How should I evaluate and manage hand pain?

Evaluation and Management of Hand Pain

Begin with plain radiographs (3 views: posteroanterior, lateral, and oblique) as your initial imaging study for any chronic hand or wrist pain, as this establishes the diagnosis in most cases and guides all subsequent management decisions. 1

Initial Clinical Assessment

Key Physical Examination Findings to Identify

• Joint distribution pattern: DIP and PIP joints plus thumb base suggest osteoarthritis; MCP joints and wrists indicate rheumatoid arthritis; asymmetric single-ray involvement points to psoriatic arthritis 2
• Nerve compression signs: Perform Tinel's and Phalen's tests for carpal tunnel syndrome, though interpret marginally positive Finkelstein tests cautiously as they may not reliably indicate De Quervain's disease 3, 4
• Tendon pathology indicators: Dorsal wrist pain worsening with flexion suggests extensor tendon involvement rather than isolated first-compartment pathology 4
• Visible deformities: Heberden nodes, joint swelling distribution, and muscle tenderness or trigger points 3
• Functional testing: Task-specific reproduction of symptoms and range of motion assessment 3

Critical Diagnostic Pitfall

Do not rely on a single clinical or radiographic feature—diagnosis requires combining multiple elements including age, gender, joint distribution, examination findings, and imaging changes. 2 Hand osteoarthritis commonly coexists with CPPD, gout, or rheumatoid arthritis, requiring evaluation for additional inflammatory conditions when atypical features appear 2

Imaging Algorithm

Initial Imaging (All Patients)

• Plain radiographs are mandatory first: Standard 3-view series (posteroanterior, lateral, oblique) assesses alignment, ulnar variance, joint spaces, impaction syndromes, static instability, fractures, soft tissue mineralization, erosions, and swelling 1
• Radiographs alone establish diagnosis in cases of arthritis, fracture complications, infection, bone tumors, and static wrist instability 4
• Lateral view is particularly critical for demonstrating malalignments and soft-tissue swelling 4

Advanced Imaging Selection (Based on Clinical Suspicion After Normal/Nonspecific Radiographs)

For suspected tendon injury, tenosynovitis, or tendon pathology:

• Ultrasound is the preferred next study if symptoms persist beyond 2 weeks—it detects tenosynovitis, tendinopathy, and synovitis while guiding therapeutic injections 1, 4
• Ultrasound is more cost-effective than MRI and can delineate specific tendons involved (abductor pollicis longus, extensor pollicis brevis, extensor carpi radialis, extensor carpi ulnaris) 4
• MRI without IV contrast is an equivalent alternative to ultrasound for tendon pathology 1

For suspected carpal tunnel syndrome:

• Either ultrasound or MRI without IV contrast is appropriate 1
• Ultrasound can measure median nerve size, a validated diagnostic technique 4

For chronic wrist pain with normal/nonspecific radiographs:

• MRI without IV contrast is usually appropriate as it accurately depicts bone marrow, articular cartilage, ligaments, TFCC, synovium, tendons, and neurovascular structures 1, 4
• Add IV contrast when inflammatory arthritis is suspected to identify active synovitis, inflammatory tenosynovitis, and bone marrow edema (osteitis), which predicts rheumatoid arthritis progression 4

For specific anatomic concerns:

• CT without IV contrast for suspected distal radioulnar joint subluxation (obtain both wrists in supination and pronation) 4
• Ultrasound for extra-articular soft tissues like ganglion cysts 4

Imaging to Avoid

Do not order bone scan, CT with contrast, CT arthrography, MR arthrography, or radiographic arthrography as initial studies—there is no supporting evidence for these modalities in chronic hand pain evaluation 1

Do not order MRI directly from the emergency department unless there is specific concern for occult fracture or infection; ultrasound is the appropriate next step 4

Laboratory Testing (When Inflammatory Conditions Suspected)

• ESR and CRP for diagnosis and prognosis of undifferentiated peripheral inflammatory arthritis 4
• Rheumatoid factor and anti-citrullinated protein antibodies as these predict rheumatoid arthritis diagnosis 4, 2
• Antinuclear antibody testing if connective tissue disease is suspected 4
• HLA-B27 when spondyloarthropathies are considered 4
• Joint aspiration and synovial fluid analysis when joint effusion is present 4
• Complete biochemical profile, creatine kinase, and renal function to identify systemic causes 3

Management Algorithm

Conservative Treatment (First-Line for All Patients)

• Education and ergonomic training: Joint protection techniques, activity pacing, proper workstation setup, and assistive device use 3, 4, 2
• Exercise regimen: Range of motion and strengthening exercises to improve function and reduce pain 3, 4, 2
• Topical NSAIDs are the first pharmacological choice due to superior safety profile over systemic medications for mild-to-moderate pain 3, 2
• Splinting/orthotics if pain impedes functioning 4

Condition-Specific Interventions

For osteoarthritis:

• Acetaminophen, NSAIDs, physical activity, and exercise 4
• Hyaluronic acid injections provide substantial pain relief and may increase functionality, though more studies are needed 5
• Corticosteroid injections are controversial for mechanical osteoarthritis 5

For inflammatory conditions (rheumatoid arthritis, De Quervain's tenosynovitis, gout):

• Corticosteroid injections provide significant pain relief and increased functionality 5
• Ultrasound guidance increases injection efficacy 5
• Note: CS injections do not change disease course in rheumatoid arthritis (unlike DMARDs) 5

For carpal tunnel syndrome:

• Corticosteroid injections provide temporary relief and serve as valuable bridge therapy to surgery when conservative treatment fails 5
• Ultrasound guidance provides significant improvement 5
• Severe cases still require surgery 5

For stenosing tenosynovitis (trigger finger):

• Corticosteroid injections with ultrasound guidance are effective 5
• Inflammatory background is associated with decreased effect 5

For focal dystonia:

• Botulinum toxin injections are indicated 3

For Raynaud's phenomenon:

• Botulinum toxin injections show encouraging results, but more studies needed for safety and efficacy determination 5

Referral Indications

Neurology referral:

• Suspected focal dystonia, progressive weakness, or signs of motor neuron disease 3

Rheumatology referral:

• Suspected inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis) 3
• Prolonged morning stiffness with symmetrical involvement 2

Hand surgery referral:

• Severe structural abnormalities, persistent ganglion cysts, or severe thumb base osteoarthritis 3
• Refractory pain after failed conservative treatment and injection therapy 5
• Infectious causes requiring drainage (felon, certain tendinitis cases) 6
• Vascular and ischemic causes (true emergencies requiring prompt intervention) 6