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Psoriasis and the Risk of Foot and Ankle Tendinopathy Or Enthesopathy in the Absence of Psoriatic Arthritis: a Population-Based Study

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Psoriasis and the Risk of Foot and Ankle Tendinopathy Or Enthesopathy in the Absence of Psoriatic Arthritis: a Population-Based Study Psoriatic arthritis RMD Open: first published as 10.1136/rmdopen-2018-000668 on 21 May 2018. Downloaded from ORIGINAL ARTICLE Psoriasis and the risk of foot and ankle tendinopathy or enthesopathy in the absence of psoriatic arthritis: a population-based study Ryan T Lewinson,1,2 Isabelle A Vallerand,1,3 Laurie M Parsons,4 Jeremy M LaMothe,5 Alexandra D Frolkis,4 Mark W Lowerison,3 Gilaad G Kaplan,4 Scott B Patten,3,6 Cheryl Barnabe3,4 To cite: Lewinson RT, ABSTRACT Vallerand IA, Parsons LM, et al. Objectives Imaging studies in patients with cutaneous Key messages Psoriasis and the risk of foot psoriasis have demonstrated asymptomatic bone and What is already known about this subject? and ankle tendinopathy or tendon changes, commonly of the foot and ankle. We enthesopathy in the absence of Imaging studies suggest that many patients sought to determine if patients with cutaneous psoriasis ► psoriatic arthritis: a population- with psoriasis have asymptomatic foot and ankle have an increased risk of clinically significant foot and based study. RMD Open bone and tendon lesions. ankle tendinopathy or enthesopathy compared with the 2018;4:e000668. doi:10.1136/ What does this study add? rmdopen-2018-000668 general population. Methods Patients with cutaneous psoriasis and a ► Patients with cutaneous psoriasis had a 25% in- general population cohort were identified inT he Health creased risk of developing tendinopathy or enthe- Prepublication history for ► Improvement Network, a general practice medical sopathy of the foot and ankle. this paper is available online. How might this impact on clinical practice? To view these files please visit records database from the UK. All patients with psoriatic arthritis were excluded. Cox proportional-hazards models ► Patients with psoriasis may present with foot and the journal online (http:// dx. doi. ankle tendinopathy or enthesopathy without neces- org/ 10. 1136/ rmdopen- 2018- (α=0.05) estimated the HR for development of foot and sarily having psoriatic arthritis. 000668). ankle tendinopathy or enthesopathy among patients with psoriasis, with adjustment for numerous covariates. http://rmdopen.bmj.com/ Received 14 February 2018 Results In total, 78 630 patients with cutaneous psoriasis Revised 2 April 2018 and 5 983 338 persons from the general population were From a musculoskeletal perspective, Accepted 1 May 2018 identified. In an unadjusted model, patients with cutaneous 8%–30% of patients with psoriasis develop psoriasis had a 25% increased risk of developing foot psoriatic arthritis,7 8 a chronic inflammatory and ankle tendinopathy or enthesopathy compared with arthropathy.8 While joint involvement is the the general population (HR 1.25, 95% CI 1.20 to 1.30, main distinguishing feature between psoriatic p<0.0001). The HR remained unchanged and statistically arthritis and psoriasis, a recognised extra-ar- significant after adjusting for covariates, and in sensitivity ticular feature of psoriatic arthritis is inflam- on September 24, 2021 by guest. Protected copyright. analyses. Conclusions These data suggest that patients with mation of tendons, usually at their insertions psoriasis can have foot and ankle tendinopathy or or entheses, termed tendinopathy and enthe- 8 9 enthesopathy without having psoriatic arthritis, presenting sopathy respectively. Most commonly, this a diagnostic challenge to physicians. Further research manifests at the plantar fascia and Achilles is needed to elucidate mechanisms contributing to this tendons,9 causing significant foot and ankle increased risk. pain and immobility. Tendon and entheseal involvement is typi- cally considered a feature exclusive to psori- INTRODUCTION atic arthritis rather than psoriasis. However, Psoriasis is an inflammatory skin disease recent studies using high-resolution periph- characterised by pruritic, erythematous, eral quantitative CT scans have shown that scaling plaques, papules and occasionally psoriasis patients without arthritis had pustules.1 2 While originally thought to be a significant enthesophyte formation, signal- For numbered affiliations see disease limited to the skin, recent evidence ling enthesopathy, compared with healthy end of article. suggests that systemic consequences occur in controls.10 Moreover, in an MRI study of Correspondence to psoriasis, such as increased risk of myocardial patients with psoriasis, it was found that 57% 3 4 5 Dr Cheryl Barnabe; infarction, chronic kidney disease, cancer had evidence of asymptomatic Achilles tend- ccbarnab@ ucalgary. ca and depression.6 inopathy.11 On ultrasound imaging, patients Lewinson RT, et al. RMD Open 2018;4:e000668. doi:10.1136/rmdopen-2018-000668 1 RMD Open RMD Open: first published as 10.1136/rmdopen-2018-000668 on 21 May 2018. Downloaded from Table 1 Read codes used to define foot and ankle cohort) and those without psoriasis (referent cohort). tendinopathy or enthesopathy in this study Diagnosis of psoriasis was based on the presence of one or more validated Read diagnostic codes (linked to N217400 Achilles tendinitis International Classification of Diseases codes) for psori- N217500 Tibialis anterior tendinitis asis.14 Any patient with a psoriasis code within 1 year of N217600 Tibialis posterior tendinitis registering in THIN was excluded from this study, to N217900 Plantar fasciitis ensure that all cases of psoriasis were incident, as done 15 N217.00 Enthesopathy of the ankle and tarsus previously. Additionally, to ensure focus on cutaneous psoriasis patients without arthritis, any patient with a N217z00 Ankle or tarsus enthesopathy NOS validated Read code for psoriatic arthritis at any time in N217000 Enthesopathy of the ankle unspecified their record was excluded from this study.16 Finally, any N217100 Enthesopathy of the tarsus unspecified patients with a Read code for foot and ankle tendinop- NyuAD00[X] Other enthesopathy of foot athy or enthesopathy (main outcome) prior to psoriasis N217.11 Tarsus enthesopathy diagnosis were excluded. The referent cohort (general population) also had a Consensus on which codes to use was established by a 1-year washout period, and any patient who had a preva- rheumatologist and orthopaedic surgeon. lent code for foot and ankle tendinopathy or enthesop- athy within this period was excluded from analysis. with spondyloarthropathy had more frequent enthe- sopathy in the absence of clinical symptoms compared Outcomes 12 with healthy controls. Thus, it appears that patients All patients were followed until the earliest of (a) devel- with psoriasis may develop pathology consistent with opment of foot and ankle tendinopathy or enthesopathy tendon dysfunction, but since these studies were rela- (main outcome), (b) transfer out of practice, (c) death tively small and without clinical follow-up, it remains or (d) end of data collection period. Patients who did not unknown whether patients with psoriasis actually experi- have a record of tendinopathy or enthesopathy during ence clinically significant tendon and entheseal disorders this follow-up period were censored. Development at a greater rate than the general population. of foot and ankle tendinopathy or enthesopathy was In this study, we used The Health Improvement defined based on the presence of any Read code relating Network (THIN), a general practice medical records to tendinopathy or enthesopathy of the foot and ankle. database in the UK, to test the hypothesis that psoriasis Read codes that were determined to relate to foot and patients without psoriatic arthritis are at increased risk of ankle tendinopathy and enthesopathy were identified as developing clinically significant foot and ankle tendinop- follows: first, all Read codes relating to tendinopathy or http://rmdopen.bmj.com/ athy or enthesopathy compared with the general popu- enthesopathy were identified. This list was then reviewed lation, thereby identifying a potential extracutaneous independently by a rheumatologist and orthopaedic manifestation. We focused exclusively on the foot and surgeon, where consensus was established on which ankle (a) as these are the most common sites observed codes would properly capture tendinopathy or enthe- for tendon dysfunction in patients with psoriatic arthritis sopathy specific to the foot and ankle. While enthesitis 9 (ie, Achilles tendon and plantar fascia), (b) as previous is the more common outcome for patients with psori- research has shown imaging evidence of disease at these atic arthritis, tendinopathy was included to broaden our 11 sites in patients with psoriasis and (c) to explore the definition since this also occurs in psoriatic arthritis.17 on September 24, 2021 by guest. Protected copyright. concept of a ‘deep Koebner’ phenomenon, with selec- Additionally, since clinically defining tendon injury as tion of a site with high mechanical loading offering tendinopathy versus enthesopathy is dependent only on pathophysiological insight. the point along the tendon at which the injury occurs, we considered both terms in our analysis in hopes of METHODS improved sensitivity, given not all patients with tendon Data source pain may have imaging to confirm where along the THIN is an electronic database that contains general tendon the injury was to classify them as enthesopathy practice medical records from the UK with up to 25 or tendinopathy. Read codes used in our analysis for foot years of follow-up.13 Additionally, data from specialists and ankle tendinopathy or enthesopathy can be found are provided to general practitioners and subsequently in table 1.
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