Osteoarthritis and inflammatory arthritis can both make the hands ache, stiffen and swell, but they are different conditions with different causes and very different treatment. Osteoarthritis most often affects the joints nearest the fingertips and the base of the thumb, produces hard, bony swelling, and causes stiffness that usually eases fairly quickly once the hands start moving. Inflammatory arthritis, such as rheumatoid arthritis, more often affects the knuckles and middle finger joints, usually in the same joints on both hands, produces soft, puffy swelling, and causes morning stiffness that commonly lasts an hour or more.
Telling them apart matters. Osteoarthritis changes slowly, and a great deal can be done to relieve it, from splints and exercises to injections and surgery. Inflammatory arthritis can damage joints within months if it is not treated, and the National Institute for Health and Care Excellence (NICE), the independent body that reviews the evidence and issues national clinical guidance for the NHS, recommends that treatment starts as early as possible, ideally within three months of persistent symptoms beginning.¹ No single feature decides which condition is present, but together the pattern of joints, the type of swelling and the length of morning stiffness usually point clearly one way. This guide explains those differences, what can be done for each condition, and when hand pain needs to be assessed promptly.
Each finger has three joints. The knuckle, where the finger meets the hand, is the metacarpophalangeal (MCP) joint. The middle joint of the finger is the proximal interphalangeal (PIP) joint, and the joint nearest the fingertip is the distal interphalangeal (DIP) joint. The thumb has two joints along its length, a knuckle and a tip joint.
Further back, each finger and the thumb also has a joint where its long hand bone (the metacarpal) meets the small bones of the wrist. These are the carpometacarpal (CMC) joints. Of these, the CMC joint at the base of the thumb is the one most likely to become painful. Across the whole hand, the fingertip joints are the most common site of osteoarthritis, and the base of the thumb is the second most common.²
Inside every joint, the ends of the bones are covered with smooth cartilage, and the joint is enclosed by a thin lining called the synovium, which produces the fluid that keeps the joint moving easily. Osteoarthritis and inflammatory arthritis start in different layers, and that difference explains almost every clue described below.
In osteoarthritis, the problem starts at the joint surface. The cartilage gradually thins, and the bone underneath responds by thickening and forming small bony outgrowths at the edges of the joint. These outgrowths produce the hard, knobbly lumps that many people notice on their fingers. Because the problem is mainly mechanical, pain tends to come with use and settle with rest, and stiffness after rest usually eases fairly quickly once the joint starts moving.⁴
In inflammatory arthritis, the problem starts in the lining. The white blood cells, which normally fight infection, turn against the body’s own tissues, in what are called autoimmune conditions. In inflammatory arthritis, these white cells attack the synovium, the lining of the joint. The lining becomes inflamed and produces excess fluid, which is why the joints become painful and swollen. The swelling feels soft and puffy rather than bony. Inflammation builds up overnight while the hands are still, which is why morning stiffness lasts a long time. If it is not controlled, the inflamed lining can damage the cartilage and bone, which is why early treatment matters so much.³
Osteoarthritis most commonly affects the fingertip (DIP) joints, followed by the base of the thumb and then the middle (PIP) joints.² It can affect both hands, but it is often uneven, with one hand or one joint worse than the others.
Inflammatory arthritis such as rheumatoid arthritis more often affects the joints closer to the hand, the knuckles (MCP) and middle finger joints (PIP), together with the wrists. A characteristic feature is symmetry: the same joints tend to be affected on both hands at the same time. The fingertip joints are usually spared.³ Psoriatic arthritis, which can occur in people with psoriasis of the skin or nails, is an exception: it can affect the fingertip joints and sometimes swells an entire finger.
Osteoarthritis produces hard swelling that feels like bone, because it is bone. Bony lumps at the fingertip joints are called Heberden’s nodes, and at the middle finger joints, Bouchard’s nodes. They can be tender, warm and slightly red while they are forming, and then often settle into painless lumps.⁴
Inflammatory swelling feels soft, warm and spongy, often across several neighbouring joints, and can make rings feel tight within a few weeks.
In osteoarthritis, stiffness on waking or after rest usually eases fairly quickly once the hands start moving. In inflammatory arthritis, morning stiffness commonly lasts an hour or more.³ This is a useful pointer, and worth noticing, but it is indicative rather than conclusive: it is the overall pattern, not the stiffness alone, that points to the diagnosis.
Osteoarthritis usually develops over months to years, often with flare-ups lasting days or weeks. Inflammatory arthritis more often develops over weeks. A single joint that becomes hot, red, swollen and extremely painful within hours is different again: joint infection and gout need to be considered, and that needs same-day assessment.
Fingertip joints are the most common site of hand osteoarthritis. In a study that assessed photographs of the hands of more than 6,300 adults, the fingertip joints were most commonly affected, followed by the base of the thumb and then the middle finger joints. Osteoarthritis at the base of the thumb was particularly common in women, and its frequency rose throughout life.²
What an X-ray shows is a poor guide to how much a hand hurts. In the Rotterdam Study, most people over 55 had some osteoarthritis visible on a hand X-ray: 67% of women and 55% of men. Yet the link between the X-ray appearance and hand pain was weak.⁵ Many people with arthritis on an X-ray have little pain, and many people with painful hands have only mild X-ray changes.
Treatment for inflammatory arthritis should start early, whatever the blood tests show. NICE recommends urgent specialist referral for persistent joint swelling of uncertain cause when the small joints of the hands are affected, even if inflammation markers and rheumatoid blood tests are normal, and recommends that treatment begins as early as possible, ideally within three months of persistent symptoms starting.¹
A great deal can be done for osteoarthritis of the hand, and treatment is usually built up in steps.⁴
Many people also find that warming the hands in the morning, for example in a bowl of warm water, makes early stiffness easier to work through.
For people who need to wear a splint over the long term, conventional plastic splints can be bulky and conspicuous. iiS Health provides silver splints made by the Dutch company We Design Silversplints. Each splint is custom-made in silver, so it looks like a piece of jewellery rather than a medical device, and can be worn every day without looking out of place. They are fitted by Miriam Parkinson, iiS Health’s hand therapist.
Inflammatory arthritis is treated by rheumatology teams with medicines that calm the immune response and protect the joints from damage. Because early treatment makes such a difference, the most useful thing a person with soft, swollen knuckles and long morning stiffness can do is to see their GP promptly rather than trying splints or supplements first.¹
Book a routine appointment with a GP or hand specialist if aching joints are making everyday tasks such as opening jars, writing or doing up buttons difficult, if pain is disturbing sleep, or if self-management has not helped after several weeks.
Book an urgent appointment, within days, if there is soft swelling of several finger joints or knuckles, if morning stiffness lasts an hour or more, or if the same joints are affected on both hands.¹
Seek same-day medical help if a single joint becomes hot, red, swollen and very painful over a few hours, especially with a fever or feeling generally unwell. NHS 111 can direct urgent care when the right service is unclear, and 999 should be called in an emergency.
Tingling, numbness, or a finger that clicks and locks are not arthritis symptoms and need a different assessment; these are covered in the related articles below.
The assessment begins with the history: which joints hurt, whether both hands are affected in the same way, how long morning stiffness lasts, how quickly symptoms developed, whether anyone in the family has arthritis or psoriasis, and how the hands are coping with daily tasks. The examination then looks at each joint in turn, feeling whether the swelling is hard and bony or soft and spongy, checking movement and grip, and looking at the skin and nails for signs of psoriasis.
X-rays help confirm osteoarthritis and plan treatment, particularly when surgery is being considered. Where inflammatory arthritis is possible, blood tests such as rheumatoid factor, anti-CCP antibodies and markers of inflammation are helpful, but they guide rather than decide: a normal result does not rule out inflammatory arthritis and should not delay referral.¹ Ultrasound can show active inflammation in the joint lining before it is obvious on examination.
“Nothing can be done for arthritis in the hands.”
This is the most common misconception, and it is not true. Splints, hand therapy, anti-inflammatory gels and injections help many people. Where these are not enough, painful fingertip joints can be fused, knuckle and middle finger joints can be replaced, and the base of the thumb can be treated with a trapeziectomy or a joint replacement. Most people with painful hand arthritis have several options.⁴
“A normal blood test means it cannot be inflammatory arthritis.”
Normal blood tests do not rule out inflammatory arthritis. Some people have what is called seronegative arthritis, in which the blood tests do not support the diagnosis but the inflammation in the joints is real. This is why persistent soft swelling of the hand joints should be assessed promptly, whatever the blood results show.¹ ³
“Bony lumps on the fingers mean the arthritis is severe.”
Heberden’s and Bouchard’s nodes are a normal feature of hand osteoarthritis. They can be sore while they form and then often become painless. How a hand looks, and how its X-ray looks, are poor guides to how much it hurts or how well it works.⁴ ⁵
“Cracking knuckles causes arthritis.”
Cracking the knuckles does not cause arthritis. A study comparing people with and without hand osteoarthritis found that those who had cracked their knuckles for years were no more likely to have arthritis in those joints, however often they had done it.⁶
Are there any supplements I can take to help with arthritis pain?
Glucosamine and chondroitin are the supplements most often tried. There is no firm evidence that they help: some people find they make a real difference to their joint pain, while others notice no difference at all. Reviews of the trials have not found that they cause more side effects than a dummy tablet,⁷ so they are reasonable to try, but they are not usually prescribed and would need to be bought. Anyone taking warfarin or other blood-thinning medicines should check with a pharmacist before starting glucosamine.
Can osteoarthritis affect both hands in the same way?
Yes. Osteoarthritis can be symmetrical, although it is often uneven. Symmetry is more typical of inflammatory arthritis, so it is one feature among several rather than a deciding factor.
Will I need an X-ray?
Not always. Typical osteoarthritis can often be recognised from the history and examination. X-rays are helpful when the pattern is unusual, when inflammatory arthritis is possible, or when treatment such as surgery is being planned.
Can hand osteoarthritis be stopped from getting worse?
There is currently no treatment that reverses osteoarthritis, but its course varies, and many people find that pain settles over time even when bony lumps remain. Exercise, joint protection, splints and the right aids make a real difference to daily function, and surgery is available when they are not enough.⁴
Are gels or tablets better for arthritic finger pain?
Anti-inflammatory gels are recommended as the first medicine to try because they are less likely to cause side effects than tablets.⁴ A pharmacist can advise on suitability alongside other medicines and health conditions.
Can a swollen finger joint be an infection?
Yes. A single joint that becomes hot, red, swollen and very painful over hours, particularly after a cut or with a fever, needs same-day assessment because joint infection can damage the joint quickly.
iiS Health, based at The Cheshire Hand Clinic in Warrington, provides specialist assessment and both surgical and non-surgical treatment for hand and wrist arthritis, including injections, joint fusion, joint replacement and silver splints.
Mr Fizan Younis is a Consultant Orthopaedic Hand and Wrist Surgeon and the founder and Medical Director of iiS Health. His procedural interests include wrist arthroscopy, endoscopic surgery and ultrasound-guided treatment.
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