Why do the end joints and the base of my thumb wear out first?

Wear follows load, and load in the hand is not spread evenly.

Two places take far more than their share.

The base of the thumb is one. That joint is shaped like a saddle, with each surface curved in two directions, which is what lets the thumb swing across the palm and oppose the fingers. The price of that freedom is that the bones are not locked together. They are held by ligaments, and stability depends on those ligaments staying tight. Every time you pinch, the muscles that hold the thumb steady press the two surfaces together with a force many times greater than the force at your fingertip. A small pinch at the tip is a large squeeze at the base. Over decades, on a joint held together by soft tissue, that adds up.

The joints nearest the fingernails are the other. Their surfaces are the smallest in the hand, so every pound of pressure is concentrated into a tiny area.

The knuckles at the base of the fingers usually escape, and the reason is instructive. Those joints have large, well matched surfaces, deep sockets, and strong surrounding tissue, so load is spread widely. When someone has obvious wear at those knuckles, it raises the question of a different cause rather than ordinary wear.

Genetics runs underneath all of this. Hand arthritis clusters strongly in families, and an old injury to a particular finger can pick out that one joint years later.

What exactly are these bumps, and why do they not go away?

They are bone. As cartilage thins, the joint becomes slightly loose and the body responds the way it always does to an unstable joint, by building.

New bone grows at the rim of the joint, in ridges and spurs, and the capsule around the joint thickens at the same time. The result is a hard, knobby collar you can feel through thin skin.

The names are simply the doctors who described them. Bumps at the joint nearest the nail are Heberden's nodes, after William Heberden, an English physician of the eighteenth century. The same bumps at the middle joint are Bouchard's nodes, after Charles Bouchard, a French physician of the nineteenth.

Two things about their behavior surprise people. The first is that they can be sore and even red while they are forming, over a period of months, and then settle into a bump that does not hurt much at all. Pain and appearance run on separate timetables. The second is that they change the shape of the finger. A joint with a spur on one side is pushed off line, so fingertips can drift sideways over the years.

Because the bone is real and structural, no medicine, cream, or exercise removes it. Treatment aims at the pain, the stiffness, and the function of the hand.

A bump beside the nail is different again. That is a mucous cyst, pushed up by a spur inside an arthritic end joint, and it can thin the skin or groove the nail.

How do I tell wear arthritis from the inflammatory kind?

The pattern usually gives it away, and the pattern is worth learning because the two are managed by different specialists with different medicines.

Wear arthritis picks out the end joints, the middle joints, and the base of the thumb. It builds over years, is worse after use, and the stiffness after rest loosens within minutes. The swelling feels hard, because it is bone.

Inflammatory arthritis behaves differently. Rheumatoid arthritis favors the knuckles at the base of the fingers and the wrist, tends to affect both hands in a matching pattern, and produces swelling that feels soft, warm, and springy, because it is thickened joint lining rather than bone. Morning stiffness lasts far longer, and can come with fatigue or with joints elsewhere. Psoriatic arthritis is the exception that catches people out, because it does attack the end joints, alongside pitting or lifting of the nails and sometimes a whole finger swollen like a sausage.

There is also an overlap form, in which end and middle joints go through episodes of hot, painful swelling and the X-ray shows erosion rather than plain wear.

Blood tests are ordered when the pattern raises the question, not routinely. They have to be read with care in both directions, since a positive result can appear in people without the disease and a negative one does not rule it out. A page cannot tell you which of these you have, and this is a distinction worth settling early, because inflammatory disease has treatment that protects the joints, and starting it promptly matters.

What does a splint actually do, and when should I wear it?

A splint does one of two jobs, and knowing which one yours is doing changes how you use it.

The first job is rest. A joint that is flaring is painful because it is moving under load. Holding it still for a stretch of hours lets the irritation settle. That is what a night splint does, and night is chosen deliberately, because a hand splinted at night is not a hand you need during the day.

The second job is support during activity. A soft neoprene sleeve around the base of the thumb, or a small oval ring around a finger joint, does not stop movement. It steadies the joint just enough to take the edge off pinch and to stop the finger buckling into an awkward position while you work.

What splints do not do is fix the joint. They also cause problems if overused, since a hand held still for weeks loses motion and strength, and the muscles that support the thumb weaken quickly. The usual pattern is a night splint for a period of weeks during a bad spell, plus a light support for the specific tasks that hurt, rather than continuous wear.

Fit matters more than material. A ring splint that is too tight swells the finger, and a thumb splint that leaves the base joint free is doing nothing at all. A hand therapist can size or make one.

How much does an injection help, and how often can I have one?

A steroid injection into a small joint of the hand is a precise piece of work.

The space is a few millimeters across, a fine needle is used, and it is sometimes placed with ultrasound. The steroid does not repair cartilage. It quiets the inflamed lining of the joint, which is where a good deal of the pain in an arthritic joint comes from.

When it works, the relief commonly begins within a few days and lasts weeks to several months. That range is wide because the response varies a great deal between people, and nobody can predict it in advance.

Frequency is a matter of judgement rather than a fixed rule. The principles are that an injection which gave months of relief is reasonable to repeat, an injection which gave two weeks is telling you the joint has moved past what steroid can do, and that repeated steroid into the same small joint is avoided because of its effects on soft tissue.

The downsides are worth knowing. A flare of pain for a day or two before the relief starts is common. The steroid can thin the fat under the skin and lighten the skin color at the site, which is often permanent and more visible in darker skin. Infection is rare but serious. Blood sugar can rise for several days in people with diabetes.

Other injected treatments, including hyaluronic acid and platelet rich plasma, are sometimes offered for hand and thumb arthritis. The honest position is that the evidence in the small joints of the hand is limited and mixed.

When is surgery on a finger joint worth it, and what does it do?

Surgery here is for one problem: a single joint that stays painful enough to interfere with your life after the rest of the ladder has been tried.

It is not done for appearance, and not to prevent future arthritis.

At the end joint, the operation is almost always fusion. The worn surfaces are removed and the two bones are held together with a small screw or pins until they unite, commonly over six to twelve weeks. The joint no longer bends. That matters less than it sounds, because the end joint contributes little to grip, and most people are satisfied with the trade.

At the middle joint, motion matters much more, so the decision splits. In the index finger, which takes sideways force during pinch, fusion is often chosen for stability. In the middle, ring, and small fingers, replacement is considered, using an implant of flexible silicone or of a harder material. Replacement aims to keep a useful arc of bending. It is a genuine trade, because implants can loosen, wear, drift out of line, or break, and the evidence on how long they last in the hand is limited.

Two smaller operations belong here. A mucous cyst is removed together with the bone spur feeding it, since removing the cyst alone invites it back. And arthritis at the base of the thumb has its own set of operations, covered on the thumb arthritis page.

What actually helps at home?

Joint protection is the single most useful idea, and it is not about doing less.

It is about doing the same things with less force through the small joints. Use the flat of the hand or the forearm instead of a pinch grip. Carry a bag on the shoulder rather than hooked in the fingers. Choose bigger handles, since a fat grip needs far less pinch force than a thin one. Use a jar opener, an electric can opener, a chunky pen, tap levers instead of knobs.

Motion is the other half. Every finger joint should be taken through its full range daily, gently and without weight, including on the days when the hand is stiff and unwilling. Stiffness that is allowed to settle in is much harder to recover than pain is to manage. Warmth from water or a heat pack first makes those minutes easier. Cold helps a joint that is hot and flaring.

For medicine, an anti-inflammatory gel rubbed into the joint is a reasonable first choice in the hand, because the joints are close to the surface and it avoids much of what the tablets do to the stomach and kidneys. Tablets are used in short courses when that is safe for you.

Pacing works better than pushing. Break long tasks into shorter blocks. A flare that follows a day of gardening is not damage, and it does not mean the gardening has to stop, only that it may need to be spread out.

What does the long run look like?

Osteoarthritis in the hand is managed rather than cured, and the honest picture is more encouraging than the appearance of the hands suggests.

Individual joints tend to follow a course. There is a period of months to a few years when a joint is actively changing, and that is when it is most painful and when the bumps grow. Then the joint stiffens, the bone stabilizes, and pain often quiets considerably, even though the joint now looks worse and moves less. Many people find their hands are less painful at seventy than at fifty-five, while looking more knobby.

What tends to persist is loss of fine dexterity and grip, particularly if the thumb base is involved, since that joint contributes most to pinch. Adapting how tasks are done keeps most people independent for the long term.

Some things are worth watching for and reporting. New swelling that is soft, hot, and symmetrical. Morning stiffness that starts lasting hours. A single joint that becomes red, hot, and exquisitely painful over a day, which needs prompt assessment rather than a wait and see approach. A mucous cyst that starts leaking, which can carry infection into the joint. And any joint whose pain climbs steadily rather than settling.

Follow up is not usually needed on a fixed schedule for straightforward wear arthritis. It is driven by symptoms, and by the point at which the ladder you are on stops holding. These are ranges, not promises.