Swollen Painful Ankle Enthesitis Psoriatic Arthritis

When you think of arthritis, you tend to think of joint pain. After all, “arth” means joint and “itis” means inflammation. It’s no different with psoriatic arthritis (PsA), a type of inflammatory arthritis that occurs in up to a third of people with the inflammatory skin condition psoriasis.

With psoriatic arthritis, the body’s immune system mistakenly sets off inflammation that attacks the synovium membrane that lines your joints, causing swelling, stiffness, redness, and pain. Over time, the inflamed synovium (called synovitis) can destroy the cartilage and bone within the joint. In what amounts to a double whammy in psoriatic arthritis, this inflammation also affects the skin, causing a buildup of cells that forms silvery scales and itchy, dry patches.

Synovitis from PsA can affect multiple joints, including the ankle joint, which is made up of three bones and primarily enables up and down movement of the foot. Psoriatic arthritis commonly affects the ankle joints.

In fact, painful, swollen, and stiff ankles can be a telltale symptom of PsA.

Symptoms of Psoriatic Arthritis in the Ankle

Symptoms of PsA depend on the severity of the disease. “It can be mild and it can be crippling,” says Vinicus Domingues, MD, a rheumatologist in Daytona Beach, Florida, and a medical advisor for CreakyJoints. The disease can present very differently from person to person. “I’ve had patients with more severe skin disease and milder joint involvement, and I’ve seen very mild joint disease and more significant entheseal disease,” he says.

Whenever the ankle is affected in psoriatic arthritis, “a person’s ability to ambulate [walk] and enjoy their quality of life and independence can certainly become compromised,” says Adam Bitterman, DO, an orthopedic surgeon and foot and ankle specialist at Hofstra/Northwell in Hempstead, New York.

People whose psoriatic arthritis is affecting the foot and ankle may feel swelling and stiffness in their feet and ankles. This is often worse in the morning. It may feel painful and take a long time to get out of bed and get moving during your morning routine. Walking and exercising may hurt. It can may be challenging to find comfortable shoes.

How can you tell if your ankle pain is due to psoriatic arthritis? There will likely be other clues.

In general, joint pain, stiffness, and swelling are the main signs of psoriatic arthritis. Joints on both sides of the body can be affected, but PsA less often affects symmetrical joints (the same joint on both sides) than rheumatoid arthritis.

Any joint may be affected by PsA, but it’s common in the large joints in the lower extremities, like the knees and ankles. Other symptoms include:

  • Skin plaques and rash (this most commonly presents as red patches of skin with silvery scales, but psoriasis rashes can take other forms too)
  • Swollen fingers and toes (this is called dactylitis, often called “sausage digits”)
  • Lower back pain (psoriatic arthritis often causes spondylitis, or inflammation of the joints in your spine)
  • Nail changes, such as crumbling, pitting, and thickening
  • Fatigue
  • Eye inflammation (called uveitis)
  • Heel, foot, and ankle pain (this is due to another type of inflammation called enthesitis that is common and unique to PsA)

The Connection Between Enthesitis and Psoriatic Arthritis

While joint pain is a key sign of PsA, pain in the ankle area is also often due to inflammation of the enthesis, the area where the tendon or ligament inserts into a bone to facilitate joint motion. This inflammation, which is known as enthesitis, is very common in PsA.

Enthesitis has been reported to occur in 35 to 50 percent of people with psoriatic arthritis, according to a 2018 paper in the journal Seminars in Arthritis and Rheumatism.

“The ankle is one of the most prominent places for enthesitis and it’s one of the most challenging features of PsA,” explains Dr. Domingues. “It’s another source of pain and other issues for patients with PsA.”

Enthesitis is unique to psoriatic arthritis and other kinds of spondyloarthritis. (Spondyloarthritis is an umbrella term for types of arthritis that have some features in common. It also includes axial spondyloarthritis, for example.)

Enthesitis doesn’t commonly occur with other forms of arthritis like rheumatoid arthritis (RA) or osteoarthritis (OA). Enthesitis is such a common hallmark of PsA that health care providers often look for its presence to confirm that joint symptoms are a symptom of PsA and not another type of arthritis.

You may not be familiar with the term enthesitis, but you’ve no doubt heard of one of the most well-known examples of enthesitis — tennis elbow, the inflammation of the tendon that attaches your forearm muscle to the elbow. This ache on the outside of your elbow is usually brought on by repetitive motion and — given enough rest — gets better on its own.

But with PsA, enthesitis is occurring because of problems with underlying inflammation and it is likely to become chronic. This means, unlike with an overuse injury, it won’t go away on its own without treatment.

When it comes to ankle involvement in psoriatic arthritis, the problem is the Achilles tendon, a fibrous band of tissue that connects the heel bone at the back of the ankle. The largest and strongest tendon in the body, the Achilles allows you to push off while walking, running, and jumping. While the Achilles tendon is already a high-stress area, for reasons not completely understood — but possibly due to genetics — people with PsA are more likely to develop enthesitis there.

When enthesitis strikes the Achilles tendon, it’s hard to extend the ankle, which makes it difficult to walk, run, and do your daily activities, says Dr. Domingues.

“The area is very tender to the touch,” he says. “It’s classic of entheseal disease to feel swelling on the back of the ankle where the Achilles tendon lies.”

Getting a Psoriatic Arthritis Diagnosis

Foot and ankle abnormalities, including joint inflammation and enthesitis, occur in up to 70 percent of people with PsA. They might be the first symptom of the disease — occurring before any significant joint symptoms. Dactylitis, the painful, sausage-like swelling of an entire toe, rather than just a joint, is another common foot-related symptom of PsA.

Some research even suggests that inflammation that starts at the entheses is what triggers joint synovitis in PsA.

The upshot: Early treatment is vital for alleviating symptoms, preventing irreversible structural damage, and maximizing quality of life. Even a six-month delay in PsA diagnosis can result in irreversible joint, noted the authors of a recent review article in the American Journal of Clinical Dermatology.

If you suspect you could have psoriatic arthritis, it’s important to see a rheumatologist for testing. If you have psoriasis, you may already be seeing a dermatologist. If that’s the case, tell them about your ankle pain, joint pain, and other PsA symptoms and they will likely refer you to a rheumatologist.

In order to diagnose psoriatic arthritis, the doctor will likely run different tests to look for signs of psoriatic arthritis and also rule out other conditions. This includes:

  • Physical exam to closely examine joints for swelling and tenderness (pain); to look for skin plaques if you don’t already have psoriasis; and to look for signs of enthesitis by pressing on areas near your heels, ankles, bottom of the foot, and more
  • Imaging tests including X-rays, ultrasounds, or MRIs to look for signs of joint damage that occur in psoriatic arthritis and to look at changes in the ligaments and tendons that can reveal enthesitis
  • Blood tests to look for signs of inflammation and to look for the presence of antibodies, which can help rule out PsA in favor of other conditions (for example, PsA does not have antibodies like rheumatoid factor and anti-cyclic citrullinated protein, which are common in rheumatoid arthritis)

Read more here about how psoriatic arthritis is diagnosed.

Treating Ankle Pain in Psoriatic Arthritis

There is no cure for PsA, but good treatments are available that may help control symptoms and prevent further damage to the ankle.

Treating PsA-related ankle symptoms involves taking medication to relieve pain and prevent long-term damage and making lifestyle changes.

“The initial treatment [for PsA in the ankle] is similar for patients with ankle injuries or ankle osteoarthritis,” says Dr. Bitterman. “But in addition to bracing and anti-inflammatory medications, rheumatologists have medications that can modify the patient’s immune response with disease-modifying medications.”

Here are some strategies for easing ankle pain, stiffness, and swelling from psoriatic arthritis.

Treat pain and underlying inflammation

Here’s a rundown on the medications recommended for PsA-related ankle pain:

Nonsteroidal anti-inflammatory drugs (NSAIDs): Over-the-counter (OTC) medications like ibuprofen (Advil) and naproxen (Aleve), as well as stronger prescription NSAIDs, can help relieve pain and swelling in the joints. “They do help, but most of the time, they’re not enough if the patient has enthesitis,” says Dr. Domingues. “Plus, there are so many side effects long term [like stomach ulcers and kidney disease] that we try to minimize their use.” Check with your health care provider to be sure these medications are safe and appropriate for you.

Steroid injections: In certain cases, steroid injections into the ankle joint can reduce inflammation quickly. These shots shouldn’t be done repeatedly, though (no more often than every six weeks and usually not more than three or four times a year), since frequent injections may damage cartilage.

In the case of enthesitis, however, steroid injections aren’t recommended, says Dr. Domingues. “They’ve been shown in multiple studies to precipitate tendon rupture.” This can require surgery and cause significant disability.

Disease-modifying anti-rheumatic drugs (DMARDs): These medications address the underlying systemic inflammation in psoriatic arthritis. They are critical for slowing and stopping the course of inflammatory disease and can treat both skin and joint pain at the same time. They fall into three general categories.

  • Conventional disease-modifying antirheumatic drugs (DMARDs), which are usually taken orally and include medication such as methotrexate
  • Targeted disease-modifying antirheumatic drugs (DMARDs), which are oral pills that are more targeted than conventional DMARDs [ex: a JAK inhibitor like tofacitinib (Xeljanz) or a PDE4 inhibitor like apremilast (Otezla)]
  • Biologic disease-modifying antirheumatic drugs (DMARDs), which are administered as injections or infusions and are more targeted than conventional DMARDs [ex: a TNF inhibitor like adalimumab (Humira) or etanercept (Enbrel), an IL-17 inhibitor like ixekizumab (Taltz), an IL-23 inhibitor like guselkumab (Tremfya) or a T-cell inhibitor like abatacept (Orencia)]

Rheumatologists often start treating PsA with methotrexate, “but the response of enthesitis to methotrexate is very low, so typically we go the biologic route,” says Dr. Domingues. Your doctor may also recommend combination treatment, in which you take methotrexate along with a biologic or targeted therapy.

“It’s very common for patients to have a good joint response and a poor entheseal response with methotrexate, so you either have to increase the medication or step up to biologics,” says Dr Domingues.

There are many different targeted therapies for psoriatic arthritis. Which one your doctor recommends will depend on a number of factors, including your specific symptoms, your medical history, your insurance coverage, and more.

Read more here about psoriatic arthritis treatments.

When it comes to treating enthesitis, which often takes longer to resolve than synovitis, patience is a must. “Treatment works for it, but it’s one of the most difficult things to treat,” says Dr. Domingues. “Sometimes it can take months — six to nine months — to get a response. Sometimes you don’t get one at all.”

Use ice and heat

Each works differently to provide pain relief, so let your symptoms be your guide to whether you employ cold or heat therapy.

  • To reduce swelling and inflammation, use ice. It constricts blood vessels in the surrounding muscles and decreases blood flow to the joints. It also creates a numbing effect that dulls the pain.
  • To reduce joint stiffness, use heat. Try a heating pad or warm shower. It helps loosen surrounding muscles and boosts circulation, which helps decrease pain signals sent from the brain to the joints.

Get a supportive brace

An ankle brace (called an ankle-foot orthosis) helps support the joint and provides compression to reduce swelling and inflammation. There are generally two types of braces: soft orthotics, which help lessen impact and relieve pressure on the foot, and firmer orthotics — the type most often recommended for arthritic ankles — that hold and stabilize the foot and prevent further joint destruction. Both custom options and OTC options exist for bracing.

“I tend to work my way up the ladder beginning with the most cost-effective version that provides the most success and usually that’s an off-the-shelf brace,” says Dr. Bitterman. “Custom bracing through an orthotist [a health care professional who makes and fits braces and splints] works extremely well when those fail and serves as accommodative devices” that reduce stress on the affected joint and help improve mobility and stability.

Stretch regularly

Tight tendons and muscles can cause and worsen ankle pain from arthritis. Regular gentle stretching to improve range of motion can be helpful. “It reduces pain by alleviating stiffness,” says Dr. Domingues, who advises working with a physical therapist to develop a program that’s right for you.

Maintain a healthy weight

“The ankle is a weight-bearing joint, and being overweight places even more pressure on it, making symptoms worse,” says Dr. Domingues. Excess body weight also increases inflammation, which fuels the painful symptoms of PsA. It can also make medical treatments less effective.

Unfortunately, joint pain — and in particular, foot and ankle pain — from psoriatic arthritis can make it difficult to exercise, which is an effective way to manage your weight, as well as PsA symptoms. Despite the common belief that exercise will aggravate joint pain and stiffness, the opposite is actually true, reports the Mayo Clinic: Lack of exercise can actually exacerbate symptoms.

Gentle low-impact exercises like swimming, cycling, and chair yoga are good options for people with ankle-related arthritis. The calorie burn can quickly add up: A 155-pound person can burn almost 250 calories slowly swimming freestyle for half an hour. Just be sure to start slowly and increase activity gradually.

Consider surgery

Ankle involvement rarely requires surgical intervention in people with psoriatic arthritis, but when medication, physical therapy, and changes to your everyday activities aren’t providing enough relief, surgery can improve quality of life and restore or maintain joint function.

Options include joint replacement or joint arthoredesis (or fusion). “These options provide significant relief by either maintaining motion or eliminating motion, respectively,” says Dr. Bitterman.

During joint replacement, parts of an arthritic or damaged joint are removed and replaced with a metal, plastic, or ceramic prosthetic device. The prosthesis is designed to replicate the movement of a normal healthy joint.

Arthrodesis is the most common surgery used to treat people with ankle joint disease, according to a recent review article on new perspectives in psoriatic arthritis. Joint fusion decreases movement of the worn-out portion of the joint/cartilage, which in turn decreases pain. The joint is then held in place with a rod or plate and screws. Over time, the bones fuse together. The downside of fusion is that you’ll permanently lose range of motion in your ankle, though much of that motion has already been lost due to the disease. The upside is that it should last a lifetime compared to an ankle replacement, which may wear out at some point. If surgery becomes necessary for your psoriatic arthritis ankle pain, be sure to thoroughly discuss your options with your surgeon.

Audio Guide: Understanding Psoriatic Arthritis Symptoms

Learn more about the range of symptoms you can experience with psoriatic arthritis. For more audio guides and insights from PsA experts, check out the Psoriatic Arthritis Club podcast.

Auraho E, et al. Enthesitis in psoriatic arthritis (Part 1): pathophysiology. Rheumatology. March 2020. doi: https://doi.org/10.1093/rheumatology/keaa039.

Bagel J, et al. Enthesitis and Dactylitis in Psoriatic Disease: A Guide for Dermatologists. American Journal of Clinical Dermatology. December 2018. doi: https://doi.org/10.1007/s40257-018-0377-2.

Interview with Adam Bitterman, DO, an orthopedic surgeon and foot and ankle specialist at Hofstra/Northwell in Hempstead, New York

Interview with Vinicus Domingues, MD, a rheumatologist in Daytona Beach, Florida

Kaeley GS, et al. Enthesitis: A hallmark of psoriatic arthritis. Seminars in Arthritis & Rheumatism. August 2018. doi: https://doi.org/10.1016/j.semarthrit.2017.12.008.

Krakowski P, et al. Psoriatic arthritis – new perspectives. Archives of Medical Science. May 2019. doi: https://doi.org/10.5114/aoms.2018.77725.

Merola JF, et al. Distinguishing rheumatoid arthritis from psoriatic arthritis. RMD Open. May 2018. doi: http://dx.doi. org/10.1136/rmdopen-2018- 000656.

Psoriatic Arthritis. American College of Rheumatology. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Psoriatic-Arthritis.

Psoriatic Arthritis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/psoriatic-arthritis/symptoms-causes/syc-20354076.