Objective To investigate the metabolic syndrome (MetS) association with radiographic and symptomatic hand osteoarthritis (OA). Methods Using 1:2 propensity-score-matching for relevant confounders, we included 2509 (MetS+896: MetS–1613) participants from the Osteoarthritis Initiative dataset. MetS and its components, according to the International Diabetes Federation criteria, were extracted from baseline data, including hypertension, abdominal obesity, dyslipidemia, and diabetes. We scored distinct hand joints based on modified Kellgren–Lawrence grade (mKL) of baseline radiographs, with OA defined as mKL≥2. In the cross-sectional analysis, we investigated the association between MetS and its components with radiographic hand OA and the presence of nodal and erosive OA phenotypes using regression models. In the longitudinal analysis, we performed Cox regression analysis for hand pain incidence in follow-up visits. Results MetS was associated with higher odds of radiographic hand OA, including the number of joints with OA (odds ratio, 95%confidence interval:1.32, 1.08–1.62), the sum of joints mKLs (2.42, 1.24–4.71), mainly in distal and proximal interphalangeal joints (DIPs:1.52, 1.08–2.14, PIPs:1.38, 1.09–1.75), but not metacarpophalangeal (MCP) and first carpometacarpal (CMC1) joints. Hand pain incidence during follow-up was higher with MetS presence (hazard ratio, 95%CI:1.25, 1.07–1.47). Erosive hand OA phenotype and joints' nodal involvement were more frequent with MetS (1.40, 1.01–1.97, and 1.28, 1.02–1.60). Conclusion MetS, a potentially modifiable risk factor, is associated with radiographic DIP and PIP OA and longitudinal hand pain incidence while sparing MCPs and CMC1. Nodal and erosive OA phenotypes are associated with MetS, suggestive of possible distinct pathophysiology.