Hand and wrist pain

Each hand and wrist is built from 27 small bones, moved by more than 30 muscles in the hand, wrist and forearm, several of whose tendons run through a bony passage at the wrist, the carpal tunnel, alongside the nerve that gives the hand much of its feeling. Any of them can be the source of the pain, and each common cause has a pattern of its own:

• Wear: hand osteoarthritis. From 45 onwards, osteoarthritis is the first suspect, at the base of the thumb and in the finger joints: pain that builds with use, stiffness that clears within half an hour of waking, and in time hard, bony bumps at the finger joints. It has a section of its own below.
• A tendon that catches: trigger finger. The finger or thumb clicks, or sticks in a bent position and has to be straightened with the other hand, with pain or tenderness in the palm at the base of the digit and stiffness that is worst in the morning; a finger that locks bent and is freed with the other hand is the tendon catching, not the picture the seek-help list puts at 999 or A&E for a hand that cannot be used. It is likelier after 40 and in people with diabetes; our trigger finger guide covers it.
• Thumb-side wrist pain: De Quervain's tenosynovitis. The pain sits at the thumb side of the wrist, tender to press, and is set off by raising the thumb, by gripping and lifting, or by using scissors, sometimes with swelling there or a click as the thumb moves; new parents picking up a small baby seem particularly prone to it. It has a guide of its own, De Quervain's tenosynovitis.
• A trapped nerve at the wrist: carpal tunnel syndrome. Tingling, numbness and pain build up gradually in the thumb, index and middle fingers, worst at night, with a weak thumb or difficulty gripping: a pattern for a GP, and for a GP within days once the numbness stays, the hand weakens or the pad at the base of the thumb shrinks, as the seek-help section says, while numbness or weakness that strikes a hand all at once is a 999 or A&E emergency, since it can be a stroke, even if it stops after a short time; our carpal tunnel syndrome guide takes it further.
• A lump: the ganglion. A smooth, soft lump under the skin near a joint or a tendon, often on the back of the wrist, that can vary in size, is usually painless and often goes away on its own over months to a year. Ganglions are the commonest lumps in the hand and wrist and are harmless; our ganglion cysts guide covers them. A different lump, firm and usually painless, is Dupuytren's contracture, a thickening of the tissue under the skin of the palm rather than a joint problem, which can in time pull the ring or little finger in towards it; it needs treatment only once the fingers can no longer be straightened or the hand no longer works normally.
• The inflammatory hand. Rheumatoid arthritis often starts in the hands and the feet, in their small joints, with soft, warm, tender swelling of the knuckles and wrists, usually on both sides, and stiffness on waking lingering past half an hour; psoriatic arthritis can look the same, with a whole finger swollen along its length, pitted or discoloured nails and, in the great majority, psoriasis. Either pattern, before it has a name, belongs to our early inflammatory arthritis guide, and a GP should see it within days.
• Fingers that change colour: Raynaud's phenomenon. Fingers that go white, then blue, and hurt as they warm up again are Raynaud's phenomenon, which has a guide of its own.
• A crystal attack: gout. Severe pain arrives suddenly in a joint that becomes hot, swollen and red, usually the big toe, though the fingers and the wrists can be attacked too; in the hand it can be mistaken for osteoarthritis. Our gout guide covers it, and a joint both hot and swollen belongs with the same-day signs in the seek-help list below, because an infected joint can look just like it; a typical attack of gout you already know is dealt with in the gout guide's own seek-help section.
• Overuse and strain. A tendon that has swollen after a sudden or repeated effort, or an ache, stiffness and tingling in the hands and wrists from repeated movements at work or play, usually eases within two or three weeks once the task is rested; tingling that has crept on with the work and stays, or an ache that has not eased by then, is for a GP, though tingling with neck pain needs the same day, as the seek-help section says.
• An injury. Pain that began with a fall or a knock is treated as a sprain or a fracture until an X-ray says otherwise. A joint in the hand or wrist that no longer moves, one knocked out of its place, or an injury that leaves very bad pain or any tingling, pins and needles or numbness, is a 999 or A&E emergency, and so is a crack heard at the injury, skin near it turned blue, grey or cold, a wrist or hand left at an odd angle or out of shape, a finger pointing at an odd angle, or bone showing through a cut, as the seek-help section below says. Bruising and swelling are the ordinary marks of a sprain, and are for NHS 111 when they are large or still getting worse; short of all these signs, NHS 111 can say whether an X-ray is needed, and a sprain is looked after as the self-care section describes.

Where the hand hurts and what sets it off usually point the way before any test is needed:

• Pain at the base of the thumb on pinching, gripping and turning, with a bump forming there over time, points to wear
• Pain at the wrist's thumb side that flares when the thumb is lifted or scissors are used points to De Quervain's
• A finger or thumb that clicks, catches or locks bent, worst in the morning, points to trigger finger
• Tingling and numbness that build up over time in the thumb, index and middle fingers, worst at night and eased by shaking the hand, point to carpal tunnel syndrome
• A smooth lump on the back of the wrist, usually painless, points to a ganglion
• Soft, warm swelling of the knuckles and wrists on both sides, with morning stiffness lasting beyond the half hour, points to inflammatory arthritis
• A whole finger swollen like a sausage, or nails with tiny pits or dents, points to psoriatic arthritis
• A finger or wrist joint gone hot, swollen and very painful in the space of a few days points to gout or to an infection in the joint, and needs the same day, as the seek-help list below says; a typical attack of gout you already know is dealt with in the gout guide

These are pointers rather than a diagnosis: several of the causes look the same to the eye, and two can be present at once, as when wear at the wrist squeezes the nerve that runs through it. Soft swelling, a finger swollen along its length, or stiffness past the half hour, is for a GP within days; a hot joint is for the same day, by the routes the seek-help list gives; tingling, or numbness that has come on gradually, is one for a GP, or for the same day with neck pain, while numbness or weakness that came on suddenly with no injury behind it, even if it stops after a short time, or tingling or numbness that followed a fall or injury, is among the 999 or A&E signs, as the seek-help section says; the rest can begin at home, though if you have diabetes a GP is the first call for those as well.

Osteoarthritis is the commonest form of arthritis, and the hand and wrist are among the places it most often reaches. The smooth cartilage that covers the ends of the bones thins and roughens, so the joint no longer moves as freely and becomes painful and stiff. In the hand it favours three sites: the base of the thumb, the joints nearest the fingertips and the middle joints of the fingers, with the index and middle fingers and the thumb affected most, and the hand you use most the worse affected. It usually appears from 45 and is commoner in women, especially over 50. The genes you inherit, an earlier injury and years of repetitive tasks all make it likelier. The firm, knobbly swellings that grow at the finger joints are bony spurs, Heberden's nodes at the fingertip joints and Bouchard's nodes at the middle ones.

The joint at the base of the thumb deserves a paragraph of its own. The pain there is brought on by thumb use, especially pinching and a strong grip, and can spread up the thumb or down to the wrist and forearm; opening jars, turning a key in a lock and holding a pen become hard work; the muscle beside the thumb can waste, as it also can when the nerve at the wrist is under pressure; and in advanced wear a bump forms at the base of the thumb and the thumb can take on a zigzag shape. It is common in women: on X-ray it is present in about a quarter of women over 55, and many of them have no significant pain from it.

Hand osteoarthritis tends to burn out. It can be painful for a few years and then improve, particularly where only the small finger joints are involved, though the bumps stay and the movement does not always return. Sometimes the weather, cold weather in particular, makes it feel worse without changing its course. Three things can look like it and are not. Gout can attack the hand, and is checked with a blood test for urate and, where a joint is swollen, a sample of its fluid. Rheumatoid arthritis, unlike osteoarthritis, favours the large knuckles, so soft, warm swelling there with morning stiffness past the half hour prompts blood tests for it and a GP within days, the route our early inflammatory arthritis guide describes. Psoriatic arthritis has no blood test, and the clue is psoriasis, your own or a close relative's. Wear at the wrist can also squeeze the nerve that runs through it, bringing the numbness, tingling and night pain of carpal tunnel syndrome on top.

What helps is a set of things done together. Keeping the hand joints moving with specific hand exercises eases stiffness and protects grip strength, while heavy lifting and exercises that load the hands with body weight are best avoided. Gadgets such as electric tin openers, tools with thicker handles, a backpack instead of hand-carried bags and easier taps and fastenings take the strain off the joints. Warmth eases stiff hands, and a bowl of warm water in the morning is as good a start as any; an ice pack helps a joint that is swollen. A splint for the thumb, worn while you work rather than all day, can help pain and function in the longer term, and a hand therapist or occupational therapist can advise on the right one. For pain, an anti-inflammatory gel rubbed into the hands is the first choice; paracetamol may help, a short course of anti-inflammatory tablets can ease pain, inflammation and swelling, and capsaicin cream, made from chillies, is prescribed for the hands where the gels have not worked. A steroid injection can calm a flare at the base of the thumb or in the middle finger joints, and can be repeated a few times with several months between. Surgery is a last resort, since the symptoms often steady over the long term: at the base of the thumb the usual operation removes the small bone that forms one side of the worn joint, which usually gives good pain relief and keeps a good grip, and a fingertip joint that stays very painful despite everything else can be fixed permanently in a slightly bent position without losing the ability to grip. The condition as a whole has its own guide, osteoarthritis.

Most hand and wrist problems are recognised from your account and an examination: where the pain is and what brings it on, how long the hand takes to get going in the morning, and what the fingers, thumb and wrist can and cannot do when moved, pressed and tested for feeling and strength. Hand osteoarthritis, De Quervain's, trigger finger, a ganglion and carpal tunnel syndrome are usually clear at this point.

Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the tendons, the joints and any lump can be scanned there and then. In the hand its value is what it can see: it can find subtle inflammation around a tendon or in the small knuckle joints that an examination on its own may miss, particularly early in an inflammatory arthritis; it shows the tendons and the soft tissues around the joints; it tells what a lump is where that is in doubt; and it guides an injection to the exact spot. Our ultrasound clinic page covers the scan.

An X-ray is taken where the state of a joint matters to the plan, though it is often not needed to confirm osteoarthritis. Blood tests are added where the question is inflammation or gout: the inflammation markers CRP and ESR, rheumatoid factor and anti-CCP antibodies when the pattern points to an inflammatory arthritis, and urate when it points to gout. Where carpal tunnel syndrome is uncertain, or surgery for it is being weighed, a nerve conduction study measures how well the nerve at the wrist is working.

Each cause has its own treatment; the assessment therefore comes first:

• Hand osteoarthritis is managed as the section above describes, from exercises, splints and gels to a guided injection for a flare and, rarely, surgery.
• De Quervain's tenosynovitis can recover over a few weeks once the aggravating activities are eased, helped by a splint that holds the thumb as well as the wrist; a steroid injection relieves it in roughly seven cases in ten, and the few that persist can have the tendon tunnel released surgically.
• Trigger finger can clear up by itself; a small splint that holds the finger straight at night, even a lollipop stick held on with tape, stops the roughened tendon catching; a steroid injection relieves the pain and the triggering about as often, less reliably in people with diabetes; and a minor operation releases the tunnel where it keeps locking.
• Carpal tunnel syndrome starts with a wrist splint worn at night, which can take up to six weeks to work; a steroid injection at the wrist follows where the splint has not helped, and surgery to release the tunnel, a short operation under local anaesthetic, clears it in most cases.
• A ganglion can safely be left alone, and many disappear by themselves; where it hurts or gets in the way, the fluid can be emptied with a needle, though a wrist ganglion often refills, or the cyst can be removed, after which it usually does not return; a lump that has become very painful, hot or red is a same-day question, or a 999 or A&E emergency with the signs the seek-help list below gives.
• The inflammatory hand is treated as a whole, not finger by finger, along the route our early inflammatory arthritis guide sets out, because the first weeks of an inflammatory arthritis count most.
• Gout has its own treatment, for the attack and for its prevention, as its guide describes.

Where an injection is the answer, it can usually be given, ultrasound-guided, during that visit. You and Dr Borukhson settle the plan together.

For a hand or wrist that has begun to hurt, or a sprain once a broken bone has been ruled out:

• Rest it when you can, but keep it moving: gentle hand and finger exercises through the day limit stiffness, and stopping altogether weakens the hand
• Frozen peas in a tea towel, or an ice pack, on the painful part for up to twenty minutes every two to three hours eases a sore or swollen joint; warmth is for stiffness, not swelling: warm water or a wheat bag loosens stiff hands before you use them, and heat on a swollen hand can make it worse
• Ask a pharmacist about painkillers: paracetamol, or ibuprofen as a gel or, if needed, as tablets, which are not suitable for everyone, and do not use the gel and the tablets together without asking, since both reach the bloodstream. Clothes that ibuprofen gel has got onto catch fire more easily, so do not smoke when you have it on, and keep clear of open flames
• Cut back on the tasks that set it off, such as typing, a vibrating tool or an instrument, and use gadgets or tools that make gripping, opening and chopping easier
• A splint from a pharmacy or supermarket supports a painful wrist or thumb, especially at night; a flexible one lets you keep using the hand
• Take rings off a finger that has swollen, and do not lift heavy objects or grip anything too tightly while it is sore
• Never try to burst a ganglion, which risks infection and damage to the skin

Hand and wrist pain can nearly always begin with self-care and a routine appointment where it does not settle. Seven pictures should not wait: the signs that an infection, even one in the hand, has become sepsis, and the signs of meningitis; a hand or wrist that has been injured or cannot be used; a hand or an arm that has suddenly turned weak or numb, or another sign of a stroke; tingling in a hand, or numbness or weakness there that has crept on, with neck pain; a joint or a part of the hand where infection is possible; a red or sore eye, or altered sight; and a severe allergic reaction to a medicine. Anyone taking anti-inflammatory tablets has two signs of their own in the lists below as well.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, though fingers or toes that change colour in the cold, as they do in Raynaud's, are not what is meant; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• After an injury, a crack heard as it happened, or skin around it that has turned blue, grey or cold, since these can be signs of a broken bone
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time, and a hand or an arm that has suddenly gone weak or numb, with no injury behind it, is one of these signs
• An eye that suddenly and completely loses its sight
• Vomiting blood, or bleeding from the back passage that is heavy or will not stop, most of all with faintness, confusion or pain in the abdomen, or vomit that is black or dark brown, since anti-inflammatory tablets, which some people take for hand osteoarthritis, can make the stomach bleed
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine, though fingers or toes that change colour in the cold, as they do in Raynaud's, are not what is meant

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• A new red, painful eye, or sight that has blurred, dimmed or changed, which needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts, since psoriatic arthritis, one of the inflammatory causes this guide names, can inflame the eye; our uveitis guide says what to look for
• A lump, a finger or the palm that has turned very painful, hot or red, or hand pain with feeling hot, cold or shivery, since an infection in the hand can show itself this way and has to be found the same day, at A&E or through NHS 111 if a fever comes with it or you feel ill, short of the signs that follow; a lump, or the skin of a finger or the palm, turned hot or red, with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, which may be less obvious on black or brown skin, feeling dizzy or faint, confusion, or skin that is cold, clammy or pale, is a 999 or A&E emergency: call 999 and do not drive yourself to A&E
• Tingling in a hand, or numbness or weakness there that has come on gradually, with neck pain, since a nerve trapped at the neck can bring it on, and seeing someone that day tells it apart from pressure on the spinal cord, as our neck pain guide explains
• Black or dark red stools, on anti-inflammatory tablets, since a bleed in the stomach or gut has to be found that day

See a GP if the pain is getting in the way of normal life, is getting worse or keeps coming back, has not eased after two weeks of care at home, or comes with tingling, or a loss of feeling that has developed gradually in the hand, where no injury came before it and the neck is not painful; and see one whatever the timescale if you have diabetes, since hand problems can be more serious then. For a lump that is getting bigger, or is hard and does not move, see a GP promptly, not at the next routine slot, because a lump that keeps growing should be scanned urgently; a wrist or hand left at an odd angle or out of shape after an injury, a finger pointing at an odd angle, or bone showing through a cut is a 999 or A&E emergency, while an injury with none of these and none of the 999 or A&E list's signs, where a bone may be broken, is one for NHS 111, which can say whether an X-ray is needed. See a GP within days if your hands are stiff on waking for longer than half an hour, swollen or not, if a finger is swollen from end to end, or if the hands are swollen, warm and red, because these are the patterns of an inflammatory arthritis and the weeks matter, as our early inflammatory arthritis guide explains. See a GP within days, too, if the numbness no longer clears, you are dropping things, the hand has grown weak over time or the pad at the base of the thumb is shrinking, since a nerve that stays squeezed is best freed early. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. With neck pain, the nerve signs above, and tingling or numbness that came on gradually, belong to the same-day list instead; a hand that turns weak or numb suddenly belongs to the first list. If you cannot tell how urgent something is, asking is never a mistake.

The hand is small and its causes of pain sit close together: wear at the base of the thumb and De Quervain's hurt in the same corner, a trapped nerve and wear at the wrist go together, and a hot finger joint can be gout, an infection or the opening of an inflammatory arthritis, and goes by the lists above first: the signs of sepsis in the first list make it a 999 or A&E emergency. Short of what the lists hold, a specialist assessment works through the rest in one visit, with the examination, ultrasound of the tendons and joints, and a guided injection or a sample of fluid where one is needed, and it catches the inflammatory hand in the weeks when treatment does most good. If your hand or wrist pain is not settling, or returns, that visit can find what is behind it and treat it.

Is the pain at the base of my thumb arthritis?

From the mid-forties onwards it often is. The joint where the thumb meets the wrist is one of the three parts of the hand that osteoarthritis most often affects, along with the joints nearest the fingertips and the middle joints of the fingers, and it is common in women: about one woman in four over 55 shows it on an X-ray, though many of them have no great pain from it. The ache sits at the base of the thumb, is brought on by pinching, gripping and turning a key or opening a jar, and can spread up into the thumb or down towards the wrist; in time a bump can form there and the thumb can take on a zigzag shape. The same corner of the wrist is where De Quervain's tenosynovitis hurts, so the two are told apart on examination. Most people with it are managed without surgery: a thumb splint, hand exercises, an anti-inflammatory gel and, for a flare that refuses to calm, a steroid injection.

How can I tell osteoarthritis of the hand from rheumatoid arthritis?

By where it is and how it behaves. Osteoarthritis favours the fingertip and middle joints of the fingers and the base of the thumb; its swellings are hard and bony; it is worse the more the hand is used; any morning stiffness clears inside half an hour; and it starts, as a rule, from 45. Rheumatoid arthritis favours the small joints of the hands, the large knuckles where the fingers meet the hand among them, and the wrists, usually on both sides; its swelling is soft, warm and tender; the morning stiffness runs past the half hour; and a hand may not close into a fist. The large knuckles are less often affected by osteoarthritis, so pain and swelling there point the other way. Psoriatic arthritis adds clues of its own: a whole finger swollen like a sausage, nails that are pitted or discoloured, and psoriasis in you or your family, though it can arrive without any. Soft swelling with prolonged morning stiffness is what our early inflammatory arthritis guide takes up, and a GP should see it within days, not weeks.

Why do my hands tingle or go numb at night?

The common reason is a nerve being squeezed at the wrist, which is carpal tunnel syndrome. The median nerve runs into the hand through a narrow passage at the wrist alongside the tendons of the fingers, and pressure there brings tingling, numbness and pain in the thumb, index and middle fingers and part of the ring finger, a weak thumb or difficulty gripping, and a habit of shaking the hand to bring the feeling back. The symptoms tend to start slowly, come and go, and are worst at night. It is commoner in pregnancy and in people with diabetes or arthritis, can go with thyroid disease, and sometimes clears by itself within a few months, particularly after a pregnancy. A splint worn at night, which keeps the wrist straight, is the first treatment and can take up to six weeks to tell; a steroid injection at the wrist is the next step, and surgery to release the tunnel usually cures it. Tingling in the ring and little fingers alone is more often a nerve squeezed at the elbow, and tingling that spreads beyond the median nerve's fingers, or that comes with neck pain, can be a nerve trapped higher up, at the neck rather than the wrist, which our neck pain guide covers. Tingling of this kind, or numbness that has come on gradually, with no injury behind it and no neck pain, is a reason to see a GP; with neck pain it is a same-day matter for a GP or NHS 111, as the neck pain guide says, and after a fall or injury it is a 999 or A&E emergency. Numbness that stays, dropping things or a hand that is slowly weakening needs a GP within days, or the same day with neck pain, while a hand or an arm that suddenly goes weak or numb is a 999 or A&E emergency too, even if it stops after a short time, since it can be a stroke, as the seek-help section says.

What tests, if any, are needed?

Often none beyond the examination: the common causes, from wear at the base of the thumb to a nerve trapped at the wrist, are usually recognised from your account and a careful look at the hand. Point-of-care ultrasound is part of the consultation with Dr Borukhson, and in the hand it pays its way by seeing what fingers cannot feel: inflammation around a tendon or in a small finger joint early in an inflammatory arthritis, the contents of a lump, and the right spot for an injection. X-rays are for the joints when their state changes the plan, blood tests for the questions of inflammation and gout, and a nerve conduction study for a carpal tunnel diagnosis that is in doubt or where surgery is being weighed.

Will I need an injection or surgery?

Most hand and wrist problems are managed without either, by splints, exercises, hand therapy, painkillers and anti-inflammatory gels. A steroid injection has its place where those have not been enough. It relieves De Quervain's in about seven cases in ten and trigger finger in about the same proportion, less reliably in people with diabetes; it eases carpal tunnel syndrome where a splint has not, though the symptoms can return after some months; and it can calm a painful flare at the base of the thumb or in the middle joints of the fingers. Under ultrasound guidance the needle is watched on the screen and guided to the right spot. Surgery is for the minority whose problem persists: releasing the tunnel the nerve runs through, which cures carpal tunnel syndrome in most cases, or the tunnel a catching tendon runs through; removing a ganglion that keeps troubling you, after which it seldom comes back; and, at the base of the thumb, an operation that takes out the small worn bone at the joint's base, which usually relieves the pain well and keeps a good grip. That referral is to a hand surgeon.

When does hand or wrist pain need a doctor?

If you cannot move a joint in the hand or wrist, or a joint has moved out of place, that is a 999 or A&E emergency; so is a fall or injury that has left very bad pain or any tingling or loss of feeling, one where a crack was heard, one after which the skin near it has gone blue, grey or cold, or one that has left a wrist or hand at an odd angle or out of shape, a finger pointing at an odd angle or bone showing through a cut; so is a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours; and so are, with a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, any of which can be sepsis or meningitis (on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet; fingers or toes that change colour in the cold, as they do in Raynaud's, are not what is meant); and so are the signs of a stroke the seek-help list names, among them a hand or an arm turned weak or numb all at once with no injury behind it, even if they stop after a short time, and an eye that suddenly and completely loses its sight; so is a lump, or the skin of a finger or the palm, gone hot or red, with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, which may be less obvious on black or brown skin, feeling dizzy or faint, confusion, or skin that is cold, clammy or pale; and so is anything else in the first list under When to seek help. Call 999 and do not drive yourself to A&E. The GP is the first call for pain that limits what you can do, that is worsening or returning, that a fortnight of home care has not eased, or that brings with it tingling, or numbness that has come on gradually, when no fall or injury came first and the neck does not hurt, and for any hand problem if you have diabetes. A lump that is getting bigger, or is hard and does not move, is a prompt question for the GP, not one for the next routine slot, and a knock or fall with none of the signs that open this answer, where a bone could still be broken, goes to NHS 111 for the X-ray question. Stiffness after waking that lasts beyond half an hour, whether or not the hands are swollen, a finger swollen from end to end, or joints that are warm and red as well as swollen: any of these calls for a GP within days, since they are the patterns of an inflammatory arthritis. Numbness that no longer clears, dropping things, a hand that has slowly grown weak or a shrinking of the pad at the base of the thumb needs a GP within days, because a nerve kept under pressure recovers best once it is freed. You need no referral to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. With neck pain, those nerve signs, like tingling or numbness that came on gradually, need a GP or NHS 111 that day, since the nerve may be caught at the neck. A finger or wrist joint that has gone hot and swollen needs an answer that day. Where there is a fever, or you are unwell in yourself, that means the same day, either at A&E or by calling NHS 111; without those, an urgent GP appointment, NHS 111 or a specialist clinic that can see you that day is the place; a typical attack of gout you already know is dealt with in the gout guide. A lump, finger or palm that has become very painful, hot or red, or pain anywhere in the hand with feeling hot, cold or shivery, also needs the same day, infection being the worry: with a fever, or if you feel ill, the hospital route just described, short of the 999 or A&E emergency signs above, and otherwise your GP or NHS 111; pain anywhere in the hand with feeling unwell needs your GP or NHS 111 that day. A red, sore eye, or sight that blurs, dims or changes, needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts.