Pain in the back of the hand

Pain in the Back of the Hand

Pain in the back of the hand is a common complaint encountered in general practice, orthopedics, rheumatology, and sports medicine. The dorsal surface of the hand comprises a complex structure of bones (metacarpals, carpals, and phalanges), joints, ligaments, tendons (notably the extensor tendons), nerves, and blood vessels. Pain in this area can be acute or chronic, localized or diffuse, and may arise from traumatic, degenerative, inflammatory, vascular, or neuropathic causes. Understanding the etiology, associated clinical features, diagnostic workup, and treatment strategies is crucial for appropriate management.

---

Causes of Pain in the Back of the Hand

1. Musculoskeletal Causes

   • Overuse injuries: Repetitive strain from typing, manual labor, or sports can lead to tendon irritation (extensor tendinopathy) or joint inflammation.

   • Arthritis: Osteoarthritis, particularly in the carpometacarpal (CMC) joints, and inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, gout) often manifest with pain, stiffness, and swelling in the dorsal hand.

   • Trauma and fractures: Direct blows, falls, or sports injuries may cause fractures of the metacarpals (e.g., “boxer’s fracture”), sprains, or ligament injuries.

   • De Quervain’s tenosynovitis: Though typically localized near the thumb, pain may radiate to the back of the hand.

2. Neurological Causes

   • Radial nerve entrapment: Compression of the superficial branch of the radial nerve can cause dorsal hand pain, numbness, or tingling.

   • Peripheral neuropathy: Conditions such as diabetes or vitamin deficiencies may present with burning or aching sensations in the hands.

3. Vascular Causes

   • Reduced circulation or Raynaud’s phenomenon may occasionally cause dorsal hand discomfort.

4. Systemic and Referred Causes

   • Pain can be referred from cervical spine pathology (e.g., cervical radiculopathy).

   • Systemic conditions such as lupus or other connective tissue disorders can also involve dorsal hand pain.

---

Symptoms Associated with Dorsal Hand Pain

• Localized tenderness over bones, joints, or tendons

• Swelling, redness, or warmth (inflammatory or infectious cause)

• Decreased grip strength or hand function

• Numbness, tingling, or burning (neuropathic component)

• Stiffness, especially in the morning (arthritis-related)

• Visible lumps or deformities (ganglion cysts, fractures, bony spurs)

---

Diagnosis

A thorough diagnosis involves:

• History: Onset, duration, nature of pain (sharp, dull, throbbing, burning), occupational/recreational risk factors, trauma history, and systemic symptoms.

• Physical Examination: Inspection for swelling, deformities, or skin changes; palpation for tenderness; range of motion testing; grip strength assessment; neurological testing for sensation and reflexes.

• Investigations:

  • X-rays for fractures or arthritis

  • MRI/ultrasound for soft tissue injuries (tendon or ligament pathology)

  • Blood tests (inflammatory markers, rheumatoid factor, uric acid) if systemic arthritis suspected

  • Nerve conduction studies for neuropathies

---

Treatment Options

Management of dorsal hand pain depends on the underlying cause and ranges from conservative therapy to surgical intervention.

1. Conservative/Non-Pharmacological Treatment

   • Rest and activity modification: Avoid repetitive stress activities.

   • Immobilization: Splints or braces for acute injuries or arthritis flare-ups.

   • Physical therapy: Strengthening, stretching, ergonomic education, and modalities such as ultrasound or heat/cold therapy.

   • Occupational therapy: Adaptive tools to reduce strain in daily activities.

2. Pharmacological Treatment

   • Analgesics:

     • Paracetamol (acetaminophen) 500–1000 mg every 6–8 hours (maximum 4 g/day).

   • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):

     • Ibuprofen 400–600 mg every 6–8 hours.

     • Naproxen 250–500 mg twice daily.

     • Diclofenac 50 mg three times daily.

   • Topical NSAIDs: Diclofenac gel applied to affected area.

   • Corticosteroid injections: For persistent arthritis, tendonitis, or ganglion cyst-related pain.

   • Disease-modifying antirheumatic drugs (DMARDs): Methotrexate, sulfasalazine, or biologics in confirmed rheumatoid or psoriatic arthritis (dosing individualized).

   • Neuropathic pain medications:

     • Gabapentin (starting dose 300 mg daily, titrated as needed).

     • Pregabalin (75–150 mg twice daily).

3. Surgical Treatment

   • Indicated in cases of:

     • Severe fractures or ligament injuries requiring fixation

     • Persistent or large ganglion cysts

     • Severe arthritis requiring joint fusion or replacement

     • Nerve entrapment syndromes unresponsive to conservative care

---

Precautions and Lifestyle Measures

• Maintain ergonomic work posture to reduce repetitive strain.

• Warm-up and stretch hands before sports or physical activity.

• Use supportive splints when performing repetitive tasks.

• Maintain good control of systemic diseases (diabetes, arthritis).

• Early medical consultation if pain is persistent, worsening, or associated with neurological deficits.

---

Drug Interactions and Contraindications

• NSAIDs: Contraindicated in peptic ulcer disease, renal impairment, or severe cardiovascular disease; interact with anticoagulants (e.g., warfarin), increasing bleeding risk.

• Corticosteroids: Risk of immunosuppression, osteoporosis; caution with long-term use.

• Gabapentinoids: May cause drowsiness, dizziness; interact with CNS depressants.

• DMARDs and biologics: Require monitoring for infections, liver toxicity, and hematological abnormalities.