Palindromic rheumatism
Overview
A rare disorder involving periodic inflammation in and around joints. Eventually, rheumatoid arthritis may develop if the condition persists.
Symptoms
* Joint pain * Joint swelling * Joint stiffness * Joint warmth * Skin nodules * Joint redness
Causes
* Inversion sprain (85% of ankle sprains) –Results in pain, swelling, and ecchymosis of the lateral malleolar area –Damage occurs to the three ligaments of inferior fibula (anterior and posterior talofibular and calcaneofibular ligaments) and peroneal muscle * Degenerative joint disease –Pain is present upon waking in the morning; relieved by mild activity –Grinding/popping occurs with motion * Inversion/eversion injury of subtalar joint –Results in pain while walking on uneven ground * Syndesmosis injury (“high ankle sprain”) –Stretching of the interosseous membrane –Results in pain at the lower leg * Avulsion fracture of the distal fibula –Results in persisting lateral malleolar pain –Difficult to differentiate from the epiphyseal line on X-ray * Repetitive injury with disruption of the ankle retinaculum –Results in chronic pain of the posterior aspect of the ankle * Poor shoe alignment * Bimalleolar fracture * Trimalleolar fracture: Bimalleolar fracture plus a fracture of the lateral aspect of the distal tibia * Neoplasm * Peroneal nerve entrapment * Diabetic (Charcot's) arthropathy
Diagnosis
Routine tests include a CBC, sedimentation rate, ASO titer, CRP, ANA, urinalysis, chemistry panel, arthritis panel, and x-rays of the involved joints. It is also wise to do a bone survey when there is multiple joint involvement. A synovial fluid analysis and culture may be done if there is sufficient joint fluid. A trial of therapy can be initiated and may be diagnostic. At this point, it is wise to refer the patient to a rheumatologist for further evaluation. Additional tests that may be ordered are found on page 279 . Polarized microscopy may reveal positive birefringent crystals of pseudogout.
Treatment
* PRICE –Protection from additional strain/injury –Relative rest (stretching is okay) ±crutches –Ice for initial 24–48 hours after trauma –Compression (elastic wrap or ankle support) –Elevation of foot (higher than the pelvis) * Casting is often indicated for fractures and significant ankle sprains * Short-term bracing may reduce risk of reinjury * Surgery may be indicated (e.g., bimalleolar fracture, trimalleolar fracture) * Physical therapy referral to improve strength, range of motion, and proprioception * NSAIDs or other analgesic