Giant cell tumor of the tendon sheath (GCTTS) is a common tumor affecting the hand and foot, often presenting diagnostic and therapeutic challenges due to its variable clinical presentations and biological behaviors. Recent evidence supports a neoplastic origin for this tumor, previously known by various names. GCTTS can be categorized as localized or diffuse, with distinct predilections for specific anatomical locations. While localized GCTTS is typically benign and more common in the hand and wrist, the diffuse form can be aggressive, also affecting the foot and ankle. This critical analysis review aims to provide a comprehensive overview of GCTTS in hand and foot, encompassing its clinical, radiological, histological, and genomic features. In addition, we summarize current management practices, discuss differential diagnoses, analyze recurrence rates following surgical excision, and offer evidence-based treatment recommendations for this diverse group of tumors.