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Pain and VAS

Hand pain & complex regional pain syndrome: assessment, multimodal analgesia, and surgical considerations for vascular compromise.

90 citationsUpdated Oct 2026

Overview

Pain assessment in hand and upper-extremity surgery relies on standardized thresholds to define clinically meaningful change and acceptable control. A change of 10 on the 100mm Visual Analog Scale (VAS) signifies a clinically important improvement or deterioration, while a VAS score of 33 or less indicates acceptable postoperative pain control [2]. For the Numeric Rating Scale (NRS), the Patient-Acceptable Symptom State (PASS) threshold in a postoperative non–shoulder hand and upper-extremity population is proposed as 2.1 [13]. Clinicians must use consistent anchors for the NRS, recognizing that the upper anchor lacks universal standardization and that meaningful change is more complex than current guidelines suggest [16]. Furthermore, important change is not consistent across the entire scale [16]. When using digital VAS (VAS-D), scores may be slightly higher than paper VAS (VAS-P) and slightly lower than verbal NRS (NRS-V); however, VAS-D may be used interchangeably with other pain scales provided therapists are aware of these slight score differences [8].

Pain characteristics extend beyond intensity to include interference and its impact on disability. Pain interference may be an important link between pain severity, impairment, and self-reported disability in participants with wrist/hand pain, suggesting that addressing this component is important to improve outcomes [12]. In patients with chronic nerve injury, pain intensity should be considered only one component of pain, and the impact of pain in the context of disability must be evaluated [18]. Mental health status may affect response to therapy in patients with hand conditions; specifically, patients with increased depressive symptoms, anxiety, and pain interference require more therapy and fewer achieve all goals [47].

Postoperative pain management should begin before surgery, and combining multiple strategies for pain treatment is beneficial for postoperative pain control [25]. Greater self-efficacy was the best determinant of satisfaction with pain relief after fracture surgery [6]. The ShotBlocker device effectively reduced the pain of injection versus controls when scores were adjusted to account for pain tolerance [24]. Long-term outcomes vary by pathology: patients with moderate or severe malunion of distal radius fractures have more disability and pain at rest than patients without malunion at 1 year, though they show a significant improvement in disability after 2–4 years [1]. The "Pillow" technique for thumb carpometacarpal joint arthritis provides pain relief and satisfactory function at an average of 12.5 years after surgery [4]. Arthroscopic wrist debridement and radial styloidectomy for advanced scapholunate advanced collapse wrist results in the majority of patients experiencing a reduction in pain [7]. Surface replacement proximal interphalangeal joint arthroplasty using the Self Locking Finger Joint Implant demonstrated good pain relief at a minimum of 2 years follow-up [35]. Conversely, outcomes of trapeziectomy and ligament reconstruction and tendon interposition show increasing VAS scores with increasing intervals from surgery [108], alongside deterioration in DASH and PRWE scores with increasing intervals from surgery [108].

Anatomy & Pathophysiology

Bony Anatomy

The skeleton of the hand and wrist comprises 27 bones, 19 of which are long bones [41]. This skeletal structure is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [41]. The base of each metacarpal articulates with the distal row of the carpus [41]. The radioulnocarpal articulation possesses two axes of movement, to which a third axis—pronation and supination from the forearm—is added [41]. These three axes permit the hand to assume any spatial configuration, facilitating placement for grasping [41]. The radial ray, or first ray, is the shortest, consisting of only three bones: a metacarpal and two phalanges [41]. The trapezium is angled anteriorly out of the carpal plane, creating an angle of approximately 45 degrees between the first and second metacarpals in the sagittal plane [41]. The thumb metacarpal is the shortest, while the index metacarpal is by far the longest [41]. The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [41]. The transverse axis of the palm, corresponding to the metacarpophalangeal articulations, is not perpendicular to the longitudinal axis represented by the median ray [41]. Instead, the transverse axis forms an acute angle of approximately 75 degrees with the longitudinal axis [41]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are situated at the distal ends of the other metacarpals [41]. The hand contains 19 bones, 17 articulations, and 19 muscles situated entirely within the hand, along with a similar number of tendons activated by forearm muscles [66].

Soft Tissue Anatomy

Extrinsic muscles originate outside the hand and insert on the hand or carpus, while intrinsic muscles have both origin and insertion within the hand [40]. Extrinsic extensors traverse six distinct fibroosseous retinacular compartments at the wrist [40]. The first, most radial compartment contains the abductor pollicis longus and extensor pollicis brevis [40]. The second extensor compartment houses the extensor carpi radialis longus and brevis [40]. The third compartment contains the extensor pollicis longus, which runs longitudinally down the forearm and turns abruptly radialward around Lister tubercle [40]. The fourth extensor compartment includes the extensor indicis proprius, lying deep to the four tendons of the extensor digitorum communis [40]. The fifth compartment contains the extensor digiti quinti [40]. The extensor carpi ulnaris tendon passes through the sixth compartment and inserts at the base of the little finger metacarpal [40]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [40]. Digital extensor tendons are stabilized over the midline of the metacarpophalangeal joint by attachment to sagittal band fibers [40]. These sagittal band fibers insert onto the volar proximal phalanx and the lateral borders of the volar plate [40]. Rupture or attenuation of these fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [40]. The extrinsic finger flexors are the flexor digitorum profundus and flexor digitorum superficialis [40]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [40]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [40].

There are seven interosseous muscles: four dorsal and three volar [68]. The dorsal interossei function as abductors, while the volar interossei function as adductors [68]. The middle finger possesses two dorsal interossei and no volar interossei because the central axis of the hand lies within it [68]. Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [68]. The superficial head abducts and weakly flexes the proximal phalanx [68]. The deep head flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [68]. The volar interossei have a single muscle head and none insert onto the proximal phalanx [68]. The abductor digiti quinti and flexor digiti quinti brevis are similar in structure and function to the superficial and deep heads of the dorsal interossei, respectively [68]. The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate, inserting onto the ulnar side of the diaphysis of the fifth metacarpal, which it flexes and supinates [68].

The flexor digitorum profundus originates from the proximal ulna and the interosseous membrane [75]. The flexor digitorum superficialis has two heads: the radial head originates from the proximal shaft of the radius, and the humeral ulnar head originates from the medial humeral epicondyle and coronoid process of the ulna [75]. The flexor pollicis longus originates from two heads: the radial head takes origin from the proximal radius and interosseous membrane, and an accessory head originates from the coronoid process of the ulna and the medial epicondyle of the humerus [75]. The fibroosseous tunnel, or digital flexor sheath, consists of annular pulleys providing mechanical stability and cruciate pulleys providing flexibility [75]. The A2 and A4 pulleys are most essential in maintaining the mechanical advantage of the flexor tendons [75]. The tenosynovium lining the fibroosseous tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [75]. Within the sheath, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [75].

The superficial palmar fascia lies in a coronal plane beneath the palmar subcutaneous tissue [78]. When present, the palmaris longus tendon terminates in continuity with the fibers of this proximal corner of the superficial palmar fascia [78]. Fibers dorsal to the neurovascular bundle are collectively called Cleland ligament, while those palmar to the neurovascular bundle are called Grayson ligament [78]. A subdermal fascial layer borders the periphery of the web spaces from roughly the radial thumb sesamoid to the ulnar side of the small finger’s proximal flexion crease [78].

The dorsal skin possesses a papillary dermis, but the papillary ridges do not show on the surface because they are neutralized by the epidermis (adelomorphic dermis) [77]. The dorsal skin possesses a normal pilosebaceous system [77]. It becomes fragile in old age and has greater vulnerability to factors causing cutaneous atrophy, such as steroid therapy [77]. In the middle finger, the distance between the wrist and the ungual fold shows an average increase of 3 cm as the finger moves from extension to full flexion [77]. Flexion at the metacarpophalangeal joint alone requires an average skin lengthening of 1.25 cm [77]. The dorsal and palmar areas of skin are independent due to a system of adhesions that anchors their common boundary to the underlying plane [77]. The necessary skin to cover the thumb distal to the metacarpophalangeal joint is about 9 cm wide and 8 cm long [70]. Skin loss of the thumb and first metacarpal is 13 cm wide and 12 cm long [70]. The skin cover of both the palmar and dorsal surfaces of the hand is 12 cm by 10 cm [70]. The skin covering each finger is 7 cm by 10 cm on both the palmar and dorsal aspects [70].

Vascular Anatomy

The "princeps pollicis" artery, the terminal branch of the radial artery, crosses the first intermetacarpal space, then runs along the ulnar side of the first metacarpal bone and along the volar surface of the adductor muscle [72]. It emerges onto the subcutaneous palmar tissue at the level of the cutaneous flexion crease of the metacarpophalangeal joint [72]. The princeps pollicis divides into two terminal rami, the collateral palmar arteries of the thumb, which run along the digital tunnel symmetrically and are of equal caliber [72]. An arcade located deep in the flexor tendon joins these two arteries at the level of the distal metaphysis of the first phalanx [72]. Only 15% of dissections fall into the classical category of palmar artery layout in the thumb [72]. In the second segment of the thumb, the main artery is the ulnar collateral artery [72]. The subtendinous anastomosis situated at the level of the neck of the first phalanx acts as a "moderator" between the two arteries [72]. In cases where the palmar ulnar collateral artery is absent, the dorsal artery takes its place by means of a branch through the subtendinous arcade [72]. In the pulp segment, the two arteries are of similar size and run through the thick fatty subcutaneous padding, then cross over and convert into the ends of the digital nerves at the level of the median axis [72]. The dorsal arteries of the thumb are vascularized by two arteries originating from the palmar arteries (princeps, commissural or anastomoses of the superficial arcade) at the level of the first metacarpal [72]. At the level of the neck of the first phalanx, an anastomosis can be found which originates from the palmar arteries [72]. The ulnar dorso-collateral artery generally stems from the "princeps pollicis" onto the medial border of the neck of the first metacarpal and heads distally remaining on the lateral surface of the finger [72].

Nerve Anatomy

The innervation of the flexor digitorum profundus of the index and middle fingers is through the anterior interosseous branch of the median nerve [75]. The profundus of the ring and little fingers is innervated by the ulnar nerve [75]. The entire flexor digitorum superficialis muscle receives innervation from the median nerve [75]. The flexor pollicis longus is innervated by the anterior interosseous branch of the median nerve [75]. The most important structure in the thenar area is the recurrent branch (motor) of the median nerve [73]. Anatomic studies have shown that there is no single longitudinal incision in the proximal palm that completely avoids the palmar cutaneous branches of the median and ulnar nerves [73]. The hand’s blood and nerve supplies are continuous with those of the rest of the limb [66].

Functional Anatomy & Biomechanics

Painless and full hand function requires seamless integration of joints, muscles, and nerves to complete even the most basic task [39]. The hand is both an organ designed to obtain information and an organ of execution [66]. It functions efficiently only if the proximal joints of the limb are stable and yet mobile [66]. The shoulder is the most mobile joint in the body and allows orientation of the upper limb as required [66]. The combined movements of the wrist and forearm place the hand in a position for grasping [66]. For gripping, the wrist is usually in flexion when close to the trunk and in extension when placed at a distance [66]. The open hand, with fingers extended and in contact, forms a balanced graceful oval in its longitudinal axis [66]. The posterior or dorsal aspect is convex, and the anterior, palmar or volar aspect is concave [66]. The digits converge in closing—that is, they flex and adduct—and diverge in opening—that is, they extend and abduct [66]. When the fingers are extended and separated, the tips of the fingers lie on the circumference of a circle whose center is the head of the third metacarpal [66].

The metacarpal arch is endowed with a great deal of adaptability because of the mobility of the peripheral metacarpals [71]. The index metacarpal is the most firmly fixed [71]. The ring metacarpal has about 10 degrees of mobility in flexion and extension [71]. The fifth metacarpal has a range of flexion–extension of approximately 20 degrees [71]. The second to fifth metacarpals are all bound together by various fibrous structures, the most distal of which is the deep transverse intermetacarpal ligament [71]. This ligament is better named the interglenoid ligament, because it ties together the anterior "glenoid ligaments" of the metacarpophalangeal articulations, known as the "volar plates" [71]. The keystones of the longitudinal arches are the metacarpophalangeal articulations, whose thick anterior glenoid capsules, the volar plates, prevent hyperextension [71]. The stability of the metacarpophalangeal joints is essential to the support of the longitudinal arch as well as of the transverse metacarpal arch [71].

The dorsal integument must be supple, elastic, and malleable [76]. The skin of the back of the hand slides distally to allow metacarpophalangeal joint flexion [76]. Interphalangeal flexion is accomplished by means of a special arrangement of skin folds on the dorsum of each articulation [76]. The vessels and nerves adapt themselves to differences in length and are surrounded by loose fibroadipose connective tissue [76]. In unrestricted areas, where the tendon has a straight trajectory, it is surrounded by the paratenon, areolar connective tissue arranged in layers [76]. In narrow crowded areas, the gliding mechanism is assured by the synovial sheath, which allows a considerable amplitude of movement [76]. The synovial sheaths at specific sites are surrounded by fibrous sheaths that keep the tendon close to the skeleton [76]. The fibrous sheath assumes the role of a pulley when the tendon changes direction [76]. The gliding mechanism represented by the synovial sheaths is much more developed on the palmar aspect [76]. There are three digitopalmar synovial sheaths for the flexor tendons of the index finger, long finger, and ring finger [76]. On the dorsal aspect, the extensor synovial tendon sheaths are present only at the level of the wrist [76]. Each synovial sheath has a visceral and parietal component separated by a potential synovial cavity containing a very thin layer of synovial fluid [76].

The articulations of the hand form functional groups arranged in kinetic chains [76]. The position of each articulation depends on the equilibrium of forces acting at that level, and this equilibrium is subject to the position of the immediately proximal articulation [76]. The wrist influences the position of the metacarpophalangeal joint; the metacarpophalangeal joint also affects the position of the proximal interphalangeal joint, which in turn affects the distal interphalangeal joint [76]. The active factor in articular equilibrium is the dynamic balance between antagonist muscles [76]. The passive factors include the restraining action of ligaments and muscular "viscoelasticity" [76]. Single articular movements around a fixed perpendicular axis simply do not exist in the hand [76]. Almost all the movements are around oblique and variable axes, resulting in combined movements permitting optimal orientation of the phalanges at the time of prehension [76].

The sarcomere is the basic unit of muscle tissue in the muscle fiber [76]. Sarcomeres are composed of interacting molecules of myosin and actin [76]. With sarcolemmal contraction, there is overlap and interdigitation of these molecules and physical shortening of the sarcomere [76]. The force of active contracture is diminished if the molecules

Classification

CRPS: Complex regional pain syndrome is classically classified into two forms: type I (formerly reflex sympathetic dystrophy) and type II (formerly causalgia) [113]. CRPS I implies no definite nerve injury, whereas CRPS II diagnosis requires evidence of nerve damage as a causative event [113]. The necessity of distinguishing between CRPS type I and type II has been recently questioned [113]. CRPS comprises a broad spectrum of clinical forms including acute CRPS, chronic CRPS, causalgia, shoulder–hand syndrome, and sympathetically mediated pain [113].

Derkash: The Derkash classification divides results following treatment of neurogenic thoracic outlet syndrome into “excellent,” “good,” “fair,” and “poor” [114]. “Excellent” is defined as no pain and easy return to preoperative professional and leisure daily activities [114]. “Good” is defined as intermittent well-tolerated pain and possible return to preoperative professional and leisure daily activities [114]. “Fair” is defined as intermittent pain with bad tolerance and difficult return to preoperative professional and leisure daily activities [114]. “Poor” is defined as no change in symptoms [114].

Other Considerations: The International Association for the Study of Pain (IASP) criteria of diagnosis include both original (Merskey and Bogduk, 1994) and modified (Harden et al., 1999; Harden et al., 2007) versions [113]. There is no definitive single test for confirming or excluding CRPS, and diagnosis relies on clinical assessment with the requirement for a sufficient number of symptoms and signs to be present [113]. The IASP criteria and CRPS severity scores showed similar sensitivity in early diagnosis, but both are poor indicators of the need for treatment [20]. The Mayo Wrist Score is determined primarily by grip strength rather than pain [19]. Classification of angular measurement according to tested systems does not reflect the patient's perspective and limits the precision of the measurement [116].

Clinical Presentation

Pain Measurement and Interpretation

Quantitative pain assessment relies on standardized thresholds to define clinical significance. A change of 10 on a 100mm visual analog scale (VAS) signifies a clinically important improvement or deterioration [2]. Postoperatively, a VAS score of 33 or less defines acceptable pain control, identifying the patient as a responder [2]. For the Numeric Rating Scale (NRS) in postoperative non–shoulder hand and upper-extremity populations, the Patient-Acceptable Symptom State (PASS) threshold is proposed at 2.1 [13]. However, the upper anchor of the 0-10 NRS lacks universal standardization, and meaningful change is not consistent across the entire scale [16]. Numeric measures such as the VAS facilitate documentation of change over time and identification of relationships between intensity and self-reported changes in daily life [23].

Digital assessment tools offer interchangeability with traditional scales, though scores vary slightly by modality. Pain scores on the digital VAS (VAS-D) may be slightly higher than the paper VAS (VAS-P) and slightly lower than the Numeric Rating Scale-Verbal (NRS-V) [8]. In chronic nerve injury, pain intensity is only one component of pain; the impact of pain in the context of disability must be considered [18]. The Pain Interference domain correlates more strongly with physical function than numerical pain scores [14]. This association between greater pain interference and worse patient-reported upper extremity function is significantly stronger for patients older than 11 years than those 11 years old or younger [26].

Patient perception and expectations significantly influence reported outcomes. Patient perception of pain control has the strongest relationship with hospital rating scores after orthopaedic trauma [54]. In carpal tunnel release surgery, the widest brief Michigan Hand Questionnaire score gap was unexpectedly seen across patients reporting the lowest pain scores [21]. Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain’s tenosynovitis [96]. Furthermore, greater pain intensity in the uninjured upper extremity is associated with greater unhelpful thinking regarding symptoms during recovery from upper-extremity injury [55].

Clinical Conditions and Outcomes

Specific pathologies present distinct pain and functional trajectories. Patients with moderate or severe malunion of distal radius fractures experience more disability and pain at rest than patients without malunion at 1 year, but show significant improvement in disability after 2–4 years [1]. Better final radiological and objective physical results are associated with better patient-perceived outcomes, as measured by the DASH score, in patients with displaced distal radius fractures [49]. For elbow pain, the differential diagnosis should not be limited to local conditions, as other etiologic possibilities should not be disregarded [48].

Complex Regional Pain Syndrome (CRPS) comprises four cardinal features: pain (out of proportion to injury), swelling, movement abnormalities, and vasomotor instability [29]. The IASP criteria and CRPS severity scores showed similar sensitivity in early diagnosis following surgical treatment of distal radial fractures, but both are poor indicators of the need for treatment [20]. Hand therapy intervention for clients recovered from CRPS resulted in a significant decrease in the amount and frequency of pain and improvement in functional status [5]. High-intensity laser therapy and mirror therapy offer conclusive evidence of pain reduction in CRPS type I in the hand area, even after the third treatment session [15].

Other upper extremity conditions demonstrate varied responses to intervention. Arthroscopic wrist debridement and radial styloidectomy for advanced scapholunate advanced collapse wrist results in good functional outcomes, with the majority of patients experiencing a reduction in pain and the ability to return to work [7]. Patients with proximal interphalangeal joint osteoarthritis treated with a modular surface gliding implant experienced a significant reduction in pain and a trend towards increased mobility [10]. In ulnar shortening for positive ulnar variance, wrist function recovered after an initial decrease from week 8 onward [11].

Systemic and psychosocial factors modulate pain presentation. Common clinical features of fibromyalgia can be grouped into six clusters based on patient perception of relevance to treatment: Pain, Fatigue, Domestic, Impairment, Affective, and Social [46]. A reduction in time off work of more than 1 day per week can be achieved in patients with fibromyalgia who have good pain responses to treatment [22]. Women in office work report higher pain intensity, longer duration, more pain locations, and poorer work ability compared to men [90]. Screening at 3 months after hand trauma may detect posttraumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention [92].

Investigations

Pain Measurement Scales and Thresholds

A change of 10 on the 100mm pain Visual Analog Scale (VAS) signifies a clinically important improvement or deterioration [2]. A VAS score of 33 or less signifies acceptable pain control, or a responder status, after surgery [2]. Meaningful change on the Numeric Rating Scale is not consistent across the entire scale [16]. Pain scores on the digital VAS (VAS-D) may be slightly higher than those on the paper VAS (VAS-P) [8]. Conversely, pain scores on the digital VAS (VAS-D) may be slightly lower than those on the verbal Numeric Rating Scale (NRS-V) [8]. Despite these minor discrepancies, the VAS-D may be used interchangeably with the paper VAS and verbal NRS scales [8].

Pain Interference and Functional Correlates

The Pain Interference domain has a larger correlation to physical function than numerical pain scores [14]. Addressing pain interference may be important to improve outcomes in patients with wrist or hand pain [12]. The association between greater pain interference and worse patient-reported upper extremity function is significantly stronger for patients older than 11 years than for those 11 years old or younger [26].

Diagnostic Criteria and Imaging

The IASP criteria and CRPS severity scores showed similar sensitivity in the early diagnosis of complex regional pain syndrome following surgical treatment of distal radial fractures [20]. Both IASP criteria and CRPS severity scores are poor indicators of the need for treatment in early complex regional pain syndrome diagnosis [20]. Magnetic resonance imaging scans may not be the standard for accurate diagnosis and can misdirect care in workers' compensation patients [153]. The radiographic appearance of the scaphotrapezial joint did not correlate with symptoms at that joint following partial trapeziectomy [148]. Subjects with early thumb carpometacarpal osteoarthritis who had 1 stage of radiographic progression had a significantly higher intensity of pain on the PRWHE pain subscale at 36-month follow-up [65].

Clinical Examination and History

Patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit [39]. A careful physical examination is essential to direct care and future testing if indicated [39].

Treatment

Pain Measurement and Interpretation

A Visual Analog Scale (VAS) score of 33 or less signifies acceptable pain control, defined as the Patient-Acceptable Symptom State, after surgery [2]. Patient perception of pain control has the strongest relationship with hospital satisfaction scores following orthopaedic trauma [54].

Non-Operative

Postoperative pain control should begin before surgery, and combining multiple strategies for pain treatment is beneficial [25]. For complex regional pain syndrome type I (CRPS-I) in the hand area, high-intensity laser therapy and mirror therapy provide conclusive evidence of pain reduction, even after the third treatment session [15]. The ShotBlocker device effectively reduced the pain of in-office injections versus controls when scores were adjusted to account for pain tolerance [24]. Injection approach does not affect patient pain perception scores or outcomes for trigger finger injections [3]. High-dose triamcinolone injections outperformed low-dose injections across most metrics, including estimated time of relief, rate of repeat injection, and rate of surgery, for soft tissue pathology of the hand [109]. Combined intervention of vitamin D supplementation and physiotherapy had a better pain-relieving effect than physiotherapy alone in adult patients with musculoskeletal disorders [98]. Perceptions of standardized thermal pain stimuli were not altered by neural mobilization techniques in individuals with carpal tunnel syndrome [155]. A reduction in time off work of more than 1 day per week can be achieved in patients with fibromyalgia who have good pain responses to treatment with pregabalin [22]. Patient controlled regional anaesthesia for severe hand pain requires very specific indications and compliant and reliable patients [111].

Operative

Implant Selection: Patients undergoing a modular surface gliding implant (CapFlex-PIP) for proximal interphalangeal joint osteoarthritis experienced a significant reduction in pain and a trend towards increased mobility [10].

Surgical Approach / Technique: Wrist function recovered after an initial decrease from week 8 onward in ulnar shortening with the UOL for positive ulnar variance [11]. There was no difference between arthroscopic and open lateral release for the treatment of lateral epicondylitis when examining the VAS score at 12 months postoperatively [27]. Functional outcome was similar 12 months after surgery for thumb basal joint arthritis arthroplasties with or without bone tunnel creation [28]. Pisiform excision is a well-tolerated, safe treatment for pain in the pisotriquetral joint resulting from arthrosis and not controlled by nonsurgical means [156]. Conservative management of little finger metacarpal fractures reported worse radiological palmar angulation at follow-up, but functional outcomes in terms of Quick-DASH and grip strength were equivalent to operative treatment [38]. Dorsal capsular imbrication for posttraumatic instability of the distal radioulnar joint resulted in excellent pain reduction and unchanged or better function in 11 of 11 patients at midterm follow-up [141].

Other Considerations: In patients with carpal tunnel syndrome, significant differences in pain trajectory were observed between sensory phenotypic groups, with mechanical hyperalgesia and sensory loss phenotypes demonstrating greater persisting neuropathic pain scores at 6 months postsurgery [36].

Complications

Pain Persistence and Neuropathic Phenotypes: Persistent pain remains a significant complication in upper extremity surgery. In carpal tunnel syndrome, patients with mechanical hyperalgesia and sensory loss phenotypes demonstrate greater persisting neuropathic pain scores at 6 months postsurgery [36]. More than half of patients who recover from early Complex Regional Pain Syndrome Type 1 continue to complain of occasional pain [128]. In revision cubital tunnel surgery, 85% of patients reported preoperative pain, and average pain VAS scores did not change or worsened in 14 of 52 procedures [120]. Primary incomplete resection of the medial intermuscular septum is associated with significantly increased odds of worsened or unchanged postoperative average pain [120]. Higher preoperative average pain VAS scores and a history of greater than one prior cubital tunnel procedure are significant predictors of worse postoperative pain [120].

Functional Outcomes and Work Status: Surgical interventions often yield measurable improvements in pain and function. Patients undergoing arthroscopic wrist debridement and radial styloidectomy for SLAC wrist experience a reduction in pain with the ability to return to work [7]. Wrist function recovers after an initial decrease from week 8 onward following ulnar shortening with the UOL [11]. In fibromyalgia patients with good pain responses, a reduction in time off work of more than 1 day per week can be achieved [22]. First dorsal compartment release with a longitudinal incision provides notable functional improvement, high levels of participant satisfaction, and few complications [50]. The outcomes, recurrence, and complication rates after 4 years of follow-up support the use of arthroscopy as a treatment for dorsal wrist ganglion [112].

Implant-Specific Pain Reduction: Specific implants demonstrate consistent pain relief. Patients undergoing CapFlex-PIP implant for PIP joint osteoarthritis experienced a significant reduction in pain and a trend towards increased mobility [10]. The SLFJ implant PIP joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion at a minimum of 2 years follow-up [35]. In patients undergoing scaphoid plate fixation and vascularized bone graft, VAS pain scores (0–10) improved significantly from 3.7±2.6 preoperatively to 1.3±1.3 postoperatively [115].

Other Considerations: Measurement Standards: A change of 10 on the 100mm pain VAS signifies a clinically important improvement or deterioration after surgery [2]. A VAS score of 33 or less signifies acceptable pain control (i.e. a responder) after surgery [2]. Patients typically complete a standard visual analog (VAS) scale to grade current pain, ranging from 0 (no pain) to 100 (the worst pain imaginable) [17]. Numeric measures of pain intensity allow documentation of change over time and identification of relationships between intensity and self-reported changes in daily life [23]. Pain scores on the digital VAS (VAS-D) may be slightly higher than the paper VAS (VAS-P) and slightly lower than the numerical rating scale (NRS-V) [8].

Procedural Variations: Injection approach for trigger finger does not affect patient pain perception scores or outcomes [3]. There was no difference between arthroscopic and open lateral release for lateral epicondylitis when examining the DASH score, VAS score, PRTEE score, grip strength, or complication rate at 12 months postoperatively [27]. Functional outcome was similar 12 months after surgery for thumb basal joint arthroplasty with or without bone tunnel creation [28]. There was no statistical difference between simple release and Z-plasty of retinaculum for de Quervain’s disease in incidence of complication [152]. Two different volumes of local anesthetic cause the same degree of discomfort during digital block administration [63].

Specific Pathologies: Hand therapy intervention for Complex Regional Pain Syndrome results in a significant decrease in the amount and frequency of pain and improvement in functional status [5]. Patients respond to extra-articular steroid injections with gradual improvement over the course of the first week [37]. Psychosocial factors are the strongest correlates of pain with corticosteroid injection for idiopathic trigger finger [147]. Patients with a positive history of specific factors and in whom flexor tendon injury is found during A1 pulley release should be explained about the possibility of prolonged postoperative symptoms [150].

Neuroma Management: None of the 26 patients who underwent Targeted Muscle Reinnervation demonstrated evidence of new neuroma pain after the procedure [64]. All but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves after Targeted Muscle Reinnervation [64].

TFCC and Pisiform: Twenty-six patients (74%) had significant reduction of pain after arthroscopic repair of triangular fibrocartilage complex tears [106]. The average visual analog scale for exertional pain was reduced from 6 ± 2 before surgery to 3 ± 3 postoperatively in patients undergoing arthroscopic TFCC repair [106]. Nine patients had persistent wrist pain after arthroscopic repair of triangular fibrocartilage complex tears [106]. Twelve patients reported no residual pain, two reported occasional mild pain, and one reported moderate pain at a mean follow-up of 6.9 years after pisiform excision [119].

Long-Term and Special Populations: Long-term outcomes for pelvic fractures are complicated by posterior pelvic pain [51]. The long-term reduction of health-related quality of life in women with vertebral fracture emerged clearly in a seven-year follow-up study [56]. The widest brief Michigan Hand Questionnaire score gap was seen across patients reporting lowest pain scores after carpal tunnel release surgery [21]. Patients involved in a personal injury claim scored worse regarding pain and hand function before treatment compared to those without a claim [59].

Pediatric Brachial Plexus Palsy: The point prevalence of pain at the time of assessment was 25% (n 16) of the 65 children evaluated for obstetrical brachial plexus palsy [102]. The lifetime prevalence of pain was 66% (n 43) of the total sample of children with obstetrical brachial plexus palsy [102]. The average intensity of the typical pain episode in children who reported having pain at some point in their lifespan was 40±19 mm on the 100-mm visual analog scale [102].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): In the great majority of patients, idiopathic frozen shoulder is a self-limiting condition in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms [158]. For ulnar shortening with the UOL, wrist function recovers after an initial decrease from week 8 onward [11].

Rehabilitation protocol: Hand therapy intervention for clients recovered from Complex Regional Pain Syndrome results in a significant decrease in the amount and frequency of pain [5] and an improvement in functional status [5].

Functional milestones: Numeric measures of pain intensity, specifically the Visual Analog Scale, allow documentation of change over time [23] and identification of relationships between intensity and self-reported changes in daily life as documented in the Disabilities of Arm, Shoulder, and Hand questionnaire [23]. Longitudinal changes on the DASH of 11 points represent minimally clinically important changes [157], as do longitudinal changes on the Quick-DASH of 16 points [157] and on the PRWE of 14 points [157]. A standard deviation of 0.5 points for pain and function was used to indicate clinical importance in the assessment of joint-protection programs [57].

Other Considerations: Patients undergoing arthroscopic wrist debridement and radial styloidectomy for advanced scapholunate advanced collapse wrist experience a reduction in pain [7] and have the ability to return to work [7]. Patients undergoing a modular surface gliding implant (CapFlex-PIP) for proximal interphalangeal joint osteoarthritis experience a significant reduction in pain [10] and show a trend towards increased mobility [10]. The Self Locking Finger Joint Implant for proximal interphalangeal joint arthroplasty demonstrates good pain relief at minimum 2 years of follow-up [35], good overall patient satisfaction at minimum 2 years of follow-up [35], and maintains joint range of motion at minimum 2 years of follow-up [35]. Functional outcome is similar 12 months after surgery for thumb basal joint arthritis arthroplasties with or without bone tunnel creation [28]. First dorsal compartment release with a longitudinal incision provides notable functional improvement [50] and high levels of participant satisfaction [50]. Scapholunate intercarpal ligamentoplasty for chronic scapholunate dissociation led to satisfactory clinical results in short- to mid-term follow-up [62] and satisfactory radiological results in short- to mid-term follow-up [62]. Arthroscopic assisted resection for triangular fibrocartilage complex lesions demonstrates persisting satisfactory subjective outcomes at 19 years of follow-up [124] and persisting satisfactory functional outcomes at 19 years of follow-up [124]. Ivory arthroplasty for trapeziometacarpal osteoarthritis improves overall function up to 10 years postoperatively [137] and reduces pain up to 10 years postoperatively [137]. Corticosteroid injection did not affect the apparently self-limited course of lateral elbow pain [145]. The association between greater pain interference and worse patient-reported upper extremity function is significantly stronger for patients older than 11 years than those 11 years old or younger [26]. Long-term reduction of health-related quality of life in women with vertebral fracture emerged clearly in a seven-year follow-up study [56].

Key Evidence

• [L2] Patients with moderate or severe malunion have more disability and pain at rest than patients without malunion at 1 year but show a significant improvement in disability after 2–4 years. [1] (10.1177/1753193411409317)
• [L2] Analgesic interventions that provide a change of 10 for the 100mm pain VAS signify a clinically important improvement or deterioration, and a VAS of 33 or less signifies acceptable pain control (i.e. a responder), after surgery. [2] (10.1093/bja/aew466)
• [L3] Our data suggest that injection approach does not affect patient pain perception scores or outcomes. [3] (10.1177/1558944717703134)
• [L4] This technique provides pain relief and satisfactory function at an average of 12.5 years after surgery. [4] (10.1016/j.jhsa.2016.04.018)
• [L4] Table 1 shows the results indicating a significant decrease in the amount and frequency of pain and improvement in their functional status. [5] (10.1197/j.jht.2006.07.004)
• [L2] Greater self-efficacy was the best determinant of satisfaction with pain relief. [6] (10.1007/s11999-014-3660-4)
• [L4] Patients experience good functional outcomes with the majority experiencing a reduction in pain with the ability to return to work. [7] (10.1177/1558944717725383)
• [L3] Therefore, the VAS-D may be used interchangeably with the other two scales but therapists must be aware that pain scores on the VAS-D may be slightly higher than the VAS-P and slightly lower than the NRS-V. [8] (10.1016/j.jht.2011.07.017)
• [L4] Patients experienced a significant reduction in pain and a trend towards increased mobility. [10] (10.1016/j.jhsa.2014.10.047)
• [L4] In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. [11] (10.1177/1558944717702465)
• [L4] Addressing pain interference may be important to improve outcomes in this population. [12] (10.1016/j.jht.2019.06.001)
• [L3] The authors propose a value of 2.1 to represent the Patient-Acceptable Symptom State (PASS) threshold for the Numeric Rating Scale (NRS) pain score in this population. [13] (10.1016/j.jhsa.2024.07.020)
• [L3] The Pain Interference domain had a larger correlation to physical function than did numerical pain scores. [14] (10.1016/j.jhsa.2017.06.004)
• [L1] The study results offer conclusive evidence of pain reduction, a highly debilitating symptom in CRPS-I, even after the third HILT treatment session. [15] (10.1016/j.jht.2025.02.009)
• [L5] The authors argue that the upper anchor of the 0-10 Numeric Rating Scale lacks universal standardization and that meaningful change is more complex than current guidelines suggest, urging clinicians to use consistent anchors and recognize that important change is not consistent across the entire scale. [16] (10.1016/j.jht.2017.12.008)
• [L2] [17] (10.1016/j.jhsa.2012.01.028)
• [L4] Pain intensity should be considered only one component of pain, and the impact of pain in the context of disability should be considered in patients with chronic nerve injury. [18] (10.1016/j.jhsa.2010.07.018)
• [L3] The Mayo Wrist Score is determined primarily by grip strength rather than pain. [19] (10.1016/j.jhsa.2007.10.003)
• [L3] The IASP criteria and CRPS severity scores showed similar sensitivity in early diagnosis, but both are poor indicators of the need for treatment. [20] (10.1177/1753193412469142)
• [L3] Unexpectedly, the widest brief Michigan Hand Questionnaire score gap was seen across patients reporting lowest pain scores. [21] (10.1177/15589447211064365)
• [L1] A reduction in time off work >1 day per week can be achieved in patients with good pain responses. [22] (10.1186/1471-2474-12-125)
• [L4] Numeric measures of pain intensity (Visual Analog Scale) allow us to document change over time and identify relationships between intensity and self-reported changes in daily life as documented in a structured questionnaire (Disabilities of Arm, Shoulder, and Hand). [23] (10.1197/j.jht.2005.07.004)
• [L1] The ShotBlocker device effectively reduced the pain of injection versus controls when scores were adjusted to account for pain tolerance. [24] (10.1177/1558944719884655)
• [L3] The evidence available suggests that postoperative pain control should begin before surgery and that combining multiple strategies for pain treatment is beneficial. [25] (10.1016/j.jhsa.2015.05.024)
• [L3] The association between greater pain interference and worse patient-reported upper extremity function was significantly stronger for patients older than 11 years than those 11 years old or younger. [26] (10.1016/j.jhsa.2020.05.011)
• [L2] There was no difference between the 2 operative modalities when examining the DASH score, VAS score, PRTEE score, grip strength, or complication rate at 12 months postoperatively. [27] (10.1016/j.arthro.2018.07.008)
• [L1] However, 12 months after surgery, the functional outcome was similar. [28] (10.1016/j.jhsa.2014.04.044)
• [L4] [29] (10.1177/1753193412471021)
• [L4] The minimum 2 years of follow-up evaluation of the SLFJ implant PIP joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion. [35] (10.1177/1558944717726136)
• [L3] [36] (10.1186/s12891-021-04832-2)
• [L1] Patients respond to extra-articular steroid injections with gradual improvement over the course of the first week. [37] (10.1016/j.jhsa.2007.08.002)
• [L1] Although conservative management reported worse radiological palmar angulation at follow-up, functional outcomes in terms of Quick-DASH and grip strength were equivalent. [38] (10.1142/s2424835520500290)
• [L4] Common clinical features of FM could be grouped into 6 clusters (Pain, Fatigue, Domestic, Impairment, Affective, and Social) based on patient perception of relevance to treatment. [46] (10.1186/1471-2474-11-134)
• [L3] There is some indication that patients with increased depressive symptoms, anxiety, and pain interference require more therapy with fewer achieving all goals, suggesting that mental health status may affect response to therapy. [47] (10.1016/j.jht.2020.10.006)
• [L5] The differential diagnosis of elbow pain should not be limited to local conditions, as other etiologic possibilities should not be disregarded. [48] (10.1016/0363-5023(93)90351-3)
• [L3] Better final radiological and objective physical results were associated with a better patient-perceived outcome, as measured by the DASH score, in this patient group. [49] (10.1197/j.jht.2007.06.001)
• [L3] First dorsal compartment release with a longitudinal incision provides notable functional improvement, high levels of participant satisfaction, and few complications. [50] (10.1016/j.hansur.2020.10.004)
• [L3] Patient perception of pain control seems to have the strongest relationship with hospital rating. [54] (10.5435/jaaos-d-20-00069)
• [L2] Given that greater pain intensity in the uninjured upper extremity is associated with greater unhelpful thinking, clinicians can be attuned to patient concerns about contralateral pain. [55] (10.1016/j.jhsa.2023.03.019)
• [L2] The long-term reduction of HRQOL in women with vertebral fracture emerged clearly in this study. [56] (10.1186/1471-2474-10-135)
• [L1] [57] (10.1016/j.jht.2018.09.012)
• [L3] [59] (10.1097/corr.0000000000002410)
• [L2] This procedure led to satisfactory clinical and radiological results in a short- to mid-term follow-up. [62] (10.1177/1753193418772801)
• [L1] The two volumes cause the same degree of discomfort. [63] (10.1142/s2424835516500363)
• [L4] None of the 26 patients who underwent TMR demonstrated evidence of new neuroma pain after the procedure, and all but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves. [64] (10.1007/s11999-014-3528-7)
• [L2] However, subjects with early CMC OA who had 1 stage of radiographic progression were found to have a significantly higher intensity of pain on the PRWHE pain subscale at 36-month follow-up. [65] (10.1177/1558944720928489)
• [L4] The present results provide new key information on pain characteristics in office workers, with women reporting higher intensity, longer duration, and more pain locations as well as poorer work ability. [90] (10.1186/1471-2474-14-226)
• [L4] Despite a limited evidence base, screening at 3 months may detect posttraumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes. [92] (10.1016/j.jht.2016.11.006)
• [L3] Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. [96] (10.1097/corr.0000000000001577)
• [L3] Combined intervention (vitamin D with physiotherapy) had a better pain-relieving effect than physiotherapy alone. [98] (10.3389/fnut.2021.717473)
• [L4] [102] (10.1016/j.jhsa.2015.02.003)
• [L4] [106] (10.1016/j.arthro.2007.01.026)
• [L4] The benefits of surgery should be balanced against the deterioration in the outcome measures of DASH and PRWE and increasing VAS scores with increasing intervals from surgery. [108] (10.1016/j.jhsa.2024.07.024)
• [L4] High-dose triamcinolone injections outperformed low-dose injections across most metrics including estimated time of relief, rate of repeat injection, and rate of surgery. [109] (10.1016/j.jhsa.2025.09.014)
• [L4] The use of such devices requires very specific indications and compliant and reliable patients. [111] (10.1177/1753193417690143)
• [L4] The outcomes, recurrence, and complications rates after 4 years of follow-up presented in this study support the use of arthroscopy as a treatment for dorsal wrist ganglion. [112] (10.1177/1558944717743601)
• [L4] [113] (10.1177/1753193412469143)
• [L1] [114] (10.1016/j.jhsa.2023.03.005)
• [L4] [115] (10.1016/j.jhsa.2016.04.021)
• [L4] Classification of angular measurement according to the tested systems does not reflect the patient's perspective; it limits the precision of the measurement and adds little value to the measurement itself. [116] (10.1016/j.jhsa.2018.06.010)
• [L4] [119] (10.1016/j.jhsa.2014.02.037)
• [L3] [120] (10.1177/1558944717743593)
• [L4] This study demonstrates persisting satisfactory subjective and functional outcomes for patients following arthroscopic assisted resection for lesions of the TFCC at 19 years of follow-up. [124] (10.1177/1558944717708029)
• [L4] [128] (10.1177/1753193408087034)
• [L2] Long-term results suggest the Ivory arthroplasty to be a reliable treatment for trapeziometacarpal osteoarthritis since it improves overall function and reduces pain up to 10 years postoperatively. [137] (10.1177/1753193418797890)
• [L4] [141] (10.1007/s00402-014-2092-7)
• [L1] Corticosteroid injection did not affect the apparently self-limited course of lateral elbow pain. [145] (10.1016/j.jhsa.2008.02.004)
• [L2] Psychosocial factors are the strongest correlates of pain with corticosteroid injection, but a large portion of the variability remains unexplained. [147] (10.1016/j.jhsa.2011.10.055)
• [L4] Satisfaction is equivalent to other published series, and the radiographic appearance of the ST joint did not correlate with symptoms at this joint. [148] (10.1016/j.jhsa.2012.02.007)
• [L4] In addition, they should explain to patients with a positive history of these factors and in whom flexor tendon injury is found during surgery about the possibility of prolonged postoperative symptoms. [150] (10.1016/j.jhsa.2018.06.023)
• [L4] Z-plasty allowed earlier return to activities of daily living but there was no statistical difference between the two groups in incidence of complication. [152] (10.1177/1753193418818341)
• [L3] Magnetic resonance imaging scans may not be the standard for accurate diagnosis and can misdirect care. [153] (10.1016/j.jhsa.2011.12.008)
• [L2] Perceptions of standardized thermal pain stimuli were not altered by either neural mobilization technique. [155] (10.1016/j.jht.2008.07.024)
• [L3] Pisiform excision is a well-tolerated, safe treatment for pain in the pisotriquetral joint resulting from arthrosis and not controlled by nonsurgical means, although patients subjectively experience impairments in function that may not be identified objectively. [156] (10.1016/j.jhsa.2014.04.019)
• [L2] Longitudinal changes on the DASH of 11 points, the Quick-DASH of 16 points, and the PRWE of 14 points represent minimally clinically important changes. [157] (10.1016/s0363-5023(12)60023-9)
• [L4] In the great majority of patients idiopathic frozen shoulder is a self-limiting condition, in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms. [158] (10.2106/00004623-197860040-00030)

See Also

• Trapeziectomy
• Trigger Finger
• Arthroscopy

References

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