Bilateral Ankle And Back Pain In A Traditional Chinese Lion Dancer

HISTORY: A 37-year-old female traditional Chinese lion dancer presented with 1.5 years of right ankle pain and swelling with recent development of left ankle pain. Prior right ankle MRI revealed a thickened distal Achilles tendon with calcifications, retrocalcaneal bursitis, moderate joint effusion, and peroneal tendinopathy with tenosynovitis. Her pain was refractory to a trial of nonsteroidal anti-inflammatory drugs, immobilization with a cast boot for 1 month, retrocalcaneal bursa corticosteroid injection, and physical therapy. She endorsed ankle stiffness that was worse in the mornings and improved with activity and noted 2 weeks of low back pain with stiffness. Her mobility was limited to the use of a cane for ambulation and inability to dance. Family history was negative for autoimmune disease. PHYSICAL EXAMINATION: Bilateral Achilles tendons were thickened with tenderness to palpation at the entheses. Right ankle was warm with palpable effusion and tenderness over the hindfoot. Pinch test was painful over the right retrocalcaneal bursa. Bilateral sacroiliac joints (SIJ) were tender to palpation. Cervical spine had restricted rotation and lateral flexion. No rashes or psoriatic plaques. 5/5 strength and intact sensation to light touch in all extremities. DIFFERENTIAL DIAGNOSIS: 1. Spondyloarthritis; 2. Rheumatoid arthritis; 3. Achilles tendinopathy with post-traumatic ankle and foot osteoarthritis; 4. Lyme arthritis TEST AND RESULTS: Laboratory: Antinuclear antibody titer 1:320, homogenous; positive HLA-B27; elevated C-reactive protein (40.7 mg/L, normal: <8) and erythrocyte sedimentation rate (27 mm/h, normal: <20); negative rheumatoid factor, cyclic citrullinated peptide, extractable nuclear antigen panel. Radiologic: Unremarkable SIJ X-rays. Pelvic MRI demonstrated left obturator internus edema with tenosynovitis and bilateral L4-5 facet arthropathy with periarticular inflammation. FINAL/WORKING DIAGNOSIS: Axial and peripheral spondyloarthritis TREATMENT AND OUTCOMES: She completed a glucocorticoid taper and started methotrexate (MTX) titrated to 25 mg weekly and adalimumab 40 mg biweekly. Now, 2.5 years after presentation, she is in clinical remission on MTX 15 mg weekly and adalimumab 40 mg biweekly. She is able to participate in all desired activities including dance.