Treatment Options for Proximal Interphalangeal Joint Conditions

Non-Surgical Management

The European League Against Rheumatism recommends education and training in ergonomic principles, pacing of activity, and use of assistive devices for every patient with hand osteoarthritis (OA) affecting the PIP joints 1, 2
Exercises to improve function and muscle strength should be considered for pain reduction and functional improvement in patients with PIP joint OA 1, 2
Thermal modalities (heat/cold) can provide symptomatic relief for PIP joint pain, according to the American College of Rheumatology 3
Topical treatments are preferred over systemic treatments due to safety considerations, with topical NSAIDs being the first pharmacological treatment of choice for PIP joint pain, as recommended by the European League Against Rheumatism 1, 2
Oral analgesics, particularly NSAIDs, should be considered for a limited duration for symptom relief in patients with PIP joint OA, according to the American College of Rheumatology 1, 2
Chondroitin sulfate may be used for pain relief and functional improvement in hand OA affecting the PIP joints, as suggested by the European League Against Rheumatism 4
Intra-articular injections of glucocorticoids may be considered specifically for painful interphalangeal joints, though they should not generally be used in other hand OA locations, according to the American College of Rheumatology 5, 6

Radiography is the initial imaging modality of choice for suspected acute PIP joint trauma, with standard 3-view radiographic examination showing most fractures and dislocations, as recommended by the American College of Radiology 7, 8
CT without IV contrast can help confirm suspected fractures in patients with PIP joint trauma, according to the American College of Radiology 8
MRI without IV contrast can detect occult fractures and evaluate for concomitant ligamentous injuries in patients with PIP joint trauma, as suggested by the American College of Radiology 8

Surgery should be considered when other treatment modalities have failed to provide adequate pain relief for PIP joint conditions, according to the American College of Rheumatology 5, 6
Arthroplasty (typically with silicone implants) is the preferred surgical technique for most PIP joints, as recommended by the American College of Rheumatology 5, 6
Arthrodesis (joint fusion) may be considered specifically for the second PIP joint (PIP-2), according to the American College of Rheumatology 5, 6
Rehabilitation is important following surgical intervention for PIP joint conditions, as suggested by the American College of Rheumatology 5
Complications of PIP joint surgery may include pain, instability, nerve dysfunction, superficial infection, and wound healing issues, according to the American College of Rheumatology 5, 6

The American College of Rheumatology recommends a treatment algorithm for PIP joint conditions, starting with conservative management (education, exercises, thermal modalities) 3
The algorithm proceeds to add pharmacological treatment (topical NSAIDs first, then oral analgesics if needed) 1
Intra-articular glucocorticoid injections may be considered for painful interphalangeal joints 5
If conservative measures fail, surgical options should be considered based on joint affected, type of condition, and patient factors 5, 2

Topical non‑steroidal anti‑inflammatory drugs (e.g., diclofenac gel) are recommended as the initial pharmacologic option after education, ergonomic training, and hand‑exercise programs, because they provide pain relief comparable to systemic NSAIDs while offering a superior safety profile. Evidence level: moderate‑quality [9][10]
After 8 weeks of use, topical NSAIDs produce small but clinically meaningful reductions in pain and improvements in hand function, with a low incidence of adverse effects even in patients at high cardiovascular or gastrointestinal risk. Evidence level: moderate‑quality 10

If topical treatment is insufficient, a short‑term course of oral NSAIDs may be added, particularly when multiple hand joints are symptomatic. Evidence level: low‑to‑moderate 10
Chondroitin sulfate can be considered as an adjunct; limited data suggest possible pain relief and functional benefit, but the overall evidence base is weak. Evidence level: low 9

Intra‑articular glucocorticoid injection is indicated for painful interphalangeal joints when clear signs of joint inflammation are present (e.g., swelling, warmth). Evidence level: low‑to‑moderate 9
The 2018 European League Against Rheumatism (EULAR) guideline advises that intra‑articular glucocorticoids “should not generally be used” for hand osteoarthritis; however, a single randomized trial demonstrated that such injections reduced movement‑related pain and joint swelling in interphalangeal OA. Evidence level: moderate (single trial) 9
This recommendation marks a shift from earlier 2007 expert‑opinion‑based guidance, which was more permissive toward intra‑articular steroids. [11][12]

Structured hand‑exercise programs aimed at enhancing joint range of motion and strengthening intrinsic hand muscles lead to decreased pain and improved functional ability. Evidence level: moderate 10
Application of thermal modalities (heat or cold) provides additional symptomatic relief for PIP joint discomfort. Evidence level: low 10

Surgical referral should be deferred until conservative measures—including education, exercises, topical/oral NSAIDs, and, when appropriate, intra‑articular injection—have failed to achieve satisfactory symptom control. Evidence level: expert opinion 9
When surgery becomes necessary, silicone‑implant arthroplasty is the preferred technique for most PIP joints; arthrodesis may be selected for specific joint configurations (e.g., PIP‑2). Evidence level: expert opinion 9

Patients whose symptoms persist despite an adequate trial (typically 3–6 months) of the full conservative regimen should be referred for surgical evaluation. Evidence level: expert opinion 9
Long‑term follow‑up plans should be individualized, reflecting the heterogeneous nature of hand osteoarthritis and variable disease trajectories. Evidence level: expert opinion 9