History and examination of the adult with hand pain

INTRODUCTION — The multiple functions of the hand are extremely important for daily life, and any deviation from normal function can lead to disability. It is important for the clinician to recognize the various traumatic and nontraumatic disorders that can lead to hand pain and dysfunction.

The history and evaluation of the adult with hand pain will be reviewed here. The differential diagnosis is lengthy, and this review will focus on some of the more common diagnoses. Thumb and wrist pain, as well as fractures and infections of the hand, are discussed in detail separately. (See "Evaluation of the patient with thumb pain" and "Evaluation of the adult with acute wrist pain" and "Overview of finger, hand, and wrist fractures" and "Overview of hand infections".)

ANATOMY — Understanding the anatomy of the hand is necessary to identify the source of pain and limit the differential diagnosis. The bones of the hand include five metacarpals, two phalanges in the thumb, and three phalanges in each of the other fingers (figure 1). The joints of each finger include the metacarpophalangeal (MCP), the proximal interphalangeal (PIP), and the distal interphalangeal (DIP); the thumb has only one interphalangeal (IP) joint.

Extrinsic muscles of the hand originate in the forearm and elbow area. The extrinsic flexor tendons for each digit travel in a fibro-osseous tunnel between the distal metacarpal and the DIP joint. The superficialis tendon attaches to the middle phalanges, and the profundus tendon attaches to the base of the distal phalanges. The extrinsic extensor tendons pass over the dorsum of the wrist in six separate tunnels that are labeled as compartments.

Intrinsic muscles of the hand include the thenar, hypothenar, interosseous, and lumbricals. The thenar muscles control adduction, abduction, and opposition of the thumb; other thumb movements are controlled by forearm muscles. The interosseous and lumbrical muscles collectively flex the MCP joints while extending the IP joints, and the interosseous muscles also abduct and adduct the fingers.

The ulnar nerve provides the motor supply to the intrinsic hand muscles (except the two radial lumbricals and the thenar muscles) (figure 2); it also provides sensation to the fifth digit and one-half of the fourth digit (figure 3). The median nerve is the motor supply to many of the forearm flexor muscles as well as the thenar muscles and the two radial lumbricals in the hand (figure 4); it is the sensory supply to the palmar aspect of the first three fingers and the radial half of the fourth digit (figure 5). The radial nerve is the motor supply to many of the extensor muscles in the forearm as well as the sensory supply to the dorsum of the hand (figure 6).

COMMON CAUSES OF HAND PAIN — Common causes of hand pain are presented below.

Osteoarthritis — Osteoarthritis (OA) commonly affects the joints in the hand, most often in patients over 40 years of age. The most common symptom associated with hand OA is joint pain, which is typically exacerbated by activity and relieved by rest. (See "Clinical manifestations and diagnosis of osteoarthritis", section on 'Hand'.)

Osteoarthritic enlargements of the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints are commonly observed and are referred to as Heberden’s and Bouchard’s nodes, respectively (image 1). The first carpometacarpal joint is another common joint affected by OA.

Inflammatory arthritis — Rheumatoid arthritis (RA) and psoriatic arthritis are the two most common forms of inflammatory arthritis affecting the hands. The onset of inflammatory changes is usually insidious, with the predominant symptoms being pain, stiffness, and fusiform swelling of many joints. The hands are a common site of early involvement, particularly the metacarpophalangeal (MCP) and PIP joints. Bilateral symmetric involvement is a characteristic feature of RA, although this may be less apparent early in the disease. Patients with RA or psoriatic arthritis are also likely to have other joint involvement as well as systemic symptoms. (See "Clinical manifestations of rheumatoid arthritis", section on 'Hands' and "Clinical manifestations and diagnosis of psoriatic arthritis", section on 'Patterns of arthritis'.)

Gout and calcium pyrophosphate deposition (CPPD) disease can also affect any of the joints of the hands and wrists. Acute attacks of the microcrystalline diseases are usually characterized by severe pain, redness, warmth, and swelling of the joint. (See "Clinical manifestations and diagnosis of gout" and "Clinical manifestations and diagnosis of calcium pyrophosphate crystal deposition (CPPD) disease".)

Trigger finger (stenosing flexor tenosynovitis) — Trigger finger is one of the most common causes of hand pain in adults. Patients with trigger finger initially describe snapping, catching, or locking of one or more fingers during flexion of the affected digit. These symptoms often become progressively severe and painful. Trigger finger is due to constriction of the first annular (A1) pulley (figure 7), which overlies the MCP joint (figure 1). The flexor tendon catches when it attempts to glide through a relatively stenotic sheath, resulting in an inability to smoothly flex or extend the finger. The patient will usually identify the pain in the palm, while the triggering is noted in the finger, but a minority of patients will identify the pain at the PIP joint level. Frequently a patient will demonstrate the locking phenomenon when describing the condition. (See "Trigger finger (stenosing flexor tenosynovitis)".)

Ganglion cyst — A ganglion cyst is a benign, fluid-filled swelling overlying a joint or tendon sheath. Pain may or may not accompany the cyst. Although they are most commonly found on the wrist, they can also arise from the digital flexor tendon sheath, most commonly arising from the A1 pulley of the finger (figure 7). A small mass may be palpable in the flexion crease at the base of the finger, which is occasionally mildly tender. Active and passive motion of the digits are unimpaired.

A digital mucous (or mucinous) cyst is a ganglion cyst that forms over the dorsal side of the DIP joint (picture 1). These occur most commonly in the fifth to seventh decades and are usually associated with an underlying OA. The diagnosis is usually based upon the physical examination, and advanced imaging is rarely needed. (See "Ganglion cysts of the wrist and hand".)

Dupuytren's contracture — Dupuytren’s contracture is characterized by progressive fibrosis of the palmar fascia which can lead to contractures that draw one or more fingers into flexion at the MCP joint, PIP joint, or both (picture 2). It occurs primarily in White males over the age of 50 and appears to have a pronounced genetic predisposition.

The incidence of Dupuytren’s contracture is two to five times higher among workers exposed to repetitive handling tasks or vibration compared with those not exposed such trauma [1]. It also occurs more frequently in patients with diabetes mellitus [2,3] and may be associated with cigarette smoking and alcohol abuse [4,5].

Patients initially may notice nodular lesions on the palmar fascia, which may or may not be painful, usually affecting the fourth and fifth digits, with puckering and tethering of the overlying skin. When patients report pain in that area, the pain will typically resolve over a few months. Over time, thickening of the palmar fascia can lead to loss of full extension. The patient often rubs the palm and fingers in an attempt to straighten them out as the condition is described. (See "Dupuytren's contracture".)

Carpal tunnel syndrome — Carpal tunnel syndrome (CTS) is the most common nerve entrapment disorder, caused by increased pressure and consequent compression of the median nerve within the carpal tunnel. Median nerve compression is most commonly idiopathic but may result from diseases that take up space or cause swelling within the carpal tunnel, from stenosis of the tunnel by bone enlargement or altered anatomy after fracture or wrist arthritis.(See "Carpal tunnel syndrome: Pathophysiology and risk factors".)

The clinical features of CTS are variable but usually include pain and paresthesia in the thumb, the first two fingers, and the radial half of the ring finger (the distribution of the median nerve). Patients often complain of pain that wakes them up at night. Paresthesia and sensory deficits may involve the entire palm area in some cases due to variable nerve innervation or patient perception. In addition, pain, but not paresthesia, may radiate proximally into the forearm and occasionally to the shoulder. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis".)

Tumors — Benign bone tumors such as simple bone cysts and enchondromas are relatively common in the phalanges [6]. These are typically asymptomatic and are often diagnosed as an incidental finding on routine hand radiographs, particularly in young adults. When there is pain associated with a bone lesion in the hand, further workup and treatment, typically including specialty referral, is indicated [7]. (See "Nonmalignant bone lesions in children and adolescents".)

Other soft tissue tumors can also occur in the hand and digits such as tenosynovial giant cell tumors, lipomas, and glomus tumors [6]. (See "Ganglion cysts of the wrist and hand", section on 'Tenosynovial giant cell tumor' and "Overview of benign lesions of the skin", section on 'Lipoma' and "Overview of benign lesions of the skin", section on 'Glomus tumor'.)

Infection — The most common infection in the hand is a paronychia [6]. Patients usually present with an exquisitely tender swelling at the base or side of the fingernail. Other superficial infections seen in the hand include cellulitis, lymphangitis, pulp space infections, herpetic whitlow, and abscesses. Deep infections also can occur and typically require surgical management. A detailed discussion of hand infections is presented elsewhere. (See "Overview of hand infections".)

Mallet finger — A mallet finger refers to a loss of terminal extension of the DIP joint of the digit. It can be classified as either bony or soft tissue depending on where the disruption of the extensor mechanism of the finger occurred. The injury occurs due to acute forceful passive flexion of the DIP joint during concomitant active joint extension. These can occur with surprisingly little trauma or force involved. The finger deformity results from stretching or complete rupture of the tendon, or from rupture with an avulsion fracture of the distal phalanx. Patients describe the obvious deformity plus pain (which can be remarkably little) over the DIP joint as well as an inability to actively extend the joint (image 2 and picture 3 and picture 4). (See "Extensor tendon injury of the distal interphalangeal joint (mallet finger)".)

Trauma — The hand is susceptible to a number of traumatic injuries. Traumatic injuries to the hand are discussed in detail in separate topics. (See "Distal phalanx fractures" and "Middle phalanx fractures" and "Proximal phalanx fractures" and "Overview of finger, hand, and wrist fractures" and "Flexor tendon injury of the distal interphalangeal joint (jersey finger)" and "Evaluation and management of fingertip injuries" and "Severe upper extremity injury in the adult patient".)

EVALUATION — The evaluation of the adult with hand pain includes a detailed history and physical examination. The history and physical examination findings determine whether additional studies should be performed.

History — The history should include inquiries about hand dominance, onset of symptoms, antecedent injury/trauma or occupational activities, and duration and specific localization of symptoms. A description of the intensity and quality of the pain should also be obtained. Specific activities that either aggravate or alleviate symptoms should be addressed. Timing of the pain, whether in the morning, at the end of the day, or in the middle of the night, should be noted. Patients with hand pain from rheumatoid arthritis (RA) tend to have symptoms of pain and stiffness first thing in the morning. Pain that wakes a patient up at night might be from carpal tunnel syndrome. Pain in the joints at the end of a work day might be from osteoarthritis (OA). Whether the patient has any functional impairment is also relevant. Finally, it is important to review comorbid conditions that may contribute to or confound the diagnosis. As an example, a history of psoriasis may be helpful in sorting out the cause of distal interphalangeal (DIP) pain or swelling.

Physical examination — The physical examination of the hand should include inspection, palpation, range of motion, strength testing, and relevant special tests. A screening neurovascular assessment of the involved extremity should also be performed.

Inspection — The palmar and dorsal surfaces of the hands are inspected for obvious deformity, masses, skin discoloration, joint swelling, bony enlargement, contracture, and the presence of cysts or nodules (picture 5). The bulk of the hand muscles must also be observed, particularly for atrophy at the thenar eminence suggesting carpal tunnel syndrome (CTS), or of the intrinsic muscles of the first web space and between the metacarpals suggesting ulnar nerve dysfunction.

Palpation — Palpation can help localize a specific region with an underlying pathologic process. All the metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints, and DIP joints should be assessed for swelling or bony enlargement. Palpation of the tendons in the palm should be evaluated for tender nodules or thickening.

●Palpation of the DIP and PIP joints – The DIP and PIP joints are palpated to assess for tenderness, swelling, and bony enlargement (picture 6 and picture 7). As an example, tenderness and bony enlargement along the margins of multiple DIP and PIP joints, rather than synovial thickening or swelling, is the key physical finding in patients with hand OA. By contrast, compressible synovial thickening and swelling of multiple PIP and MCP joints is a physical finding much more suggestive of RA or another inflammatory arthritis.

●Palpation of the MCP joints – The individual MCP joints are palpated for swelling. They may also be gently squeezed to determine involvement of these joints. Pain with MCP squeeze is common in patients with RA.

●Palpation of the palmar fascia for nodularity – Palpation of the palmar fascia is used to assess for nodules or for tendon like bands limiting finger extension (referred to as cords) (picture 8). (See "Dupuytren's contracture".)

●Palpation of the flexor tendon – The flexor tendon is palpated for localized tenderness, particularly at the A1 pulley area, and for cyst formation (picture 9). The majority of flexor tendon cysts associated with trigger finger (stenosing tenosynovitis) occur within one centimeter of the flexor creases at the base of the fingers.

Range of motion — Range of motion is assessed by opening and closing the hand. Testing the overall function of the hand can help distinguish a focal musculoskeletal process affecting one joint or finger from systemic rheumatologic conditions, determine the number of affected joints, and assess the severity of the condition.

●Opening and closing the hands – Asking the patient to open and close the hand assesses the full and smooth movement of the small joints of the hand comparing the individual fingers. Inability to flex or extend across a joint or malalignment with motion may suggest an underlying tendon disruption, displacement, or joint subluxation or dislocation. Arthritis from any cause, trigger finger, and Dupuytren’s contracture can all affect hand movement. Angular deformities (as opposed to loss of flexion/extension) are almost always related to trauma or an arthritic processes.

Strength testing — Strength testing can include resisted motion in both flexion and extension across each joint.

●Resisted flexion and extension – Resisted flexion and extension of an individual joint (eg, MCP or PIP) while maintaining the other digits extended will aid in the evaluation of the function of the tendons. A complete inability to flex across one joint is more likely related to a mechanical failure of one tendon (ie, mallet finger with extensor tendon rupture) but may also occur from neurologic causes, particularly if multiple tendons in a characteristic distribution are involved.

●Grip strength – Gripping provides an objective measurement of the integrity and strength of the intrinsic muscles of the hand and of the forearm muscles. Grip strength can be crudely estimated by manual gripping of the examiner’s fingers (picture 10). Physical measurement using a dynamometer is more accurate and reproducible (picture 11). The differential diagnosis of reduced grip strength is quite broad and includes essentially all conditions producing pain in the hand. Therefore, reduced grip strength is only useful as a global measure of function. It is only diagnostically useful in conjunction with the rest of the clinical picture.

Special tests — Additional maneuvers can be performed depending on the initial history and physical examination findings. We describe a few common maneuvers below. Additional maneuvers can be found in separate topic reviews.

●Confirming the presence of finger triggering – The mechanical function of the affected finger is assessed in patients with suspected trigger finger to document the presence of triggering (picture 12). Locking or clicking with movement should be demonstrated when the patient is asked to fully open and close the hand. The locking does not have to occur with every repetition. (See "Trigger finger (stenosing flexor tenosynovitis)", section on 'Diagnosis'.)

●Cyst transillumination – The presence of some ganglion cysts of the hand and wrist can be strongly supported by using a small penlight or laser pointer. The light is seen to travel through the cyst, illuminating it in a distinctly different way than the surrounding tissue. (See "Ganglion cysts of the wrist and hand", section on 'Diagnosis'.)

●Provocative maneuvers for carpal tunnel syndrome – Provocative maneuvers for carpal tunnel syndrome include the Phalen (picture 13), Tinel (picture 14), and manual carpal compression. While these tests can be helpful when interpreted in the appropriate clinical context, their sensitivity and specificity is moderate at best. These maneuvers are described in detail separately. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Provocative maneuvers'.)

ADDITIONAL STUDIES — Depending on the history and physical examination findings, additional studies may help identify or confirm the underlying diagnosis. Patients with persistent or chronic symptoms despite these measures or those who have systemic symptoms or more severe initial symptoms such as palpable swelling, nodularity, synovial thickening, or early joint contracture should have a more comprehensive examination for specific conditions.

Imaging — Plain film radiography of the hand is generally indicated in patients with joint pain and inflammation, a history of trauma, or the presence of a deformity. As examples, the diagnosis of osteoarthritis (OA) of the hands rarely requires plain radiographs (image 3), but is indicated when the patient presents with evidence of joint swelling or synovial thickening suggestive of the presence of an inflammatory arthritis (see "Clinical manifestations of rheumatoid arthritis", section on 'Plain film radiography'). In the case of a mallet finger deformity, plain radiographs may confirm avulsion fracture of the distal phalanx (image 2). (See "Extensor tendon injury of the distal interphalangeal joint (mallet finger)", section on 'Diagnostic imaging'.)

If further detail of the bony anatomy is required, computed tomography (CT) may be considered. If detailed imaging of soft tissue anatomy is required, advanced imaging with ultrasonography or magnetic resonance imaging (MRI) is indicated. However, advanced imaging is rarely needed for the vast majority of patients and typically only helpful in confirming a diagnosis based on a thorough history and physical examination.

Injections and aspirations — Aspirations and injections of the hand joints can be both diagnostic and therapeutic. Like most joints, aspiration can yield important diagnostic information; however, given their small size, there are some technical limitations to joint aspiration in the fingers and hand, and the volume of fluid obtained is likely to be very small. If joint infection is suspected, the synovial fluid should be sent for Gram stain, cell count, and culture. Diagnoses such as gout and pseudogout can be confirmed by crystal analysis with polarized microscopy. (See "Synovial fluid analysis" and "Ganglion cysts of the wrist and hand", section on 'Ganglion cyst aspiration'.)

Ganglia and retinacular cysts can sometimes be treated with simple aspiration with varying degrees of recurrence (see "Ganglion cysts of the wrist and hand" and "Ganglion cysts of the wrist and hand", section on 'Ganglion cyst aspiration'). Patients with persistent or severe symptoms from trigger finger may benefit for a local glucocorticoid injection. (See "Trigger finger (stenosing flexor tenosynovitis)", section on 'Glucocorticoid injection'.)

Laboratory testing — Acute phase reactants, particularly the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), are relatively nonspecific tests that should be limited to patients with suspected inflammatory arthritis or infection. Many patients with inflammatory arthritis will have elevated levels, although such findings lack diagnostic specificity. Acute phase reactants may also be elevated in the setting of concurrent non-rheumatologic inflammatory conditions. Normal results of acute phase reactants may occur early during inflammatory rheumatic disease, especially if only a modest degree of inflammation is present. (See "Acute phase reactants".)

In patients with suspected rheumatoid arthritis (RA), rheumatoid factor (RF) and anti-citrullinated peptide (CCP) antibody should be obtained.

Electrodiagnostic testing — Neurodiagnostic testing includes nerve conduction studies and electromyography which should be obtained in selected patients with symptoms or signs suggestive of a neurologic disorder of the hand or upper extremity. This testing is most commonly indicated in patients with a failure to respond to initial treatment measures (eg, splinting for carpal tunnel syndrome) or for severe disease (eg, evidence of atrophy). (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis", section on 'Electrodiagnostic testing'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Hand pain (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Anatomy – Understanding the anatomy of the hand is necessary to identify the source of pain and limit the differential diagnosis. This includes an understanding of the bones of the hand (figure 1), the extrinsic and intrinsic muscles of the hand, and the motor and sensory supply from the ulnar, median, and radial nerves. (See 'Anatomy' above.)

●Common causes of hand pain – The differential diagnosis of hand pain is lengthy, but some common causes include osteoarthritis (OA), inflammatory arthritis, trigger finger (stenosing flexor tenosynovitis), ganglion cysts, Dupuytren’s contracture, carpal tunnel syndrome, tumors, infections, mallet finger, and a variety of other traumatic injuries. (See 'Common causes of hand pain' above.)

●Evaluation – The evaluation of the adult with hand pain includes a detailed history and physical examination. The history and physical examination findings determine whether additional studies should be performed. (See 'Evaluation' above.)

•History – The history should include inquiries about hand dominance, onset of symptoms, antecedent injury/trauma or occupational activities, and duration and specific localization of symptoms. A description of the intensity and quality of the pain should also be obtained. Specific activities that either aggravate or alleviate symptoms should be addressed. Whether the patient has any functional impairment is also relevant. Finally, it is important to review comorbid conditions that may contribute to or confound the diagnosis. (See 'History' above.)

•Physical examination – The physical examination of the hand should include inspection (picture 5), palpation, range of motion, strength testing, and any relevant special tests. A screening neurovascular assessment of the involved extremity should also be performed. (See 'Physical examination' above.)

•Additional studies – Depending on the history and physical examination findings, additional studies may help identify or confirm the underlying diagnosis. These include imaging studies, joint injections and aspirations, laboratory testing, and electrodiagnostic testing. (See 'Additional studies' above.)