Ankle Arthritis

Psoriatic arthritis is a form of arthritis that affects some people who have psoriasis — a condition that features red patches of skin topped with silvery scales. Most people develop psoriasis first and are later diagnosed with psoriatic arthritis, but the joint problems can sometimes begin before skin patches appear.

Joint pain, stiffness and swelling are the main signs and symptoms of psoriatic arthritis. They can affect any part of your body, including your fingertips and spine, and can range from relatively mild to severe. In both psoriasis and psoriatic arthritis, disease flares may alternate with periods of remission.

No cure for psoriatic arthritis exists, so the focus is on controlling symptoms and preventing damage to your joints. Without treatment, psoriatic arthritis may be disabling.

Both psoriatic arthritis and psoriasis are chronic diseases that get worse over time, but you may have periods when your symptoms improve or go into remission alternating with times when symptoms become worse.

Psoriatic arthritis can affect joints on just one side or on both sides of your body. The signs and symptoms of psoriatic arthritis often resemble those of rheumatoid arthritis. Both diseases cause joints to become painful, swollen and warm to the touch.

However, psoriatic arthritis is more likely to also cause:

• Swollen fingers and toes. Psoriatic arthritis can cause a painful, sausage-like swelling of your fingers and toes. You may also develop swelling and deformities in your hands and feet before having significant joint symptoms.
• Foot pain. Psoriatic arthritis can also cause pain at the points where tendons and ligaments attach to your bones — especially at the back of your heel (Achilles tendinitis) or in the sole of your foot (plantar fasciitis).
• Lower back pain. Some people develop a condition called spondylitis as a result of psoriatic arthritis. Spondylitis mainly causes inflammation of the joints between the vertebrae of your spine and in the joints between your spine and pelvis (sacroiliitis).

When to see a doctor

If you have psoriasis, be sure to tell your doctor if you develop joint pain. Psoriatic arthritis can severely damage your joints if left untreated.

Psoriatic arthritis occurs when your body's immune system begins to attack healthy cells and tissue. The abnormal immune response causes inflammation in your joints as well as overproduction of skin cells.

It's not entirely clear why the immune system attacks healthy tissue, but it seems likely that both genetic and environmental factors play a role. Many people with psoriatic arthritis have a family history of either psoriasis or psoriatic arthritis. Researchers have discovered certain genetic markers that appear to be associated with psoriatic arthritis.

Physical trauma or something in the environment — such as a viral or bacterial infection — may trigger psoriatic arthritis in people with an inherited tendency.

Several factors can increase your risk of psoriatic arthritis, including:

• Psoriasis. Having psoriasis is the single greatest risk factor for developing psoriatic arthritis. People who have pitted, deformed nails are especially likely to develop psoriatic arthritis.
• Your family history. Many people with psoriatic arthritis have a parent or a sibling with the disease.
• Your age. Although anyone can develop psoriatic arthritis, it occurs most often in adults between the ages of 30 and 50.

A small percentage of people with psoriatic arthritis develop arthritis mutilans — a severe, painful and disabling form of the disease. Over time, arthritis mutilans destroys the small bones in the hands, especially the fingers, leading to permanent deformity and disability.

People who have psoriatic arthritis sometimes also develop eye problems such as pinkeye (conjunctivitis) or uveitis, which can cause painful, reddened eyes and blurred vision. They are also at higher risk of cardiovascular disease.

During the exam, your doctor may:

• Closely examine your joints for signs of swelling or tenderness
• Check your fingernails for pitting, flaking and other abnormalities
• Press on the soles of your feet and around your heels to find tender areas

No single test can confirm a diagnosis of psoriatic arthritis. But some types of tests can rule out other causes of joint pain, such as rheumatoid arthritis or gout.

Imaging tests

• X-rays. Plain X-rays can help pinpoint changes in the joints that occur in psoriatic arthritis but not in other arthritic conditions.
• Magnetic resonance imaging (MRI). MRI uses radio waves and a strong magnetic field to produce very detailed images of both hard and soft tissues in your body. This type of imaging test may be used to check for problems with the tendons and ligaments in your feet and lower back.

Laboratory tests

• Rheumatoid factor (RF). RF is an antibody that's often present in the blood of people with rheumatoid arthritis, but it's not usually in the blood of people with psoriatic arthritis. For that reason, this test can help your doctor distinguish between the two conditions.
• Joint fluid test. Using a needle, your doctor can remove a small sample of fluid from one of your affected joints — often the knee. Uric acid crystals in your joint fluid may indicate that you have gout rather than psoriatic arthritis.

Treatment

No cure exists for psoriatic arthritis, so treatment focuses on controlling inflammation in your affected joints to prevent joint pain and disability.

Medications

Drugs used to treat psoriatic arthritis include:

• NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription.
  Side effects may include stomach irritation, heart problems, and liver and kidney damage.
• Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of psoriatic arthritis and save the joints and other tissues from permanent damage.
  Common DMARDs include methotrexate (Trexall, Otrexup, others), leflunomide (Arava) and sulfasalazine (Azulfidine). Side effects vary but may include liver damage, bone marrow suppression and severe lung infections.
• Immunosuppressants. These medications act to tame your immune system, which is out of control in psoriatic arthritis.
  Examples include azathioprine (Imuran, Azasan) and cyclosporine (Gengraf, Neoral, Sandimmune). These medications can increase your susceptibility to infection.
• Biologic agents. Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), ixekizumab (Taltz), secukinumab (Cosentyx), tofacitinib (Xeljanz) and ustekinumab (Stelara).
  These medications target specific parts of the immune system that trigger inflammation and lead to joint damage. These drugs can increase the risk of infections. Higher doses of tofacitinib can increase the risk of blood clots in the lungs. Biologic agents can be used alone or combined with DMARDs, such as methotrexate.
• Newer oral medication. Apremilast (Otezla) decreases the activity of an enzyme in the body that controls the activity of inflammation within cells. Potential side effects include diarrhea, nausea and headaches.

Surgical and other procedures

• Steroid injections. This type of medication reduces inflammation quickly and is sometimes injected into an affected joint.
• Joint replacement surgery. Joints that have been severely damaged by psoriatic arthritis can be replaced with artificial prostheses made of metal and plastic.

Lifestyle and home remedies

• Protect your joints. Changing the way you carry out everyday tasks can make a tremendous difference in how you feel.
  For example, you can avoid straining your finger joints by using gadgets such as jar openers to twist the lids from jars, by lifting heavy pans or other objects with both hands, and by pushing doors open with your whole body instead of just your fingers.
• Maintain a healthy weight. Maintaining a healthy weight places less strain on your joints, leading to reduced pain and increased energy and mobility.
  Losing weight if needed can also help your medications work better. Some psoriatic arthritis medications are less effective in people who have a body mass index of 25.0 to 29.9 (overweight).
  The best way to increase nutrients while limiting calories is to eat more plant-based foods — fruits, vegetables and whole grains.
• Exercise regularly. Exercise can help keep your joints flexible and your muscles strong. Types of exercises that are less stressful on joints include biking, swimming and walking.
• Stop smoking. Smoking is associated with a higher risk of developing psoriasis and with more-severe symptoms of psoriasis.
• Limit alcohol use. Alcohol can increase your risk of psoriasis, decrease the effectiveness of your treatment and increase side effects from some medications, such as methotrexate.
• Pace yourself. Battling pain and inflammation can leave you feeling exhausted. In addition, some arthritis medications can cause fatigue.
  The key isn't to stop being active entirely, but to rest before you become too tired. Divide exercise or work activities into short segments. Find time to relax several times throughout the day.

Coping and support

Psoriatic arthritis can be particularly discouraging because the emotional pain that psoriasis can cause is compounded by joint pain and, in some cases, disability.

The support of friends and family can make a tremendous difference when you're facing the physical and psychological challenges of psoriatic arthritis. For some people, support groups can offer the same benefits.

A counselor or therapist can help you devise coping strategies to reduce your stress levels. The chemicals your body releases when you're under stress can aggravate both psoriasis and psoriatic arthritis.

Preparing for your appointment

You're likely to first discuss your signs and symptoms with your family doctor. He or she may refer you to a doctor specializing in the treatment of arthritis and related disorders (rheumatologist).

What you can do

Before your appointment, you may want to write a list of answers to the following questions:

• What types of symptoms are you having? When did they begin?
• Do you or any of your close family members have psoriasis?
• Has anyone in your immediate family ever had psoriatic arthritis?
• What medications and supplements do you take?

You may want to bring a friend or a family member with you to your appointment. It's hard to remember everything about a complicated condition, and another person may remember information that you miss.

What to expect from your doctor

Your doctor might ask some of the following questions:

• What joints are affected?
• Are there any activities or positions that make your symptoms better or worse?
• What treatments have you already tried? Have any of them helped?

Reactive arthritis is joint pain and swelling triggered by an infection in another part of your body — most often your intestines, genitals or urinary tract.

Reactive arthritis usually targets your knees and the joints of your ankles and feet. Inflammation also can affect your eyes, skin and urethra.

Previously, reactive arthritis was sometimes called Reiter's syndrome, which was characterized by eye, urethra and joint inflammation.

Reactive arthritis isn't common. For most people, signs and symptoms come and go, eventually disappearing within 12 months.

The signs and symptoms of reactive arthritis generally start one to four weeks after exposure to a triggering infection. They might include:

• Pain and stiffness. The joint pain associated with reactive arthritis most commonly occurs in your knees, ankles and feet. You also might have pain in your heels, low back or buttocks.
• Eye inflammation. Many people who have reactive arthritis also develop eye inflammation (conjunctivitis).
• Urinary problems. Increased frequency and discomfort during urination may occur, as can inflammation of the prostate gland or cervix.
• Inflammation of soft tissue where it enters bone (enthesitis). This might include muscles, tendons and ligaments.
• Swollen toes or fingers. In some cases, your toes or fingers might become so swollen that they resemble sausages.
• Skin problems. Reactive arthritis can affect your skin a variety of ways, including a rash on your soles and palms and mouth sores.
• Low back pain. The pain tends to be worse at night or in the morning.

When to see a doctor

If you develop joint pain within a month of having diarrhea or a genital infection, contact your doctor.

Reactive arthritis develops in reaction to an infection in your body, often in your intestines, genitals or urinary tract. You might not be aware of the triggering infection if it causes mild symptoms or none at all.

Numerous bacteria can cause reactive arthritis. Some are transmitted sexually, and others are foodborne. The most common ones include:

• Chlamydia
• Salmonella
• Shigella
• Yersinia
• Campylobacter
• Clostridium difficile

Reactive arthritis isn't contagious. However, the bacteria that cause it can be transmitted sexually or in contaminated food. Only a few of the people who are exposed to these bacteria develop reactive arthritis.

Certain factors increase your risk of reactive arthritis:

• Age. Reactive arthritis occurs most frequently in adults between the ages of 20 and 40.
• Sex. Women and men are equally likely to develop reactive arthritis in response to foodborne infections. However, men are more likely than are women to develop reactive arthritis in response to sexually transmitted bacteria.
• Hereditary factors. A specific genetic marker has been linked to reactive arthritis. But many people who have this marker never develop the condition.

Genetic factors appear to play a role in whether you're likely to develop reactive arthritis. Though you can't change your genetic makeup, you can reduce your exposure to the bacteria that may lead to reactive arthritis.

Make sure your food is stored at proper temperatures and is cooked properly to help you avoid the many foodborne bacteria that can cause reactive arthritis, including salmonella, shigella, yersinia and campylobacter. Some sexually transmitted infections can trigger reactive arthritis. Using condoms might lower your risk.

During the physical exam, your doctor is likely to check your joints for signs and symptoms of inflammation, such as swelling, warmth and tenderness, and test range of motion in your spine and affected joints. Your doctor might also check your eyes for inflammation and your skin for rashes.

Blood tests

Your doctor might recommend that a sample of your blood be tested for:

• Evidence of past or current infection
• Signs of inflammation
• Antibodies associated with other types of arthritis
• A genetic marker linked to reactive arthritis

Joint fluid tests

Your doctor might use a needle to withdraw a sample of fluid from within an affected joint. This fluid will be tested for:

• White blood cell count. An increased number of white blood cells might indicate inflammation or an infection.
• Infections. Bacteria in your joint fluid might indicate septic arthritis, which can result in severe joint damage.
• Crystals. Uric acid crystals in your joint fluid might indicate gout. This very painful type of arthritis often affects the big toe.

Imaging tests

X-rays of your low back, pelvis and joints can indicate whether you have any of the characteristic signs of reactive arthritis.

Treatment

The goal of treatment is to manage your symptoms and treat an infection that could still be present.

Medications

If your reactive arthritis was triggered by a bacterial infection, your doctor might prescribe an antibiotic if there is evidence of persistent infection. Which antibiotic you take depends on the bacteria that are present.

Other medications might include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). Prescription NSAIDs, such as indomethacin (Indocin), can relieve the inflammation and pain of reactive arthritis.
• Corticosteroids. Injection of a corticosteroid into affected joints can reduce inflammation and allow you to return to your normal activity level.
• Topical steroids. These might be used for skin rashes caused by reactive arthritis.
• Rheumatoid arthritis drugs. Limited evidence suggests that medications such as sulfasalazine (Azulfidine), methotrexate (Trexall) or etanercept (Enbrel) can relieve pain and stiffness for some people with reactive arthritis.

Physical therapy

A physical therapist can provide you with targeted exercises for your joints and muscles. Strengthening exercises develop the muscles around your affected joints, which increase the joint's support. Range-of-motion exercises can increase your joints' flexibility and reduce stiffness.

Preparing for your appointment

You'll likely start by seeing your primary care provider, who might refer you to a doctor who specializes in arthritis (rheumatologist) for further evaluation.

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as fasting before having a specific test. Make a list of:

• Your symptoms, including any that seem unrelated to the reason for your appointment
• Key personal information, including your and your family's medical history
• All medications, vitamins or other supplements you take, including doses
• Questions to ask the doctor

Take a family member or friend along, if possible, to help you remember the information you're given. For reactive arthritis, basic questions to ask your doctor include:

• What is likely causing my symptoms or condition?
• What are other possible causes?
• What tests do I need? What treatment approach do you recommend?
• How soon do you expect my symptoms to improve with treatment?
• Is there anything I can do now to help relieve my joint pain?
• Am I at risk of long-term complications from this condition?
• I have these other health conditions. How can I best manage them together?

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

• When did your symptoms begin?
• Have they been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Have you had a recent infection?

Septic arthritis is a painful infection in a joint. The infection can come from germs that travel through your bloodstream from another part of your body. Septic arthritis can also occur when a penetrating injury delivers germs directly into the joint.

Infants and older adults are most likely to develop septic arthritis. Knees are most commonly affected, but septic arthritis also can affect hips, shoulders and other joints. The infection can quickly and severely damage the cartilage and bone within the joint, so prompt treatment is crucial.

Treatment involves draining the joint with a needle or surgically. Antibiotics also are usually needed to treat the infection.

Septic arthritis typically causes extreme discomfort and difficulty using the affected joint. The joint could be swollen, red and warm, and you might have a fever.

When to see a doctor

See your doctor if you have sudden onset of severe pain in a joint. Prompt treatment can help minimize joint damage.

Septic arthritis can be caused by bacterial, viral or fungal infections. Bacterial infection with Staphylococcus aureus (staph) is the most common cause. Staph commonly lives on even healthy skin.

Septic arthritis can develop when an infection, such as a skin infection or urinary tract infection, spreads through your bloodstream to a joint. Less commonly, a puncture wound, drug injection, or surgery in or near a joint can give the germs entry into the joint space.

The lining of your joints (synovium) has little ability to protect itself from infection. Your body's reaction to the infection — including inflammation that can increase pressure and reduce blood flow within the joint — contributes to the damage.

Risk factors for septic arthritis include:

• Existing joint problems. Chronic diseases and conditions that affect your joints — such as osteoarthritis, gout, rheumatoid arthritis or lupus — can increase your risk of septic arthritis, as can an artificial joint, previous joint surgery and joint injury.
• Taking medications for rheumatoid arthritis. People with rheumatoid arthritis have a further increase in risk because of medications they take that can suppress the immune system, making infections more likely to occur. Diagnosing septic arthritis in people with rheumatoid arthritis is difficult because many of the signs and symptoms are similar.
• Skin fragility. Skin that breaks easily and heals poorly can give bacteria access to your body. Skin conditions such as psoriasis and eczema increase your risk of septic arthritis, as do infected skin wounds. People who regularly inject drugs also have a higher risk of infection at the site of injection.
• Weak immune system. People with a weak immune system are at greater risk of septic arthritis. This includes people with diabetes, kidney and liver problems, and those taking drugs that suppress their immune systems.
• Joint trauma. Animal bites, puncture wounds or cuts over a joint can put you at risk of septic arthritis.

Having a combination of risk factors puts you at greater risk than having just one risk factor does.

If treatment is delayed, septic arthritis can lead to joint degeneration and permanent damage.

The following tests typically help diagnose septic arthritis:

• Joint fluid analysis. Infections can alter the color, consistency, volume and makeup of the fluid within your joints. A sample of this fluid can be withdrawn from your affected joint with a needle. Laboratory tests can determine what organism is causing your infection, so your doctor will know which medications to prescribe.
• Blood tests. These can determine if there are signs of infection in your blood. A sample of your blood is removed from a vein with a needle.
• Imaging tests. X-rays and other imaging tests of the affected joint can assess damage to the joint.

Treatment

Doctors rely on joint drainage and antibiotic drugs to treat septic arthritis.

Joint drainage

Removing the infected joint fluid is crucial. Drainage methods include:

• Needle. In some cases, your doctor can withdraw the infected fluid with a needle inserted into the joint space.
• Scope procedure. In arthroscopy (ahr-THROS-kuh-pee), a flexible tube with a video camera at its tip is placed in your joint through a small incision. Suction and drainage tubes are then inserted through small incisions around your joint.
• Open surgery. Some joints, such as the hip, are more difficult to drain with a needle or arthroscopy, so an open surgical procedure might be necessary.

Antibiotics

To select the most effective medication, your doctor must identify the microbe causing your infection. Antibiotics are usually given through a vein in your arm at first. Later, you may be able to switch to oral antibiotics.

Typically, treatment lasts from two to six weeks. Antibiotics carry a risk of side effects, including nausea, vomiting and diarrhea. Allergic reactions also can occur. Ask your doctor about what side effects to expect from your medication.

Preparing for your appointment

If you have painful and inflamed joints, you're likely to start by seeing your family doctor. He or she may refer you to an orthopedic surgeon, infectious disease specialist or joint specialist (rheumatologist).

Here's some information to help you get ready for your appointment.

What you can do

When you call to make the appointment, ask if you need to do anything in advance, such as fasting for certain tests. Make a list of:

• Your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment
• Key personal information, including other medical conditions you have and recent infections
• Medications, vitamins or supplements you take, including doses
• Questions to ask your doctor

Take a family member or friend along, if possible, to help you remember information you're given.

For septic arthritis, questions to ask your doctor include:

• What is likely causing my symptoms?
• Are there other possible causes?
• What tests do I need?
• Is my condition likely temporary or chronic?
• What's the best course of action?
• Are there alternatives to the approach you're suggesting?
• How soon can I expect my symptoms to improve with treatment?
• What can I do in the meantime to help relieve my joint pain?
• Am I at risk of long-term complications from this condition?
• How can I best manage this condition with my other health problems?
• Should I see a specialist?
• Are there brochures or other printed material that I can take? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you questions, such as:

• When did your symptoms begin?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Have you ever had joint surgery or joint replacement?
• Do you use recreational drugs?