How to win over wrist and hand pain

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Hand and wrist pain is often due to arthritis.

Sources of pain in this region include joints, tendons, ligaments, bones, and nerves.

The wrist consists of the interaction among the ulna, radius, eight carpal (wrist) bones and the metacarpal bones of the hand. The metacarpals articulate with the phalanges (finger bones). Each finger (except for the thumb which has two), has three phalanges, proximal, middle, and distal. As one might imagine, this is a complex area.

The wrist is a common area of involvement for rheumatoid arthritis involvement. Patients will complain of pain and reduced grip strength. Objective findings demonstrate swelling and tenderness as well as reduced range of motion. Treatment involves better systemic management of the arthritis as well as splinting and glucocorticoid injection.

Crystal induced forms of arthritis such as gout and pseudogout also affect the wrist. The treatment is intra-articular steroid injection and at least with gout, better systemic control of the disease.

A common cause of localized swelling in the wrist is a ganglion cyst. These are benign and should be treated only if symptomatic.

Inflammatory forms of arthritis such as rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, gout, pseudogout, and even inflammatory erosive osteoarthritis may cause significant symptoms in the hands. Patients complain of morning stiffness, pain, and swelling. Examination shows evidence of inflammation. The inflammation may involve just the joints or may also involve the tendons. The distribution of swelling sometimes helps with diagnosis. For instance patients may present with bony swelling involving the last row of joints distal interphalangeal joints). These bony swellings are called Heberden’s nodes and suggest osteoarthritis. Treatment consists of anti inflammatory medication, splinting, and glucocorticoid injection. Paraffin baths are soothing aids.

On occasion, arthroscopic intervention is helpful for both diagnosis as well as treatment.

Occupational and physical therapy is another beneficial modality.

Osteoarthritis at the base of the thumb can be particularly painful. Multiple treatments including anti inflammatory drugs, splinting, injection, arthroscopy, and open surgery are employed depending on the level of involvement.

Treatment depends on diagnosis. Sometimes, local measures such as injection with glucocorticoid, splinting, thermal modalities (heat or ice), and topical agents like Blue Relief may be effective.

Trauma can cause fracture, dislocation, or damage to the ligaments, often requiring the intervention of a hand surgeon.

Vascular problems can also cause hand pain. For instance, patients with Raynaud’s phenomenon will have blanching of the fingers. This condition is due to involuntary spasm of the arteries in the hands. Raynaud’s can be a sign of underlying diseases such as systemic lupus erythematosus or progressive systemic sclerosis (scleroderma).

Another problem that rarely develops is reflex sympathetic dystrophy. This occurs after trauma and causes severe pain, skin changes, sweating, and color changes in the affected limb.

Tendinitis is a common problem in the wrist and hand. Inflammatory arthritis can be associated with significant tendon problems in rheumatoid arthritis. Psoriatic arthritis typically causes severe involvement of the finger tendons. Fingers can become so swollen they look like sausages. Treatment will involve systemic medicines as well as injection with glucocorticoid. Needle tenotomy with autologous tissue grafting is a minimally invasive procedure using a small needle with ultrasound guidance. This often prevents the need for surgery.

Repetitive motion along with grasping, pushing, pulling, and tugging can lead to tendonitis. Examples of activities that can do this are gardening and woodworking.

Tendonitis in the hands can cause the finger to “catch” or “lock.” This condition is called trigger finger. Management usually requires injection with glucocorticoid.

Tendinitis affecting the tendons that permit extension of the thumb can be particularly painful. This is called DeQuervain’s tenosynovitis. The treatment is injection of the affected tendon sheath with glucocorticoid and splinting.

Nerve compression can also cause discomfort in the hands. Three major nerves innervate the hand. They are the median nerve, radial nerve, and ulnar nerve.

Median nerve compression is responsible for carpal tunnel syndrome. Patients typically will have numbness and tingling in the thumb, index, middle, and part of the fourth finger. Patients will often shake their hands or drape them over the

side of the bed at night to get relief. Examination will show the presence of a positive Tinel’s sign (reproduction of symptoms elicited by tapping on the carpal tunnel). Some common causes of carpal tunnel syndrome include repetitive motion, pregnancy, arthritis, thyroid disease. Diagnosis is confirmed with nerve conduction testing.

Treatment will involve the use of splints, vitamin B 6, glucocorticoid injection, and sometimes surgery. A newer method of percutaneous ultrasound guided release is minimally invasive and requires only local anesthetic. Contact the Arthritis Treatment Center for more information.

Radial nerve entrapment at the wrist also can occur. Patients will sometimes have numbness on the top of the hand and will show weakness of wrist extension. They may have “wrist drop” (inability to extend the hand).

Ulnar nerve entrapment at the wrist will present with numbness of the fourth and fifth finger. If muscles are involved, the patient will have a “claw hand.”

Treatment for both radial nerve as well as ulnar nerve entrapment will depend on the severity. Milder cases will respond to splinting or injection or to a new procedure called ultrasound guided hydrodissection. More severe cases may require surgery.

Infections in the hands can be quite painful and debilitating. Surgical intervention is often required.

Laboratory testing is dependent on history and physical evaluation.

X-rays are not that helpful unless fracture is suspected. Magnetic resonance imaging is very useful in evaluating arthritis conditions. Diagnostic ultrasound is also helpful.

Patients with end stage arthritis often will find relief with joint replacement surgery.

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