Hand Pain Algorithm

Done

Safety

Red Flags — Exclude Surgical & Serious Emergencies First

Always rule out infections, vascular compromise and malignancy before proceeding with routine assessment.

Septic arthritis / tenosynovitis Fusiform finger swelling, pain on passive extension, flexed resting posture, flexor sheath tenderness (Kanavel signs), or a hot swollen joint → Same-day ED / hand surgery — 999 only if shocked, septic, rapidly deteriorating or threatened limb. Do not delay transfer for community blood tests or imaging; aspiration, operative assessment and antibiotics follow the receiving hospital's pathway (allergy, local microbiology, bite/water exposure, immunosuppression)

Acute vascular compromise A cold, painful, pale/blue or mottled hand or digit with sensory or motor change — an absent radial pulse is not required for digital ischaemia → 999 / immediate ED — vascular or hand surgery. Document capillary refill, temperature, colour, sensation, motor function and Doppler signals if available; Allen's test must not delay referral

High-pressure injection injury Small puncture wound, history of grease gun / paint gun injury — a tiny puncture wound can hide extensive deep-tissue injury → Immediate specialist hand/plastic surgery assessment even if the wound looks benign. Do not explore or close the wound in primary care

Human bite / fight-bite Clenched-fist injury over a knuckle (MCP joint), or any bite that may have reached a joint, tendon or bone — a small wound can hide joint or tendon-sheath infection → Same-day ED / hand surgery even if the wound looks minor. Do not close the wound in primary care

Necrotising fasciitis Rapidly progressive pain/swelling, spreading erythema, disproportionate pain, systemic toxicity, bullae, skin anaesthesia, crepitus, skin discolouration or necrosis → 999 — immediate hospital surgical assessment and sepsis management

Fracture / dislocation Open fracture, dislocation, significant tendon injury, rotational deformity, neurovascular deficit or suspected intra-articular injury → Urgent same-day ED / hand trauma. Uncomplicated injuries → local minor-injury/hand-trauma pathway

Malignancy (bone / soft tissue) Persistent focal bone pain at rest, night pain, unexplained swelling or a pathological fracture (especially with known malignancy) → imaging and appropriate urgent referral. Suspected cancer · sarcoma (NICE NG12, updated April 2026): unexplained lump increasing in size → consider urgent direct-access ultrasound (within 2 weeks); suspected cancer pathway referral if ultrasound suggests soft-tissue sarcoma or is indeterminate with persistent clinical concern, or if X-ray suggests bone sarcoma. Do not biopsy or excise a possible sarcoma outside the specialist pathway

Acute gout / pseudogout Explosive onset, extreme tenderness, erythema — rule out septic joint before labelling inflammatory → Same-day ED / hand surgery if septic arthritis cannot be reasonably excluded or systemically unwell

Compartment syndrome Post-trauma or post-casting: severe pain out of proportion, pain on passive stretch, tense swelling, paraesthesia, escalating analgesic requirement. Pulselessness, pallor and paralysis are late signs — a palpable pulse does not exclude compartment syndrome → 999 / emergency surgical assessment

Septic arthritis rapidly destroys articular cartilage; high-pressure injection injuries carry a substantial amputation risk if specialist treatment is delayed. Compartment syndrome becomes irreversible if decompression is delayed. These diagnoses must be excluded before any reassurance is given.

Done

Diagnose

History & Diagnostic Framework — Characterise the Pain

Use structured history to differentiate mechanical, inflammatory, neuropathic, and vascular causes.

Onset & duration

Acute (<6 weeks) vs chronic (>3 months). Sudden onset favours fracture, gout, or vascular event. Insidious favours OA, RA, or carpal tunnel.

Character

Burning/tingling → neuropathic (carpal tunnel, ulnar neuropathy). Aching/stiffness → inflammatory. Sharp/mechanical → tendon, ligament, OA.

Morning stiffness

>30 min → inflammatory (RA, psoriatic). <30 min → OA. Night pain with relief on shaking hand → carpal tunnel syndrome (CTS).

Distribution

Thumb base → 1st CMC OA or de Quervain's. Radial 3½ digits → CTS. Little/ring fingers → ulnar neuropathy. MCP/PIP joints bilateral → RA.

Aggravating factors

Pinching/gripping → 1st CMC OA. Repetitive flexion/extension → tendinopathy, de Quervain's. Sleep → CTS.

Systemic features

Fever, weight loss, fatigue, rash, eye symptoms → systemic inflammatory disease. Check medication list (fluoroquinolones → tendon rupture).

Occupation / hobbies

Vibrating tools → vibration white finger / HAVS. Repetitive pinch grip → de Quervain's, trigger finger.

Past history

Psoriasis, IBD, gout history, diabetes (CTS), thyroid disease (CTS), previous trauma.

The anatomical distribution of pain is the single most useful diagnostic pointer in hand pain. History-directed examination is the core of assessment — a well-taken history will identify the correct diagnosis in most hand pain presentations without imaging. Morning stiffness duration reliably differentiates inflammatory from degenerative arthritis and changes the entire management pathway.

Done

Diagnose

Classification — Identify the Diagnostic Category

Hand pain diagnoses cluster into five categories — each drives a distinct treatment pathway.

Osteoarthritis

Heberden's nodes (DIP), Bouchard's nodes (PIP), 1st CMC squaring, crepitus. Diagnose typical hand OA clinically (age 45 or over, activity-related pain, no or brief morning stiffness). X-ray only if atypical, diagnostic uncertainty, trauma, marked deformity, suspected inflammatory/crystal arthritis, focal bone swelling or concern about malignancy. 1st CMC OA: thumb-base pain, reduced pinch strength, pain with opposition/abduction. Degenerative

Carpal Tunnel Syndrome

Tinel's, Phalen's, Durkan's tests. Nocturnal symptoms, thenar wasting in advanced cases. Typical CTS can be diagnosed clinically from nocturnal or activity-related median-distribution paraesthesia, with or without thenar weakness. Consider NCS if the diagnosis is uncertain, symptoms are atypical or severe, there is motor deficit/thenar wasting, an alternative neuropathy or cervical radiculopathy is possible, or surgery is being considered. Neuropathic

De Quervain's tenosynovitis

Pain at radial styloid, Finkelstein's test positive. Commonest in women aged 30–50, and in pregnancy and after childbirth. Tendon

Trigger finger

A1 pulley stenosis, painful clicking or locking of digit in flexion. Grade I–IV (Quinnell classification). Tendon

Rheumatoid arthritis

Bilateral MCP/PIP synovitis, sparing DIPs, ulnar deviation, early morning stiffness >30 min. 2010 ACR/EULAR criteria are classification criteria and do not confirm RA in primary care — diagnosis is rheumatologist-led. Inflammatory

Gout / pseudogout

Acute episodic. Gout: serum urate supports but does not confirm the diagnosis alone. CPPD (pseudogout): chondrocalcinosis on X-ray may support the diagnosis; definitive diagnosis is by calcium pyrophosphate crystals in synovial fluid. MTP1 or wrist/MCP. Crystal arthropathy

Dupuytren's contracture

Palmar cord, ring/little finger flexion contracture, nodules. Hueston tabletop test positive. Fibroproliferative

HAVS / Raynaud's

Vibrating tool exposure, episodic blanching/cyanosis with cold, Stockholm Workshop Scale. Vascular

Classification drives management entirely. Suspected RA (persistent synovitis) needs urgent rheumatology referral (NICE NG100) — without waiting for blood results — to prevent joint destruction. CTS with thenar wasting needs urgent surgical review. OA is managed in primary care with analgesia and physiotherapy. Correct categorisation avoids both under-treatment of inflammatory disease and over-investigation of benign mechanical conditions.

Done

Diagnose

Targeted Examination — Confirm the Working Diagnosis

Perform a focused hand examination based on the suspected diagnosis.

Inspection

Swelling pattern (fusiform = tenosynovitis; bony = OA nodes; soft = synovitis), deformity, skin changes, muscle wasting, nail pitting (psoriatic arthritis)

Tinel's test

Percuss carpal tunnel → tingling in median nerve distribution → supports CTS

Phalen's test

Wrist flexion >60 sec → symptoms reproduced → supports CTS

Finkelstein's test

Thumb enclosed in fist, ulnar deviation → pain over radial styloid → de Quervain's tenosynovitis

Grind test (1st CMC)

Axial compression + rotation of thumb metacarpal → pain/crepitus at base of thumb → 1st CMC OA

Grip & pinch strength

Compare bilaterally. Reduced grip → CTS, RA, tendon pathology. Use Jamar dynamometer if available

Trigger digit

Palpate A1 pulley (proximal palmar crease), reproduce triggering, assess passive extension range. Quinnell grade I–IV

Neurovascular

Document light touch and, where relevant, two-point discrimination compared with the opposite hand. Record objective sensory loss, motor weakness, thenar/intrinsic wasting and vascular findings (capillary refill, temperature, colour). Allen's test only for suspected arterial insufficiency — never delay emergency referral for it

Typical nocturnal median-distribution symptoms with supportive Tinel's/Phalen's findings justify empirical treatment without nerve conduction studies in typical presentations. The Finkelstein test supports (but does not alone confirm) de Quervain's and should be performed in all patients with radial-sided wrist/hand pain. Thenar wasting in CTS indicates chronic, severe compression — these patients need urgent orthopaedic review rather than splints alone.

Done

Diagnose

Investigations — Order Selectively, Interpret Accurately

Avoid blanket investigation. Target tests to the suspected diagnosis category.

Inflammatory markers

CRP, ESR, FBC — if inflammatory features. Elevated CRP + bilateral synovitis → urgent RA workup. Normal CRP/ESR does not exclude RA or other inflammatory arthritis — do not delay referral.

Immunology

RF + anti-CCP — if RA suspected. Anti-CCP is supportive rather than diagnostic; negative RF/anti-CCP does not exclude RA. Seropositive RA has worse prognosis. Do not use RF alone (false positives are common). Do not delay referral for results.

Urate

Serum urate — in suspected gout. Supports but does not confirm gout alone. If urate is below 360 μmol/L during a flare and suspicion remains high, repeat at least 2 weeks after the flare has settled. If the diagnosis remains uncertain, consider aspiration for crystals and culture, or ultrasound/DECT where available. Target <360 μmol/L on ULT.

Blood glucose / TFTs

HbA1c, TSH — only if clinically indicated in CTS (diabetes and hypothyroidism are relevant comorbidities, but treating them does not replace CTS-specific management)

X-ray hands

X-ray — for atypical OA or diagnostic uncertainty (not routine for typical hand OA), gout (rat-bite erosions), trauma, chondrocalcinosis (supports CPPD). Often normal in early RA.

Ultrasound

USS — guided injection planning, confirming tenosynovitis, trigger finger. Order if examination inconclusive. Rheumatology may perform in-clinic.

Nerve conduction

NCS — if the diagnosis is uncertain, symptoms are atypical or severe, there is motor deficit/thenar wasting, an alternative neuropathy or radiculopathy is possible, or surgery is being considered (follow the local surgical pathway). Not needed for empirical splinting trial. Refer to neurophysiology via the NHS e-Referral Service.

Do NOT routinely order

MRI hands (reserve for soft tissue masses, suspected avascular necrosis), ANA (low specificity in hand pain unless systemic features present)

Anti-CCP is more specific than RF, but both are supportive rather than diagnostic. NICE NG100 advises urgent referral for suspected persistent synovitis even if CRP/ESR, RF or anti-CCP are normal, as early DMARD therapy prevents irreversible joint damage. NCS for CTS should not delay empirical treatment — an initial nocturnal splinting trial is appropriate first-line. Over-investigating atypical hand pain drives unnecessary anxiety and imaging costs.

Done

Refer

Referral Criteria — Know When to Escalate

999 / emergency

Emergency Shocked, septic or rapidly deteriorating patient; threatened limb; necrotising fasciitis; compartment syndrome; acute limb or digital ischaemia

Same-day hospital / hand

Urgent Suspected septic arthritis, pyogenic flexor tenosynovitis, high-pressure injection injury, human bite / fight-bite injury, open fracture, dislocation or neurovascular compromise, suspected major flexor/extensor tendon injury. Do not delay transfer for community blood tests or imaging

Sarcoma

NICE NG12 NICE NG12 (updated April 2026): unexplained lump increasing in size → consider urgent direct-access ultrasound (within 2 weeks); ultrasound suggesting soft tissue sarcoma (or uncertain with persisting concern), or X-ray suggesting bone sarcoma → suspected cancer pathway referral. Do not biopsy or excise a possible sarcoma outside the specialist pathway. Persistent focal bone pain at rest, night pain, unexplained swelling or pathological fracture (especially with known malignancy) → imaging and appropriate urgent referral

Rheumatology urgent

Urgent Suspected persistent synovitis affecting the small joints of the hands or feet, or more than one joint, or symptoms present for 3 months or more before seeking advice — refer urgently even with normal CRP/ESR, RF or anti-CCP, and do not delay referral for blood results (NICE NG100); follow the local referral standard. Also: unexplained inflammatory polyarthritis, suspected vasculitis or connective-tissue disease

Orthopaedics routine

Routine CTS failing conservative treatment or with severe NCS abnormality (thenar wasting, objective motor weakness or severe/progressive sensory loss → urgent surgical assessment), de Quervain's failed steroid injection × 2, trigger finger grade III–IV, Dupuytren's contracture affecting function (Hueston test positive), 1st CMC OA failed conservative Rx

Occupational health

Routine HAVS — employer legal duty of care. Stockholm Workshop Scale grade, quantitative sensory testing, cold provocation test.

Physiotherapy

Self-refer / refer OA hands (therapeutic exercise tailored to the person), CTS mild–moderate (splinting + nerve gliding), post-fracture rehab, tendinopathy

Primary care manage

Typical hand OA, mild CTS without weakness/atrophy (splinting trial), uncomplicated de Quervain's, uncomplicated trigger finger, stable Dupuytren's without substantial functional impairment, gout once septic arthritis has been reasonably excluded (flare treatment + ULT planning)

NICE NG100 asks for urgent referral of suspected persistent synovitis, without waiting for blood results, because DMARDs started early improve long-term joint outcomes. CTS with thenar wasting represents permanent motor axon loss — surgical decompression can arrest but not reverse established atrophy. High-pressure injection injuries are frequently underestimated; the British Society for Surgery of the Hand recommends all such injuries be assessed in a specialist hand unit within 6 hours.

Done

Treat

Treatment Pathway — Condition-Specific Drug & Procedural Ladder

Match treatment to diagnosis. Three most common primary care conditions shown.

Hand OA (NICE NG226)

Step 1Exercise + topical NSAID — consider a topical NSAID per the local (e.g. Local) formulary and current SPC (NICE NG226: consider a topical NSAID for OA outside the knee). Do not routinely offer paracetamol or weak opioids (NG226). Review 4 weeks.

Step 2Consider an oral NSAID if a topical NSAID is ineffective or unsuitable — lowest effective dose for the shortest time (e.g. naproxen per local formulary) after individual GI, renal, hepatic and cardiovascular risk assessment; offer gastroprotection such as a PPI (NICE NG226). Review.

Step 3Intra-articular corticosteroid — consider in selected cases once the diagnosis is secure (NICE NG226), explaining that benefit is short-term. Drug, dose and any repeat per the locally approved hand-injection protocol, by a trained practitioner; discuss infection, skin/subcutaneous atrophy, tendon injury and transient hyperglycaemia. Refer if no response.

Step 4Refer orthopaedics — joint replacement / trapeziectomy for severe 1st CMC OA. Arthroplasty for severely affected DIP/PIP joints.

Carpal Tunnel Syndrome

Step 1Neutral-position wrist splint — worn at night as an initial trial (e.g. 6 weeks — not a fixed NICE duration). Consider relevant comorbidities (hypothyroidism, diabetes, pregnancy).

Step 2Corticosteroid injection — consider for short-term symptom relief where appropriate and where the practitioner is trained. Discuss recurrence and complications. Repeated injections should follow the local hand/MSK protocol and are not a substitute for surgical referral in progressive motor deficit or thenar wasting.

Step 3Surgical decompression — carpal tunnel release. Refer for surgical assessment (orthopaedics/plastics) if thenar wasting, objective motor weakness, severe/progressive sensory loss, severe NCS abnormality or failure of conservative treatment. Follow the local surgical pathway regarding NCS.

Gout — Acute Attack + Long-term ULT

AcuteNSAID, colchicine or a short course of oral corticosteroid (NICE NG219) once septic arthritis has been reasonably excluded — choose by renal/hepatic function, cardiovascular/GI risk, interactions and preference, with doses from the current local formulary/SPC. Colchicine has a narrow therapeutic index: serious toxicity with renal or hepatic impairment, elderly/frail patients, macrolides, ciclosporin, strong CYP3A4/P-glycoprotein inhibitors and some statin combinations.

PreventAllopurinol — start at least 2–4 weeks after the flare settles, or during a flare if flares are frequent (NICE NG219). Start low (dose per renal function, age, ethnicity, interacting drugs and local formulary/SPC) and use monthly serum urate to guide dose increases to target <360 μmol/L; consider <300 μmol/L in tophaceous/chronic gout or continued frequent flares. Discuss flare prophylaxis; if the patient chooses it, offer colchicine while titrating (NICE NG219). ULT is usually lifelong.

Next steps: see Carpal tunnel syndrome · Osteoarthritis · Gout · Rheumatoid arthritis

NICE NG226 (2022) puts exercise first and advises considering a topical NSAID for hand OA before an oral NSAID, which has more systemic risk; paracetamol and weak opioids are not routinely offered. NICE NG219 advises starting urate-lowering therapy at least 2–4 weeks after a flare has settled (earlier, even during a flare, if flares are frequent). Colchicine prophylaxis during ULT titration reduces flares. Steroid injections for CTS give short-term relief, and symptoms often recur.

Done

Lifestyle

Non-Pharmacological Interventions — Lifestyle is Treatment

Physiotherapy / hand therapy Refer to hand therapist for OA, CTS, post-injection, post-fracture. Splinting, nerve gliding, joint protection techniques. Exercise and hand therapy are core OA treatments in NICE NG226.

Joint protection Avoid high-stress grip/pinch activities. Adaptive equipment (jar openers, key turners). Ergonomic keyboard assessment for CTS/OA. OT referral for severe function loss.

Exercise — hand strengthening Gentle range-of-motion and strengthening exercises for OA (e.g., putty therapy). Therapeutic exercise tailored to the person's needs, with education and support (NICE NG226).

Weight management Maintain a healthy weight — weight management where appropriate may reduce gout risk and OA symptoms. Refer to Tier 3 weight management if BMI >35 with comorbidities.

Dietary advice (gout) Explain that lifestyle measures may reduce risk but do not replace urate-lowering therapy when indicated. NICE NG219: insufficient evidence that any specific diet prevents flares or lowers serum urate — follow a healthy, balanced diet and maintain a healthy weight.

Alcohol reduction (gout) Avoid excessive alcohol, particularly binge drinking; keep within ≤14 units/week with alcohol-free days.

Workplace modification HAVS — employer must reduce vibration exposure (Control of Vibration at Work Regs 2005). Anti-vibration gloves, tool rotation, regular breaks. Refer occupational health.

Heat / cold therapy Warm wax bath before activity (OA), ice massage after. Paraffin wax is a commonly used adjunct for hand OA symptom relief (not a specific NICE NG226 recommendation; exercise is the core treatment). Available via hand therapy department.

NICE NG226 places non-pharmacological treatment — particularly exercise and joint protection — before pharmacological treatment in the OA management hierarchy. For gout, NICE NG219 finds insufficient evidence that any specific diet prevents flares or lowers serum urate — lifestyle advice does not replace ULT when indicated. HAVS is a prescribed disease for Industrial Injuries Disablement Benefit, employers must report diagnosed cases in exposed workers under RIDDOR 2013, and the Control of Vibration at Work Regulations 2005 require employers to control exposure and provide health surveillance.

Done

Safety

Follow-Up, Monitoring & Safety-Netting

2 weeks

NSAID review based on risk and duration — consider renal function/BP after initiation or dose change in higher-risk patients (CKD, elderly). Assess response to steroid injection (CTS, de Quervain's, gout)

4–6 weeks

Review CTS splinting trial — if no improvement, proceed to steroid injection or refer. Review OA analgesia adequacy. Check gout acute episode resolved before commencing allopurinol.

3 months

During ULT titration: monthly serum urate (renal function as indicated; LFT/FBC only if indicated by local protocol or comorbidity), titrating to target <360 μmol/L. Review physiotherapy progress. RA disease activity (e.g. DAS28) is assessed in specialist care; DMARD monitoring follows the drug-specific shared-care protocol (e.g. RCOphth eye screening for hydroxychloroquine).

6 months

Long-term NSAIDs: reassess need and cardiovascular, renal and GI risk at regular risk-based intervals. OA function review — consider referral if progressive disability. Consider annual urate check once ULT stable.

Safety-net 999 / ED

999: rapidly spreading redness/swelling with severe pain or feeling very unwell (necrotising fasciitis), or a cold, pale, blue or mottled hand or digit with numbness or weakness, or severe, worsening pain with tight swelling after an injury or in a plaster cast (compartment syndrome). Same-day ED/hand unit: hot swollen joint, or a swollen, flexed, exquisitely tender finger (septic joint / flexor sheath infection), any grease/paint-gun injection injury, or a bite or punch-on-a-tooth wound over a knuckle

Safety-net same-day GP

Severe worsening pain, loss of hand function, new neurological symptoms (grip weakness, new numbness), systemic upset with joint symptoms

Re-refer if

RA not well-controlled on DMARDs (liaise with rheumatology), CTS recurrence after surgery, Dupuytren's recurrence, gout if the diagnosis is uncertain, ULT is contraindicated, not tolerated or ineffective, CKD stage 3b–5 or organ transplant (NICE NG219)

Allopurinol requires 3–6 months of careful dose titration with monitoring; the target urate of <360 μmol/L reduces gout flares. Long-term NSAIDs carry significant GI, cardiovascular and renal risks — regular risk-based review is needed. NICE NG100 monitoring for active RA (CRP and a composite score such as DAS28 monthly in specialist care until the treatment target is reached) ensure early identification of treatment failure and prompt DMARD switching.