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All Posts Tagged Tag: ‘enthesopathy’

Can reducing stress on the legs of Mice teach us about Spondyloarthritis?

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http://i650.photobucket.com/albums/uu221/dunc_89/mouse-cute.jpg

Courtesy of photobucket.com

By Dr Irwin Lim, Rheumatologist

Professor Dirk Elewaut visited us at our Parramatta clinic today. He’s on a speaker tour around Australia and kindly agreed to come to talk to our team (I’m really ticked off that I forgot to get a photo for this post).

He talked about many aspects of Ankylosing Spondylitis (AS) and spondyloarthritis (SpA). It was entertaining and engaging. One particular topic has been playing on my mind so I thought I’d give you my simple man’s interpretation.

In a series of experiments, his group looked at how mechanical stress can lead to enthesitis (learn about enthesitis here) and new bone formation, features common to AS/SpA.

  • They convinced some genetically modified mice to take part. These mice get a spondyloarthritis-type disease.
  • The first signs of inflammation in these mice occur at the enthesis, and typically at the achilles tendon insertion and/or plantar fascia insertion.
  • When they looked under a microscope, these areas in these mice show lots of inflammatory cells. This is what would be expected.
  • They then (as ethically & comfortably as possible) suspended the hind limbs of the mice. This meant that there was much reduced load on these hind limbs.
  • In these unloaded hind limbs, there was very much less accumulation of inflammatory cells at the enthesis. There is also less new bone formation.

The conclusion is that these findings provide proof of the concept that actual mechanical strain drives both entheseal inflammation and new bone formation (click here for the abstract).

Now, mice and humans are quite different.

But, let’s assume that these findings can be applied to patients with SpA.

We know our patients with AS and SpA get a lot of heel pain and achilles problems, in addition to enthesitis elsewhere.

If a trigger for this is mechanical load or stress, some questions arise:

  • is this why males get the disease in their early adulthood when they’re running around and playing more vigorous sport?
  • exercise usually helps patients with AS and SpA greatly but could it possibly be detrimental?
  • perhaps, the type of exercise matters more: high impact like jogging versus lower impact like swimming
  • is a desk-based sit-on-your-bum job better than a stand-all-day type of job?

I am by no means advocating stopping or changing exercise if you have AS or SpA. We just don’t know yet.

A lot more research in mice (they’re convincing some mice to now run very far and very fast to see what this does to the entheseal region) and some research in humans will be needed.

But, I thought it would be interesting for you to ponder.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
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I came for my arthritis. Why are you staring at my belly button?

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Psoriasis at Umbilicus

Psoriasis at Umbilicus

By Dr Irwin Lim, Rheumatologist

This is such a nice photo. I had to share it with you.

Classic psoriatic rash.

He presented with various aches and pains, including a most frustrating chronic tennis elbow (lateral epicondylitis) affecting his cricket. A little dry scalp, somewhat scaly. And this rash, at the umbilicus. A classic, often “hidden” site.

I use this as a reminder that the diagnosis of Psoriatic Arthritis needs a high index of suspicion and then a hunt for clues.

In the last few months, I’ve written the following posts to try and raise awareness:

  • The Arthritis that affects Nails, Tendons (Entheses) & Skin (link)
  • Psoriatic Arthritis: it’s easy to miss (link)
  • The Nails giveth the Diagnosis (link)
  • Which PsA Questionnaires do you think a dermatology clinic will use? (link)
  • Psoriatic Arthritis for Dermatologists: A Rheumatology Perspective (link)
  • Tennis Elbow: sometimes it means more (link)

Phew! That’s a lot of reminders.

This blog’s also read, as you would expect, by our BJC Health team, and I’m writing this post with our physiotherapists and exercise physiologists in mind. I’m positive they, like their colleagues outside our clinic, are seeing patients presenting to them for tendon and/or entheseal (entheses = area where tendons connect to bone) problems. Sometimes, there is an underlying disease.

I’m working on helping us not miss this difficult-to-make diagnosis.

BJC Health established the Sydney Spondyloarthritis Centre in 2011. We raise the profile of these diseases, we provide a better pathway to diagnosis, provide education as well as world-class treatment. Most importantly, we care & we want to improve the lives of people suffering from these diseases. Read about it here.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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Tennis Elbow: sometimes it means more

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Tennis elbowBy Dr Irwin Lim, Rheumatologist

Tennis elbow (or lateral epicondylitis) is common. Chances are you’ve experienced it or know someone who has.

You don’t need to have played tennis. Typically, any repetitive activity straining the forearm extensor muscles can lead to it. It can be quite irritating and can restrict your activities a lot.

Physiotherapists often work on the forearm muscles. The good ones also try to improve the upper limb biomechanics.

GPs often prescribe anti-inflammatory medications or inject corticosteroids (rheumatologists do this too).

Sports doctors & orthopaedic surgeons may inject all sorts of stuff, including PRP (platelet rich plasma) or autologous blood.

Most cases are due to mechanical injury and repeated aggravation, and there is a clear need to avoid the repetitive aggravation.

But, sometimes, it’s a symptom/sign of an underlying disease.

The tennis elbow may be very chronic and hard to treat.  There may be repeated episodes affecting either elbow. Or the person suffering this complaint may be really prone to tendon injury. For example, they may also have suffered patella tendon issues or plantar fasciitis or been told they have heel spurs.

Tendons, and their Entheses, the region where the tendons insert, are a common area affected by spondyloarthritis. Think of Psoriatic Arthritis. Think of Ankylosing Spondylitis.

When faced with recalcitrant and/or widespread tendinopathy or enthesopathy (read Enthesopathy:What’s that?), the rheumatologist will usually cast a wider net, and consider a deeper cause. Many of our patients have spent frustrating months or even years attempting to get their tennis elbow fixed.

Sometimes, it means more that overuse.

Does this change things for you?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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Psoriatic Arthritis: It’s easy to miss

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By Dr Irwin Lim, Rheumatologist

I have a sneaky suspicion that in dermatology clinics and GP rooms all around the land, many patients with psoriasis sit unaware of why they have pain in their joints, tendons or spine.

Ok, it’s more than a suspicion. We know this occurs.

Psoriasis is a really common skin condition. It causes a reddish, scaly rash. Typically on the elbows or over the knees, or on the scalp but it can affect any bit of skin. It can be very mild with a small patch or terrible severe covering large parts of the body.

Up to 30% of patients with this skin disease are thought to also get musculoskeletal problems. Rheumatological Issues.

That’s why we rheumatologists are involved in the care of psoriasis patients. And we want to be more involved.

Psoriatic arthritis (read more) is unfortunately easy to miss. Easy to not think of and therefore, often not diagnosed or misdiagnosed.

If patients with the skin condition present with polyarthritis, that is, multiple painful and swollen joints simultaneously, it will usually be picked up. Florid disease triggers action.

The more common scenario is the patient who has “minor” complaints. Possibly just a knee which is a little swollen. Or a wrist which aches in the morning. Or maybe, it’s been that damn Achilles’ tendon or tennis elbow (enthesopathy) that has been irritating for months. In many, there’s some neck or lower back pain that’s associated with morning stiffness.

Sometimes, it’s all the above, waxing and waning over years.

Each complaint/symptom can be explained away on the basis of poor body mechanics or some trauma such as a lifting injury or excessive exercise.

It’s easy to miss (and misdiagnose).

Frustratingly, blood tests often don’t help. Psoriatic arthritis belongs to the seronegative spondyloarthritis group (learn more about this group). Seronegative because the RF (rheumatoid factor) tests is negative but in many cases, inflammatory markers are not raised. There is also no specific antibody test we can measure for psoriatic arthritis.

Makes our lives difficult, doesn’t it?

Radiology can be helpful. There can be erosions seen on Xrays and often there is some overgrowth of bone that can be suggestive. These changes take time to develop so by the time the changes are very suggestive of psoriatic arthritis, it’s pretty late. Early on, what you see on radiology can be non-specific and can be explained by other reasons.

Calcaneal Spurs

I’m painting a pretty demoralising picture.

Like so much in rheumatology, we need to do better. It does start with awareness but we then need targeted campaigns to highlight this problem in clinics where patients are already being seen: Skin units, Dermatology clinics and the local GPs’ rooms.

We want ways to stop this diagnosis being missed. Any ideas how?

BJC Health established the Sydney Spondyloarthritis Centre in 2011. We raise the profile of these diseases, we provide a better pathway to diagnosis, provide education as well as world-class treatment. Most importantly, we care & we want to improve the lives of people suffering from these diseases. Read about it here.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
Enter your email address: Delivered by FeedBurner

The Arthritis that affects Nails, Tendons (Entheses) & Skin

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By Dr Irwin Lim, Rheumatologist

The non-doctors among you will still clearly see the destruction evident in those hands.

This lady presented late with the damage already done. For decades, she had been treated as having Osteoarthritis of the hands. She does have this, but she also reported intermittent painful softer tissue swelling with a lot of stiffness.

In her case, she has both osteoarthritis of the hands and psoriatic arthritis.

The clue was her skin.

She has psoriasis affecting her scalp and her elbows. This has been mild and has been treated with steroid creams and tar-based shampoos over the years. Psoriasis is a very common skin condition with the skin becoming red and irritated, and typically scaly.

Chances are that someone in your family or someone you know has psoriasis.

The diagnosis of psoriasis is usually pretty straightforward. It needs a doctor to look at the skin for the typical features.

In up to 30% of patients with psoriasis, there is an associated arthritis. This makes Psoriatic arthritis very common and like many rheumatic disease, the diagnosis seems to often be missed.

Some patients with psoriasis have changes in their nails, such as increased pits seen in the nail, increased ridges or even lifting of the nail. These patients  with nail involvement are more likely to also have their joints affected.

Psoriatic arthritis can present in many ways:

  • Big joint disease, such as knee swelling or pain
  • Small joint disease, such as swelling in the joints in the hands or feet
  • Spine disease with Inflammatory Spinal Pain
  • Swelling of the toes or fingers, to the point the involved digit looks like a sausage (called dactylitis)
  • It can affect all of the above, in any combination.
  • It can affect many joints simultaneously, or only 1 joint.
  • The arthritis can occur periodically or can be progressive, either slowly or rapidly.
  • The arthritis can be relatively mild or can be terrible destructive.

In addition, tendon problems and more specifically, inflammation where tendons insert (known as Enthesopathy / Enthesitis) are very common. Think of tennis elbow, quadriceps tendinopathy, plantar fasciitis or achilles problems.

The ability of psoriatic arthritis to present in such a diverse way may be one reason it’s not diagnosed more often. Perhaps, the symptoms are explained in some other way. Wear and tear, osteoarthritis, sporting injury are all easy to blame.

We really do need to improve awareness of this disease.

Most patients with psoriasis have never been told about the possible non-skin manifestations.

If you or someone you know has psoriasis, and is complaining of joint or tendon problems, at least consider psoriatic arthritis as a possible cause.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
Enter your email address: Delivered by FeedBurner
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