What could cause severe pain, limited flexion and extension, and palpable nodules in my fingers that prevent me from fully opening and closing my hands or gripping a utensil, and how should I manage it?

Severe Hand Pain with Nodules and Inability to Grip: Hand Osteoarthritis

You most likely have hand osteoarthritis, and the knots in your fingers are Heberden's nodes (at the fingertips) and/or Bouchard's nodes (at the middle knuckles)—these bony nodules are the hallmark of this condition and explain why you cannot fully open or close your hands. 1, 2

Why This Is Hand Osteoarthritis

The presence of palpable nodules ("knots") in your fingers combined with severe pain and inability to fully flex or extend your hands is pathognomonic for hand osteoarthritis, not rheumatoid arthritis or other inflammatory conditions. 2

• Heberden's nodes (bony enlargements at the fingertips) and Bouchard's nodes (at the middle finger joints) are essentially absent in rheumatoid arthritis and strongly indicate osteoarthritis 2
• These nodules are associated with underlying osteophyte formation (bone spurs) with an odds ratio of 5.15, meaning they reflect actual bony changes rather than soft tissue inflammation 1, 2
• Your functional impairment—inability to hold utensils and needing to scoop food with fingers—can be as severe as rheumatoid arthritis, so this needs aggressive management 1

Immediate Treatment Plan

First-Line Non-Pharmacological Interventions

Start with assistive devices immediately to help you eat and perform daily activities while pursuing other treatments. 1, 3

• Obtain adaptive utensils with built-up handles that require less grip strength—occupational therapy can provide these 1, 3
• Use joint protection techniques: avoid pinching motions, use larger joints when possible, and distribute force across multiple joints 3
• Apply thermal modalities (warm water soaks or paraffin baths) for 15-20 minutes before meals to reduce stiffness and pain 3

First-Line Pharmacological Treatment

Apply topical NSAIDs (like diclofenac gel) to the affected finger joints 3-4 times daily—this is the preferred first-choice medication over oral pain relievers. 1, 3

• Topical NSAIDs have superior safety compared to oral medications, especially if you're over 75 years old 3
• If topical NSAIDs provide insufficient relief after 1-2 weeks, add acetaminophen up to 4 grams daily (1000mg four times daily) as it has the best efficacy-to-safety ratio for oral analgesics 3
• Avoid oral NSAIDs for prolonged use, especially if you have cardiovascular risk factors or are elderly 3

Orthoses and Splinting

Use resting splints for your fingers, particularly if your thumb base is involved, to reduce pain and improve function. 1, 3

• Splints should be worn during activities that provoke pain and at night 1
• Custom-fitted splints from occupational therapy are preferable to over-the-counter options 1

Exercise Therapy

Begin gentle range-of-motion exercises once acute pain is controlled—this prevents further stiffness and contracture. 1

• Perform finger flexion and extension exercises 2-3 times daily, working within pain tolerance 1
• Grip-strengthening exercises should be added gradually as pain improves 1

When to Consider Injections

If specific finger joints remain severely painful despite topical treatment, consider intra-articular corticosteroid injections for those individual joints. 1, 3

• Injections are particularly useful for painful interphalangeal joints (the joints where your nodules are located) 1
• These provide temporary relief for acute flares but are not recommended as routine treatment 1

When to Consider Surgery

Surgery (joint fusion or replacement) should be considered if you have persistent severe disability preventing self-care despite 3-6 months of conservative treatment. 3, 4

• Your inability to feed yourself properly meets the threshold for considering surgical intervention 3
• Surgical options include arthrodesis (joint fusion) or arthroplasty (joint replacement) depending on which joints are most affected 3
• Surgery is safe and effective when conservative treatments fail 4

Critical Follow-Up

You need formal assessment within 1-2 weeks to evaluate your functional status using validated measures and adjust treatment. 1

• Your functional impairment should be monitored with validated tools like the Health Assessment Questionnaire or Cochin scale 1
• Reassessment at 6 weeks is essential to determine if you're responding to conservative management or need escalation to injections or surgical consultation 1

Common Pitfalls to Avoid

• Do not dismiss this as "just arthritis"—your functional impairment is severe enough to warrant aggressive multimodal treatment 1
• Do not use oral NSAIDs as first-line treatment when topical options are safer and equally effective for hand osteoarthritis 1, 3
• Do not delay occupational therapy referral—assistive devices can immediately improve your quality of life while other treatments take effect 1, 3
• Recognize that hand osteoarthritis can have variable disease course; some patients develop erosive osteoarthritis with worse long-term outcomes requiring earlier surgical intervention 1