Arthritic, Metabolic, and Vascular Disorders

Chapter 10 Arthritic, Metabolic, and Vascular Disorders

Gregory Rowdon, David Taylor

Introduction 241

Inflammatory/rheumatologic 241

Metabolic disease 245

Vascular/lymphatic disorders 247

Introduction

Foot and ankle problems are common complaints to the physician who cares for athletes. Most of these complaints can be attributed directly to the athlete’s training and competition with their sport. However, athletes are not immune from disease. Most of these athletes will present to the sports medicine physician assuming their complaints are related to their participation, and many will try to explain their complaints as being secondary to some aspect of their training. Although the vast number of complaints evaluated by the sports medicine physician is directly attributable to a primary musculoskeletal source, the physician must maintain an appropriate differential diagnosis to include those disease states that also can affect the musculoskeletal system. The foot and ankle are common sites for these disease states to present as they mimic sports injuries.

Many of the individuals who present to a sports medicine clinic are not “highly competitive” athletes but are athletes nonetheless. These individuals are commonly referred to as “recreational athletes” and generally are older. They strive to maximize their abilities in their own chosen activity while attempting to reap the myriad of benefits of a healthy lifestyle. This group of athletes may have concurrent disease states that must be taken into account as they attempt to maintain their healthy, active lifestyle. Diseases such as diabetes, gout, thyroid conditions, osteoporosis, and so forth can present with musculoskeletal complaints. The purpose of this chapter is to review those disease states, which may mimic a primary musculoskeletal problem in both the competitive and recreational athlete. Knowledge of these conditions is essential to the physician caring for athletes.

Inflammatory/Rheumatologic

Still’s disease (adult onset)

Still’s disease is a seronegative polyarthritis that usually affects young adults. It is characterized in its initial manifestation as a spiking fever and a red/salmon colored rash, usually over the trunk and extremities. The rash is transient and appears at the time of the fever spikes. The inflammatory arthritis is a polyarthritis or oligoarthritis. It commonly affects the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints, as well as the wrists, knees, hips, and shoulders. Occasionally, the cervical spine, intertarsal joints, temporomandibular joints (TMJ), and the distal interphalangeal (DIP) joints are affected. It may lead to fusion of the carpal-metacarpal and the intercarpal joints. Laboratory evaluation commonly shows an elevated white blood cell count as well as an elevated erythrocyte sedimentation rate (ESR). Anemia of chronic disease is commonly present. Secondary nonmusculoskeletal findings include lymphadenopathy, hepatosplenomegaly, pericarditis, and carditis. The disease is treated with either high-dose aspirin or other nonsteroidal anti-inflammatory medicines. Often, oral steroids are required to control the disease. Overall, Still’s disease has a good prognosis.

Ankylosing spondylitis

Ankylosing spondylitis is an insidious onset seronegative inflammatory condition affecting young individuals, that is, generally younger than 40 years old. It has a uniform sex distribution, but the disease seems to be milder in females. Also, females have more peripheral involvement, rather than spine involvement. Ankylosing spondylitis affects the sacroiliac (SI) joints, followed by the spine and peripheral joints, respectively. There usually is symmetric loss of spine movement. The peripheral joint involvement occurs in 20% to 30% of ankylosing spondylitis patients and has a predilection for the lower extremities. Achilles’ tendinitis, plantar fascitis, and costochondritis also are associated with the disease process. It is common to have fatigue, weight loss, low-grade fever, and in more severe cases, uveitis, pulmonary fibrosis, and cardiac abnormalities. Laboratory findings include an elevated ESR. The natural history of ankylosing spondylitis is poorly defined, with some patients experiencing minimal disease and some patients experiencing severe disease. Treatment usually involves physical therapy and anti-inflammatories.

Reiter’s syndrome

Reiter’s syndrome involves the triad of arthritis, uveitis, and conjunctivitis. It commonly occurs following an episode of either genitourinary or gastrointestinal infection. It has associated features of inflammatory eye lesions, balanitis, oral ulcers, and keratodermatitis. Reiter’s syndrome has a male to female occurrence of 5:1. The arthritis experienced in Reiter’s syndrome is a reactive arthritis rather than an infectious arthritis. It usually occurs 2 to 6 weeks following the onset of an infectious episode. It is asymmetric and mainly affects knees and ankles. It is usually of acute onset. There may be diffuse swelling of fingers and toes, that is, sausage digits. There is commonly inflammatory change at both the Achilles’ tendon insertion and the plantar fascial origin. There also may be associated low-back pain with involvement of the SI joints, making it difficult to distinguish it at times from ankylosing spondylitis. The conjunctivitis in Reiter’s syndrome is either unilateral or bilateral. It usually is mild and transient and is a noninfectious source like the arthritis. Common skin lesions in Reiter’s syndrome are small, shallow, painless, penile ulcers called balanitis circinata. Another associated skin lesion is keratoderma blenorrhagica, which represents hyperkeratotic skin lesions mainly involving the soles of the feet, but they also can be found on the palms and the scrotum. Radiographic findings may demonstrate erosions or periosteal changes, particularly at the Achilles’ tendon insertion or plantar fascial origin. Also, an asymmetric sacroiliitis may be present that is in contrast to the symmetric involvement of ankylosing spondylitis. Reiter’s syndrome also is seronegative but usually demonstrates an elevated ESR and elevated white blood count. Treatment for Reiter’s syndrome involves anti-inflammatory medications and intra-articular steroid injections as well as physical therapy. Systemic oral steroids have been shown to be of minimal benefit. Topical steroids are used for the skin lesions and for the conjunctivitis. The prognosis for Reiter’s syndrome usually falls into one of three courses; the majority of athletes experience recurrent attacks of arthritis, whereas others experience a single, self-limited episode or a continuous, unremitting course.

Psoriatic arthritis

Psoriatic arthritis is the combination of psoriasis and inflammatory arthritis. To make a definitive diagnosis of psoriatic arthritis, skin or nail changes of psoriasis must be present at some point in the course of the disease. The arthritic changes can be present before skin changes develop. The joint pattern in psoriatic arthritis is variable but commonly includes a pauciarticular asymmetric arthritis involving the peripheral joints. It is common to have the spine involved in combination with peripheral joints as well as inflammation of tendon and insertion points of tendons, that is, enthesitis. Digits may become sausage like. There often are associated eye changes, including conjunctivitis, iritis, and episcleritis. Psoriatic arthritis has an equal sex distribution and usually has onset in the 30- to 40-year-old age group. Laboratory results are often normal, but some athletes will present with an elevated ESR and/or a normocytic normochromic anemia. Synovial fluid evaluation typically reveals a mild inflammatory process. Radiographs often reveal DIP erosive disease, sacroiliitis, and enthesopathy and/or periostitis. Treatment of psoriatic arthritis involves the use of anti-inflammatory medications, physical therapy, and intra-articular corticosteroids to treat the inflammatory arthritis. The focus of treatment, however, involves treating the athlete’s skin lesions. Oral methotrexate is a common therapeutic choice because it treats both the skin lesions and the arthritis. Overall, psoriatic arthritis has a good prognosis.

Enteropathic arthritis

Enteropathic arthritis is arthritis associated with inflammatory gastrointestinal (GI) conditions including ulcerative colitis and Crohn’s disease, and infectious GI conditions, including Shigella, Salmonella, Campylobacter, Yersinia, and Whipple’s disease. The arthritis, when associated with ulcerative colitis or Crohn’s disease, usually is one of a peripheral arthritis with associated sacroiliitis and less often enthesopathies. It often is a transient, oligoarticular, migratory, nondestructive arthritis associated with the bowel disease activity. The knees and ankles are most often involved. Synovial fluid from the affected joints contains mild to severe inflammation. There are a variety of associated cutaneous lesions with the disease, and mucosal, serosal, and ocular lesions may occur. The arthritis with ulcerative colitis and Crohn’s disease often resolves with medical or surgical treatment of the intestinal disease.

The arthritis associated with enteropathic infection often comes on a few weeks following the bowel symptoms. The arthritis, in this case, is a reactive arthritis and, again, affects mainly knees and ankles. There also may be axial joint involvement. Enthesopathies, although not common in association with ulcerative colitis and Crohn’s disease, are common in association with infectious GI conditions and typically involve the plantar fascia and Achilles’ tendon insertions. The arthritis is usually self-limited, resolving weeks to months after the bowel infection. Treatment is symptomatic involving the use of anti-inflammatory medications, physical therapy, and intra-articular corticosteroid injections.

Rheumatoid arthritis

Rheumatoid arthritis is a chronic, systemic inflammatory disease characterized by significant joint involvement. It affects multiple systems extensively, and thus a full detailed description of the disease is beyond the scope of this chapter. It involves symmetric upper extremity, knee, and foot destructive changes, sparing the DIP joints of the hands and feet. It results in progressive joint destruction and deformity. Again, there are multiple extra-articular features, including rheumatoid nodules, arteritis, neuropathies, scleritis, and pericarditis. Lymphadenopathy and splenomegaly are common. The incidence in females is two to three times greater than in males. It may occur at any age and increases in frequency with increasing age. Hand, wrist, knee, and foot are most commonly involved, but any diarthrodial joint can be affected. The elbows, shoulders, sternoclavicular (SC) joints, hips, ankles, and temporomandibular joints (TMJ) are less commonly involved. Spine involvement is limited to the upper cervical spine.

Feet and ankle changes are similar to those seen in the hands. Cocking up of the toes may occur secondary to subluxation of the metatarsal heads. This gives the digits a claw-like appearance. Fibular deviation of the first through fourth toes may occur. Bursal inflammation about the foot/ankle also occurs with the retrocalcaneal bursa being most common. Laboratory evaluation usually shows a normocytic, normochromic or hyperchromic anemia. There often is an elevated ESR and positive rheumatoid factor. Joint fluid evaluation reveals mild inflammation. Treatment involves anti-inflammatory medications, as well as physical therapy. Intra-articular corticosteroid injections are used for symptomatic joints not responsive to initial treatment. Second-line therapy involves disease-modifying antirheumatic drugs (DMARDs) with the trend toward more aggressive/earlier use of these drugs.

Systemic lupus erythematosus (SLE)

SLE is a chronic, multisystem inflammatory disease affecting bone, joints, tendons, skin, kidney, heart, lungs, GI tract, and central nervous system (CNS). Again, a full and detailed description of the disease process is beyond the scope of this text. SLE has a 9:1 female to male ratio. The arthralgias and arthritis are a common presenting complaint. The arthralgia/arthritis often is symmetric. Joint capsule, ligamentous, and tendon involvement can be prominent in the disease, and hand or foot deformities may develop. There often are marked laboratory abnormalities, including a normocytic, normochromic anemia, leukopenia, thrombocytopenia, elevated ESR, and positive antinuclear antibody (ANA) and double-stranded DNA. Treatment is with anti-inflammatories, topical/oral steroids, antimalarials, and immunosuppressive agents.

Gout

The pathogenesis of gouty arthropathy involves tissue deposition of uric acid crystals from a supersaturated extracellular fluid. Gout involves recurrent attacks of severe articular or periarticular inflammation. Late involvement of the disease involves crystal deposition of uric acid within articular, osseous, soft tissue, and cartilaginous structures. These tophi occur late (>10 years) in the disease. There may be renal impairment with or without uric acid urinary calculi. Hyperuricemia may be demonstrated in individuals without gout and uric acid levels may be within the normal range in individuals showing clinical gouty arthropathy. Gout is a disease of middle-aged men and postmenopausal women. It increases in frequency with age.

An acute, gouty, arthritic flare most commonly involves the great toe metatarsophalangeal (MTP) joint but also commonly involves the ankle. It usually involves a single joint with an acute onset, often during the evening hours. The joint often appears warm, red, and swollen and usually is exquisitely tender. The flare may subside spontaneously 3 to 10 days following onset without treatment. Individuals often are symptom free following an acute attack, but over time, if untreated, the attacks may increase in frequency, increase in the number of joints affected, and increase in duration of symptoms when flared. The flares may be triggered by trauma, alcohol, drugs, stress, or medical illness. Tophi when present occur most commonly in the synovial tissue, subchondral bone, olecranon bursa, patellar and Achilles’ tendons, subcutaneous tissue on the extensor surface of the forearms, and overlying joints. Radiographic findings in gout usually are negative. Often they are obtained to rule out other joint processes, such as a septic joint, or to evaluate for the presence of chondrocalcinosis. More chronic cases can show periarticular erosions and frank degenerative changes, especially in the great toe MTP joint. The gold standard for diagnosis is monosodium uric crystals demonstrated in joint fluid. The white blood cell count from a symptomatic joint usually reveals moderate inflammation. Treatment in the acute setting may involve colchicine, anti-inflammatory medications, steroids, or intramuscular adrenocorticotrophic hormone (ACTH). Treatment in the chronic setting may also involve the use of colchicine as well as allopurinol or probenecid.

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Tags: Baxters The Foot and Ankle in Sport

Jul 18, 2016 | Posted by admin in SPORT MEDICINE | Comments Off

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