“HEEL PAIN”: EXPANDING OUR DIFFERENTIAL DIAGNOSIS TO INCLUDE SERONEGATIVE SPONDYLOARTHROPATHIES - PDF Document

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  1. 1 “HEEL PAIN”: EXPANDING OUR DIFFERENTIAL DIAGNOSIS TO INCLUDE SERONEGATIVE SPONDYLOARTHROPATHIES AMBER HERRICK, MS, PA-C ASAPA 2019

  2. 2 • No Disclosures

  3. LECTURE OBJECTIVES 3 • List the seronegative spondyloarthropathies (SpA) • Recognize the clinical features and extra-articular manifestations of seronegative SpA • Expand your review of systems and physical exam to broaden your differential diagnosis • Identify appropriate laboratory and diagnostic tests for seronegative SpA • Determine first line treatment options or indications for referral

  4. 4 CASE STUDY

  5. CASE STUDY 5 • 17-year-old male presents to your office with a history of low back pain, worsening over the past few months • He recalls having intermittent back pain for at least a year • On occasion, pain radiates into the buttocks • ROS: denies fever, weight loss, night sweats, incontinence, or hx of trauma • Denies family history of “back problems” • No pertinent medical history • He is a Junior in high school, runs cross country • Denies tobacco/ETOH/recreational drug use

  6. 6 WHAT IS IN YOUR DIFFERENTIAL? Musculoskeletal (Mechanical) Infection Malignancy Inflammatory • Lumbar sprain/strain • Scoliosis • Spondylolysis • Spondylolisthesis • Osteomyelitis • Epidural abscess • SI joint infection • Solid malignancy • Primary or metastatic • Leukemia/lymphoma • Ankylosing spondylitis • Psoriatic arthritis • IBD-associated arthritis • Reactive arthritis

  7. 7 INFLAMMATORY VS. MECHANICAL BACK PAIN Understanding the pattern of pain

  8. PATTERN OF PAIN 8 Morning stiffness • How long? Effect of exercise and rest • Does the pain improve with activity? What about rest? Nocturnal pain • What time of the night?

  9. INFLAMMATORY VS. MECHANICAL BACK PAIN 9 Hx Inflammatory < 40 Insidious > 3 months > 60 min Frequent Mechanical Age of onset Type of onset Symptom duration Morning stiffness Nocturnal pain Effect of exercise/activity Improvement Rest Any Acute More sudden onset < 30 min Absent Exacerbation Improvement No improvement DubaAS, et al. 2018 Poddubnyy D, et al. 2015

  10. OUR PATIENT 10 • 17-year-old male presents to your office with a history of low back pain, worsening over the past few months • He recalls having intermittent back pain for at least a year • On occasion, the pain radiates into the buttocks • ROS: denies fever, weight loss, night sweats, incontinence, or hx of trauma • Morning stiffness: generally lasting for 1-2 hrs, improves with stretching • Back pain is better with activity, worse with rest • He is able to run cross-country w/out exacerbating his back pain • Has noticed the pain wake him up in the middle of the night

  11. DIFFERENTIAL FOR INFLAMMATORY BACK PAIN… 11 • Ankylosing Spondylitis • Psoriatic Arthritis Seronegative Spondyloarthropathies (SpA) • Reactive Arthritis • Arthritis associated with IBD • Gout

  12. SERONEGATIVE SPONDYLOARTHROPATHIES 12 Ankylosing Spondylitis Undifferentiated SpA Arthritis with IBD Sacroiliitis Psoriatic Arthritis Reactive Arthritis • In the United States, the overall prevalence of SpA is 1% • Typical age of onset is between 17 and 45 • Delay in diagnosis reported to be between 5 and 10 years • Ankylosing Spondylitis is the most prevalent followed by Psoriatic Arthritis

  13. SPONDYLOARTHRITIS 13 Spondyloarthopathy (SpA) “Classic Features” Ankylosing Spondylitis “Bamboo spine” PsoriaticArthritis Psoriasis,nail pitting, “sausage digits” Reactive Arthritis (formerly Reiter’s Syndrome) Arthritis associated with IBD “Can’t see, can’t pee, can’t climb a tree” Ulcerative Colitis or Crohn disease

  14. SPONDYLOARTHRITIS (SPA) 14 A family of inflammatory rheumatic diseases that cause arthritis Two Classifications: • Predominately Axial Disease 1. Ankylosing Spondylitis (AS) 2. Non-radiographic axial SpA • Axial symptoms • SI joints (sacroilitis) • Spine (spondylitis) Possible overlap • Peripheral symptoms • Peripheral arthritis • Enthesitis • Dactylitis • Predominately Peripheral Disease 1. Reactive arthritis (ReA) 2. Psoriatic arthritis (PsA) 3. Arthritis associated with IBD 4. Undifferentiated SpA

  15. SHARED CLINICAL FEATURES OF SPONDYLOARTHRITIS 15 • Inflammatory back pain • Enthesitis • Dactylitis • Peripheral arthritis • Uveitis • Similar association with HLA-B27 • Usually RF-negative (seronegative)

  16. 16 CLINICAL FEATURES

  17. INFLAMMATORY BACK PAIN 17 • Often chronic with stiffness • Predominantly of the lower back/buttocks • Alternating buttock pain • SI joint tenderness Hx Inflammatory < 40 Insidious > 3 months > 60 min Frequent Improvement No improvement • Limited spinal mobility • Special maneuvers • Modified Schober • Occiput-to-wall • Chest expansion • FABER test Age of onset Type of onset Symptom duration Morning stiffness Nocturnal pain Effect of exercise/activity Rest

  18. 18 On forward flexion, distance < 5 cm is abnormal

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  21. ARTHRITIS AND ENTHESITIS 21 • Peripheral arthritis • Predominantly found in the lower limbs, frequently asymmetrical • Generally swollen and painful “Heel Pain” • Enthesitis • Particularly the insertion of the achilles tendon or the plantar fascia at the calcaneus • May appreciate swelling and local tenderness on exam

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  24. DACTYLITIS 24 • “Sausage digit” • Fingers and toes • What do the hands look like ?

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  26. 26 EXPANDING THE REVIEW OF SYSTEMS…

  27. HISTORY AND EXAM CLUES 27 • Skin • Psoriasis, erythema nodosum, pyoderma gangrenosum • Rash? Nail changes? • Nail pitting, onycholysis (PsA); (ReA) • Circinate balanitis, keratoderma blennorrhagicum (ReA) • HEENT • Eye: pain, redness, visual disturbances? • Uveitis; conjunctivitis (ReA) • Arthritis associated with IBD; ReA • Oral mucosa: ulcers? • GI/GU • Arthritis associated with IBD • FHx of IBD? Hospitalizations? Surgeries? Bowel habits? • ReA • Dysuria? Sexually active/STI? • Recent diarrheal illness/colitis? • ReA; AS DubaAS, et al. 2018

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  29. ASSESSMENT OF SPONDYLOARTHRITIS INTERNATIONAL SOCIETY (ASAS) CRITERIA FOR AXIAL SPONDYLOARTHRITIS 29 In patients with ≥ 3 months back pain and age at onset < 45 years Sensitivity = 82.9% Specificity = 84.4% HLA-B27 plus ≥ 2 SpA features Sacroiliitis on imaging* plus ≥ 1 SpA feature Or SpA Features • Dactylitis • Inflammatory back pain • FHx of SpA • Psoriasis • Arthritis • HLA-B27 • Crohn’s/ UC • Enthesitis (heel) • Good response to NSAIDs • Elevated CRP • Uveitis * Sacroilitis on imaging refers to definite radiographic sacroilitis according to the modified New York criteria or sacroilitis on MRI according to the ASAS consensus definition Sieper J, et al. 2017

  30. ASSESSMENT OF SPONDYLOARTHRITIS INTERNATIONAL SOCIETY (ASAS) CRITERIA FOR PERIPHERAL SPONDYLOARTHRITIS In patients with peripheral manifestations ONLY Sensitivity = 77.8% Specificity = 82.2% Arthritis* or enthesitis or dactylitis plus ≥ 1 SpA Feature ≥ 2 SpA Features • Preceding infection • Uveitis • Arthritis Or • HLA-B27 • Psoriasis • Enthesitis • Crohn’s/ UC • Dactylitis • Sacroilitis on imaging • Inflammatory back pain (ever) • FHx for SpA *Peripheral arthritis: usually predominantly lower limb and/or asymmetric arthritis Braun J, et al. 2012; Rudwaleti, et al. 2011

  31. 31 WORKUP AND TREATMENT

  32. DIAGNOSTIC STUDIES 32 • X-rays—preferred initial modality • Sacroiliitis and spondylitis • Squaring of the vertebrae, syndesmophytes, ankylosis (fusion) (AS) • “bamboo” spine • “Pencil in cup” deformity (PsA) • MRI useful for detecting early axial inflammatory disease • MSK Ultrasound • Joint inflammation, enthesitis, and tendonitis

  33. 33 ANKYLOSING SPONDYLITIS Sclerotic change with almost complete fusion of the SI joints bilaterally (grade IV sacroiliitis) • Syndesmophyte formation of the lumbar spine • Case courtesy of Townsville radiology training, Radiopaedia.org, rID: 18889

  34. 34 PSORIATIC ARTHRITIS • “Pencil-in-cup” Case courtesy of RMH Core Conditions, Radiopaedia.org, rID: 33845

  35. LABORATORY EVALUATION 35 • CBC • CMP • CRP or ESR • HLA-B27 • Sensitivity: 80-90%, specificity 90% • * RF/Anti-CCP • Arthrocentesis/synovial fluid analysis • ? STI testing

  36. ASSESSMENT OF SPONDYLOARTHRITIS INTERNATIONAL SOCIETY (ASAS) CRITERIA FOR AXIAL SPONDYLOARTHRITIS 36 In patients with ≥ 3 months back pain and age at onset < 45 years HLA-B27 plus ≥ 2 SpA features Sacroiliitis on imaging* plus ≥ 1 SpA feature Or SpA Features • Dactylitis • Inflammatory back pain • FHx of SpA • Psoriasis • Arthritis • HLA-B27 • Crohn’s/ UC • Enthesitis (heel) • Good response to NSAIDs • Elevated CRP • Uveitis * Sacroilitis on imaging refers to definite radiographic sacroilitis according to the modified New York criteria or sacroilitis on MRI according to the ASAS consensus definition. Sieper, et. al 2017

  37. TREATMENT 37 Predominant Manifestation Axial Manifestations: back pain and stiffness Peripheral Manifestations: arthritis, enthesitis, dactylitis NSAIDs First-line therapy Non-pharmacological treatment: education, exercise, physical therapy, rehabilitation, self-help groups, smoking cessation Local Steroids DMARDs Second-line therapy TNF-alpha blocker or IL-17 blocker Additional therapy in special clinical situations Analgesics Surgery Sieper, et al. 2017

  38. REFERRAL 38 In patients with ≥ 3 months back pain and age at onset < 45 years Refer to a rheumatologist if at least one of the following parameters is present: Inflammatory back pain; Elevated acute phase reactants HLA-B27 positivity; Good response to NSAIDs Sacroiliitis on imaging (X- ray or MRI); Positive family history for SpA Extra-articular manifestations; Poddubnny D, et al. 2015

  39. THANK YOU! 39 Amber Herrick, MS, PA-C aherri@midwestern.edu

  40. REFERENCES 40 • Sieper J and Poddubnyy D. Axial spondyloarthritis. Lancet. 2017; 390:73-84. doi: 10.1016- S0140-6736(16)315191-4. • Duba SA, Mathew SD. The Seronegative Spondyloarthropathies. Prim Car Clin Office Pract. 2018; 45: 271-287. doi: 10.1016/j.pop.2018.02.005 • Poddubnyy D, van Tubergen A, Landewé R, et al. Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis. Ann Rheum Dis. 2015;74:1483–1487 • Spondylitis Association of America (https://www.spondylitis.org/) • Braun J and Sieper J. Classification, Diagnosis, and Referral of Patients with Axial Spondyloarthritis. Rhum Dis Clin N Am. 2012; 38: 477-485. http://dx.doi.org/10.1016/j.rdc.2012.08.002

  41. REFERENCES 41 • UpToDate • Radiopaedia • Young People, Bad Backs: Understanding Inflammatory Back Disease. Benjamin J Smith, PA-C, DFAAPA. 2018 AAPA Conference. • Rheumatology 101: Understanding the Basics of Degen/Autoimmune Syndromes: OA, RA, Ankylosing Spondylitis (AS), SLE. Antonio Giannelli MsA, PA-C, DFAAPA. 2018 AAPA Conference. • Seronegative Spondyloarthropathies: The Great Deceiver. Antonio Giannelli MsA, PA-C, DFAAPA. 2017 AAPA Conference. • Rudwaleti M, et al. The Assessment of Spondyloyarthritis international Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011; 70: 25-31. doi: 10.1136/ard.2010.133645