Sports-Related Joint Pain … or is it?

ALYSHA TAXTER, MD Disclosures

 None Objectives

 Case 1  Discussion

 Case 2  Discussion Case 1

 3 year old female started gymnastics class and fell off trampoline

 Previously healthy  No fevers or URI symptoms  Limp does not slow her down

Laboratory Workup

13.6 10.2 220 Lyme studies:  ELISA: IgG positive, IgM positive  ANC 5700  Western blot: IgG 3  ALC 3200 bands, IgM 1 band (negative Lyme testing)  ESR 14

 CRP <0.5mg/dL  normal CMP  negative parvo B19  ANA positive 1:320

Western Blot: Lyme arthritis is a late finding

Western blotting in the serodiagnosis of Lyme disease. Dressler F, Whalen JA, Reinhardt BN, Steere AC. J Infect Dis. 1993 Feb;167(2):392-400 Lyme Arthritis Photo courtesy of David Sherry Lyme Arthritis Treatment

 Amoxicillin 50 mg/kg/day div TID (max 500 mg po TID) x 28 days  Cefuroxime 30 mg/kg/day div BID (max 500 mg po BID) x 28 days  Doxycycline 4 mg/kg/day div BID (max 100 mg po BID) if older than 8 years x 28 days  One or two courses of po antibiotics  Corticosteroid injection for refractory Lyme arthritis  Arthritis is not due to persistent infection  Likely due to persistently activated immune response

Red Book Physical Exam

 Leg length discrepancy: the affected leg is longer by 2 cm  Lacks full extension of left knee  Thigh atrophy  Knee is warm to touch without erythema or induration

Leg length discrepancy

Photo courtesy of David Sherry Thigh Atrophy

 Typically not grossly apparent  Need to measure

Photo courtesy of David Sherry Oligoarticular Juvenile Idiopathic Arthritis

 Arthritis in 4 or fewer joints for 6 weeks  Usually swollen and warm but not painful  70% ANA positive – usually low titer  TMJ disease  20% asymptomatic (esp if ANA+)  Treatments:  Intra-articular corticosteroid injection  NSAIDS  Methotrexate  Biologics

When to test an ANA

 Lupus  Raynaud phenomenon  Juvenile idiopathic arthritis

 Do not test for myalgias or fatigue Oligoarticular JIA: classic phenotype 1-3 year old Caucasian girl 20% asymptomatic iritis 70% + ANA leads to higher risk of iritis

.Visual loss, blindness .1975 - 7/90 .1989 - 0/278

ANA

thigh atrophy

knee > ankle > fingers

leg length discrepancy Slide courtesy of Dr. David Sherry Photo courtesy of Dr. David Sherry Photo courtesy of Dr. David Sherry Flare: cells in anterior chamber Synechiae: adhesion of lens to cornea

Band Keratopathy: calcium deposits on cornea

Cassidy et al Sports Clearance?

 Okay to participate in  Our goal is for kids to be activity as tolerated asymptomatic and be  Avoid highly dynamic active in any sport they sports if actively choose inflamed  Consider PT if joint  Consider inserts/lifts if significant leg length discrepancy Case 2

 14 year old male with foot pain  Does not interfere with basketball practice or games  Limps with leg and foot pain afterwards  Worse the next morning  Limps and morning stiffness for 30 minutes  Initially with ankle and mid-foot pain, now with back pain •Metatarsal heads •Base of the 5th • •Plantar fascial insertion insertion

Photos courtesy of Dr. David Sherry •Sinding-Larsen-Johansson = inferior patellar pole •Osgood-Schlatter = tibial tuberosity

Photos courtesy of Dr. David Sherry Greater trochanter Sacroiliac Joint

Photos courtesy of Dr. David Sherry Modified Schober Test

10 cm > 21 cm 5 cm

Standing Forward flexion

What is Enthesitis?

Inflammation where a tendon  Patella at 6:00 o’clock attaches to a bone  Patella 2:00 and 10:00  Metatarsal heads o’clock  insertion  Greater trochanter  Achilles tendon insertion  Sacral iliac joints (lower  Tibial tuberosity third of the joint)

Laboratory Workup

13.3 8.7 425

 ANC 5100  ALC 2500  ESR 42 (<20)  CRP 2.0 mg/dL (0-0.9)  Negative celiac  HLA B27 positive Imaging

Enthesitis-Related Arthritis

 Arthritis and enthesitis -OR-  Arthritis or enthesitis with 2 of the following  Sacroiliac joint tenderness  HLA B27 positive  First degree relative with B27 disease  Anterior uveitis  Onset of arthritis in a male over age 6 Enthesitis-Related Arthritis

 Onset late childhood-adolescence  Males>females  B27 disease associated with inflammatory bowel disease  Can have familial occurrence  Usually lower-extremity enthesitis

 Can see enthesitis with other diseases as well as children without arthritis Sports Clearance?

 Participate in activity as tolerated  Stay active!  Encourage stretching  Our goal is for kids to be as active as their peers

Juvenile Idiopathic Arthritis

 Oligoarticular (pauciarticular) <5 joints  Polyarticular >4 joints  Systemic  Enthesitis-related  Psoriatic  Undifferentiated Take-Home Points

 Oligoarticular arthritis typically has normal labs  Look at other joints if one is swollen  ANA does not diagnose arthritis  Consider enthesitis related arthritis if multiple enthesopathies and back pain  Stay active! References

 The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt L, Fish D, Dumler JS, Nadelman RB. Clin Infect Dis. 2006 Nov 1;43(9):1089-134. Epub 2006 Oct 2. Erratum in: Clin Infect Dis. 2007 Oct 1;45(7):941.  Outcomes of children treated for Lyme arthritis: results of a large pediatric cohort.Tory HO, Zurakowski D, Sundel RP. J Rheumatol. 2010 May;37(5):1049-55. doi: 10.3899/jrheum.090711. Epub 2010 Apr 1. PMID: 20360182  Treatment of Lyme arthritis. Steere AC, Levin RE, Molloy PJ, Kalish RA, Abraham JH 3rd, Liu NY, Schmid CH. Arthritis Rheum. 1994 Jun;37(6):878-88.  Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis. Feder HM Jr, Abeles M, Bernstein M, Whitaker-Worth D, Grant- Kels JM. Clin Dermatol. 2006 Nov-Dec;24(6):509-20.  Sensitive and specific serodiagnosis of Lyme disease by enzyme-linked immunosorbent assay with a peptide based on an immunodominant conserved region of Borrelia burgdorferi vlsE. Liang FT, Steere AC, Marques AR, Johnson BJ, Miller JN, Philipp MT. J Clin Microbiol. 1999 Dec;37(12):3990-6.  Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. American College of Pathologists. Arch Pathol Lab Med 2000;124(1):71–81.  Evidence-based guidelines for the use of immunologic tests: Antinuclear antibody testing. Solomon DH, Kavanaugh AJ, Schur PH. Arthritis Rheum 2002;47(4):434-44.  Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, Piazza A, Pradella M, Rizzotti P. Am J Clin Pathol 2002;117(2):316-24.  Red Book: 2006 Report of the Committee of Infectious Diseases. 27th edition. Elk Grove Village, IL: American Academy of Pediatrics; 2006.  Textbook of Pediatric Rheumatology. Cassidy et al. 6th edition. Philadelphia, PA: Elsevier, 2011.