Arthritis psoriatic achilles tendon spur

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Most cases of heel pain encountered in clinical practice are likely to have a biomechanical reason and respond to the usual treatment protocols.

Various systemic arthritides are capable of presentation as heel pain. These include the seronegative arthritides, psoriatic arthritis, Reiter’s disease, diffuse idiopathic skeletal hyperostosis, rheumatoid arthritis, fibromyalgia, and gout.

These patients may have other joint symptoms and should be questioned regarding other joint symptoms. This, in conjunction with careful imaging evaluation and laboratory testing, may provide help in proper diagnosis and treatment of these patients.

Psoriatic Arthritis (PsA) is an inflammatory arthritis that occurs in 2-7% of those with psoriasis (psoriasis affects 1-2% of population). Most have previous long history of psoriasis – and many people with psoriasis can develop arthritis. There is a high association with HLA-B27 and HIV infection.

There are five clinical types:

1) Oligoarticular and polyarthritis with distal interphalangeal joint involvement - asymmetric – usually get the classic ‘sausage’ digits (affects 50-70%).
2) Asymmetric involvement of distal interphalangeal joints of hands and feet – digits affected - usually have nail changes; progressive bone erosions frequently occur (affects 5-10%)
3) Symmetric seronegative polyarthritis resembling rheumatoid arthritis (in 15-25%; morning stiffness and fatigue are common) – usually milder/less destructive than rheumatoid arthritis and does not develop extra-articular manifestations.
4) Sacroilitis and spondylitis (in 5%; resembles ankylosing spondylitis) – spinal involvement is predominant feature
5) Arthritis mutilans (widespread destructive polyarthritis with marked bone resorption; in about 1-5%; often get osteolysis of bones in fingers and toes; frequently get back pain)

The major clinical features are:

• Male incidence is the same as females. The age range is 35-50 years (juvenile form, usually 9-12 years).
• Symptoms are variable due to different clinical types. The interphalangeal joints of the fingers and toes are most commonly involved; knee and ankle are occasionally involved.
• The arthritis precedes or occurs simultaneously with the onset of the psoriasis in about a third of cases.
• There is no relationship between severity of psoriasis and psoriatic arthritis, but the arthritis is more common in those with more severe skin lesions.
• There is a relationship between the severity of psoriatic nail changes and arthritis. Occasionally patients have fatigue, fever, conjunctivitis and iritis.

Laboratory tests show elevated ESR, mild low white count, negative RA factor, mild anemia and a high neutrophil count in synovial fluid.

The differential diagnosis includes Reiter’s syndrome, gout, rheumatoid arthritis.

Involvement of the foot is frequent. Heel pain is the presenting feature in up to 10%.

Foot involvement is usually bilateral and asymmetric. It may be the initial presenting feature of psoriatic arthritis and usually affects the the interphalangeal joints.

Posterior tibial tendon problems may be presenting feature of psoriatic arthritis – other tendon sheaths can also be commonly involved.

X-rays of the foot show erosions (bilateral and symmetrical), bone proliferation, joint space loss (often severe), osteolysis of distal tufts, destruction of IPJ’s, and ‘pencil in a cup’ deformity of phalanges. The calcaneus will generally show proliferative and erosive changes of posterior and inferior aspects. The Achilles tendon may be thickened.

“Sausage toe” is a condition where the toe is swollen (dactylitis) due to involvement of MPJ, PIPJ and DIPJ’s.

Up to 70% of patients get plantar heel pain and other entheses also get affected.

Involvement of the plantar fascia can also occur.

Tarsal tunnel syndrome may be seen. Finally, nail changes occur in 80% with pitting, ridging, hyperkeratosis and onycholysis.

The tendon problems that occur with psoriatic arthritis may respond to steroid injection.

However, a newer treatment for tendonitis may be more effective. Percutaneous needle tenotomy is a technique where a small gauge needle is introduced using local anesthetic and ultrasound guidance. The needle is used to poke several small holes in the tendon. This procedure is called "tenotomy." Tenotomy induces an acute inflammatory response. Then, platelet rich plasma, obtained from a sample of the patient's whole blood is injected into the area where tenotomy has been performed. Platelets are cells that contain multiple healing and growth factors. The result? Normal good quality tendon tissue is stimulated to grow with natural healing.

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