is not first-line for nonspecific hand pain 5

Laboratory Testing

Order basic inflammatory and autoimmune panel if symptoms persist beyond initial assessment:

• CRP, ESR, CBC, and uric acid (though normal values do not exclude inflammatory arthritis) 2
• Consider ANA, RF, and anti-CCP if inflammatory arthritis suspected 1
• Normal uric acid excludes gout 2
• Remember that erosive hand osteoarthritis commonly presents with normal or only mildly elevated CRP 2

Initial Management

Begin treatment immediately while diagnostic workup proceeds:

First-line pharmacological therapy:

• Start paracetamol (acetaminophen) up to 4 grams daily as first-choice oral analgesic 2
• Apply topical NSAIDs directly to affected hand joints—these are preferred over systemic treatments for localized involvement 1, 2
• If paracetamol inadequate, add oral NSAIDs (such as ibuprofen) at lowest effective dose for shortest duration 2, 6
• For GI risk patients, use NSAIDs with gastroprotection or selective COX-2 inhibitors 2

Non-pharmacological interventions (initiate concurrently):

• Prescribe range-of-motion and strengthening exercises 1, 2
• Provide education on joint protection techniques 2
• Consider splints or orthoses, particularly if thumb base involved 2
• Apply local heat (paraffin wax, hot packs) before exercises 2

Second-Line and Advanced Interventions

For inadequate response to initial therapy:

• Intra-articular corticosteroid injection for painful interphalangeal joints or thumb base osteoarthritis 1, 2
• Consider early rheumatology referral if joint swelling (synovitis) persists beyond 4 weeks 1

For suspected inflammatory arthritis with Grade 2 severity (moderate pain with inflammation limiting instrumental activities):

• Initiate prednisone 10-20 mg daily for 4-6 weeks if NSAIDs inadequate 1
• Slow taper over 4-6 weeks according to response 1
• If unable to reduce corticosteroid below 10 mg daily after 3 months, consider disease-modifying antirheumatic drugs 1

Critical Pitfalls to Avoid

Do not assume normal inflammatory markers exclude inflammatory arthritis—erosive hand osteoarthritis commonly presents with normal or only mildly elevated CRP 2

Normal radiographs do not exclude significant pathology in hand pain, particularly tendon disorders, early inflammatory arthritis, or soft tissue pathology 3, 5

Early recognition is critical to avoid erosive joint damage in inflammatory arthritis—corticosteroid-sparing agents should be considered earlier than with other conditions due to prolonged treatment requirements 1

Functional impairment in hand osteoarthritis can be as severe as rheumatoid arthritis and requires careful assessment 2

Follow-Up Strategy

Re-evaluate response to treatment periodically:

• Monitor for development of erosive changes indicating worse prognosis 2
• Patients with inflammatory arthritis require serial rheumatologic examinations including inflammatory markers every 4-6 weeks after treatment initiation 1
• Adjust management based on treatment response and disease progression 2