Background

Psoriatic arthritis is an inflammatory disease of the bones and joints associated with psoriasis, which is a condition that causes a scaly, plaque-like rash on the skin. Athletes with psoriatic arthritis may experience painful, swollen or stiff joints, and many joints will be painful and swollen at the same time. The most commonly affected joints are those in the fingers and the spine, but any joint can be affected.

Psoriatic arthritis is relatively uncommon, only occurring in about 1 percent of the population worldwide. However, somewhere between 10- 20 percent of patients with psoriasis may develop psoriatic arthritis.

The odds of developing psoriatic arthritis are slightly higher for people with very bad psoriasis, which can be seen with involvement of the scalp or the groin or changes in toenails and fingernails. Patients with psoriasis who are obese are also at higher risk. Psoriasis and psoriatic arthritis tends to run in families. About 40 percent of patients suffering from psoriatic arthritis have a family member who also has the condition. Occasionally, athletes will develop arthritis symptoms before developing any psoriasis rash.

Symptoms

• Joint pain and stiffness
• Joint swelling
• Morning stiffness
• Back pain
• Swollen and painful fingers or toes
• Swelling of the hands or feet
• Inflammation in ligaments and tendons where they attach to bones (enthesitis)
• Red or painful eyes (conjunctivitis/uveitis/iritis)
• Shortness of breath (pulmonary fibrosis)
• Fatigue

Sports Medicine Evaluation & Treatment

Psoriatic arthritis may seem like a sports-related injury if you have a swollen, painful joint. The sports medicine doctor may ask you about your symptoms and any similar previous symptoms. You may be asked to fill out a questionnaire about your symptoms and your general health. An exam of the affected joints will be performed, pushing on areas to look for pain and evaluating your ability to move those joints. You may receive an X-ray to look more closely for changes in your bones, which might indicate psoriatic arthritis. In some cases, more specialized imaging, such as an MRI, may be necessary to look for evidence of inflammation early in the disease. The doctor may want to order blood work or take a sample of joint fluid to look for evidence of inflammation and rule out other kinds of arthritis or infection.

Potential treatment options may include:

• Patient education
• Physical therapy or prescribed exercise
• Weight reduction
• Anti-inflammatory medications (ibuprofen/naproxen)
• Corticosteroid injection into the joint
• Specialized medications that affect your immune system

• such as methotrexate, leflunomide, or tumor necrosis
• factor (TNF) blockers
• Referral to a Rheumatologist

Injury Prevention

There is no known way to prevent psoriatic arthritis from happening, but diagnosing the disease early is important. If recognized early, patients can do things to prevent the disease from getting worse. Losing weight (if needed), staying active and starting on medications to decrease inflammation can help slow down changes in bones and joints and prevent flares. This will allow patients to continue the physical activities they enjoy.

Return to Play

At times, sports participation can be limited by the pain and stiffness associated with psoriatic arthritis. Once the athlete starts treatment and the pain and stiffness improve, a return to play as tolerated is appropriate. Patients who play contact sports may be more likely to have flares from contact and injury. Decisions about any return to playing contact sports should be individualized and involve a risk-benefit discussion between the player and their sports medicine physician.

AMSSM Member Authors
M. Terese Whipple, MD and Christopher Hogrefe, MD

References
Alinaghi F, Calov M, Kristensen LE, et al. Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational and clinical studies. J Am Acad Dermatol. Jan 2019; 80 (1): 251-265.
Duvetorp A, Ostergaard M, Skov L et al. Quality of life and contact with healthcare systems among patients with psoriatic arthritis: Results from the NORdic Patient survey of Psoriasis and Psoriatic arthritis (NORAPP). Archives of Derm Research. 23 March 2019; 311: 351-360.
Flemming DJ, Bernard SA. Arthritis mimicking sports-related injuries. Clin Sports Med. July 2013; 32(3):577-97.
Richland CT, Colbert RA, Gladman DD. Psoriatic Arthritis. N Engl J Med. 2017; 376 (10): 957-970.
Tinazzi I, Adami S, Zanolin EM et al. The early psoriatic arthritis screening questionnaire: A simple and fast method for the identification of arthritis in patients with psoriasis. Rheumatology. Nov 2012; 51(11): 2058-2063.