Regular readers might remember that during marathon training back in 2013 I developed a nasty case of Proximal Hamstring Tendinopathy (PHT). Fortunately with some rehab, a graded return to running and a little gait re-training my PHT resolved and no longer causes me any pain. I've moved on from the injury but a recent development has left me wondering if there was more to my PHT than met the eye…

We know from research that tendinopathy is often caused by a rapid increase in load. In runners we often hear the common story of pain starting after a big change in training but there are other factors to consider too. One often neglected piece of the puzzle is past medical history and, in my case, psoriasis.

Psoriasis is a common skin complaint characterised by patches of red, flaky skin. I've had it since I was a teenager. It can also be accompanied by psoriatic arthritis which involves inflammation of the joints and may present with insertional tendinopathy, like PHT. Now this isn't news to me and I was aware of this when my PHT started but I had no joint pain to speak of…until now!…

…Over Christmas this year I started to develop some finger pain in the Distal Interphalangeal Joint (DIP – the joint at the end of your finger) of my left middle finger. DIP joints are a common site for psoriatic arthritis. I also have nail bed changes (see picture below) which are more common in those with psoriatic arthritis.

These changes over Christmas got me wondering about whether I might have the early signs of psoriatic arthritis and prompted me to ask some friends who work in Rheumatology. @PDKirwan, @PhysioJack and @DrAiLynTan were a great help and suggested that with a history of psoriasis, tendinopathy, nail bed changes and finger pain I should see a rheumatologist. I made an appointment and half expected to be told, “dont' worry there's nothing wrong” but that's not quite how it went!…

… After a brief subjective history and examination the consultant said something along the lines of, “You may well have psoriatic arthritis but we'll need further tests to know one way or the other.” He was concerned that joint symptoms I'd happily dismissed as normal aches and pains might be the very early signs of inflammatory joint pain.

In my case of PHT my symptoms co-incided with a rapid increase in hill running (see below) which is known to be an aggravating factor for the hamstring tendon. It still seems likely that this was the underlying cause but it may be that a low level of psoriatic arthritis was present and influenced the tendon's ability to manage load. Trauma or rapid increase in loading can lead to an onset or aggravation of psoriatic arthritis and related tendon symptoms.

At the moment we don't know whether I have psoriatic arthritis or whether it was in anyway implicated in the development of my tendon pain. It's certainly food for thought though with tendon symptoms which are often dismissed as purely load related. My case certainly isn't an isolated one. I see lots of patients for 'second opinion' work when previous treatment has failed. Recently we've had a longstanding case of bilateral achilles tendon pain that appears to be due to previously undiagnosed ankylosing spondylitis and are awaiting rheumatology assessment for other patients with tendon and plantar fascial pain. So what can we take from all this?…

…Don't forget the past medical history! Seek appropriate specialist input if you suspect involvement of rheumatological conditions including psoriatic arthritis, rheumatoid arthritis, ankylosing spondylitis and gout. Most of these conditions present with joint pain, swelling and early morning stiffness but these signs can be subtle in early stages. Early diagnosis is important for long term joint health and effective treatment. Despite this, diagnosis is frequently delayed, for example the average time to diagnosis of ankylosing spondylitis can be as high as 8-11 years (although Danish research does suggest this is improving).

We're currently developing a questionnaire to help clinicians identify relevant medical history and plan appropriate treatment and onward referral. We'll share this shortly on the site. As for me I'm presently awaiting an ultrasound of my achilles tendon and x-rays of my hand and wrists… I'll keep you posted!!…

If you're concerned about your joint health consult your physio, GP or health professional. It's best to get these things checked out!

 

2 COMMENTS

  1. Severe and recalcitrant (especially bilateral) plantar fasciopathy, Achilles tendinopathy should always prompt consideration of seronegative inflammatory arthritis – AS, enteropathic, psoriatic etc.

  2. […] Psoriatic Arthritis (PsA) is a spondyolarthropathy usually linked to the skin condition psoriasis which typically presents as red, flaky patches of skin. The Psoriasis Foundation suggests that around 30% of those with psoriasis will go on to develop PsA. Those with nail changes (see below) are more likely to develop inflammatory joint symptoms so if you identify thickening, whitening or pitting of the nails it should raise your index of suspicion. The British Association of Dermatologists developed this assessment form for suspected PsA. I have a history of psoriasis, nail changes, joint pain (albeit very mild) and proximal hamstring tendinopathy which has prompted me to see a rheumalogist (more on that here). […]

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