Ankylosing Spondylitis – Case StudiesPresented by: Katelyn S. Kervin, ATS

Senior Presentation

INTRODUCTION

CASE STUDY 1

CASE STUDY 2

ANKYLOSING SPONDYLITIS

REFERENCES

DIAGNOSIS

•Back injuries are among the most common of all athletic injuries.

•A back injury is nothing more than involuntary, intermittent and sometimes prolonged contractions of the muscles of the back.

•Back injuries can be quite painful and debilitating, and they can knock out the ‘weekend warrior’ or the elite athlete completely out of action for weeks at a time.

A 17-year-old female high school three sport athlete was at lacrosse practice when she realized that her Sacroiliac Joint felt extremely tight and painful when she would perform flexion. The pain that she experiences when she performs flexion wraps from her Sacroiliac Joint around to her quadriceps; in addition the pain sometimes shoots down the posterior aspect of her leg, which includes nerve roots L1 and L2. She does have a family history of back problems. She feels as if weather does impact they was she feels daily. Her primary care physician was seen which then referred her to physical therapy stating that it was a Piriformis injury. The pain became worse the more active she had become; colder weather, rainy and snowy days brought on more pain. To alleviate the pain she was forced to become completely inactive. She took off one month, then returned to activities and started to run 3 miles per day with some sprinting, noticing no pain. During her senior year of high school, the pain returned. The pain began during practices and continues at night, approximately increasing one hour after practice and will last from two hours up to two to three days with little sleep included. She now plays division 1 lacrosse for the University of Massachusetts at Amherst. She has seen multiple physicians and has had multiple opinions on what and why her pain occurs in her lower back and SI joint. She has seen her primary care physician, two physical therapists, two UMASS sports physicians and two Rheumatologists. Within those physician visits she has had two X-Rays, three MRI’s and one bone scan, along with a full Rheumatologist exam including an eye exam, capillary refill and flexibility exam for her back. Her physical therapists have examined her flexibility more in depth by checking rotation for her legs, back, neck and head.

Athlete 1 has a twin sister, Athlete 2, who expresses the same pain symptoms that athlete 1 does. Athlete 2, a 20-year-old female lacrosse player, first noticed her pain in her lower back and SI joint her freshman year in college. During winter conditioning for lacrosse her freshman year she noticed having severe tightness in her lower back and SI joint when she would perform flexion. Her pain starts in the same place as her sisters, and wraps around to her quadriceps and the pain shoots down the posterior aspect of the leg. The first physician that she saw about her pain was the UMASS sports physician, who already had an idea of what condition may be diagnosed because of her sister. She also saw a physical therapist at UMASS as well. She never took any time off, she practiced and played straight through her pain. She was prescribed Neproxin medication for the cold, rainy and snowy days but besides that she stated that she feels fine. When she is in pain though, nothing seems to help the pain go, no medication helps, except for complete rest. She has completed an X-Ray and an MRI to determine the diagnosis of her pain.

•Ankylosing Spondylitis (AS) is a form of chronic inflammation of the spine and the sacroiliac joints. The term Ankylosing is derived from the Greek word akylos, meaning stiffening of the joint, while spondylos means vertebra. The exact cause of AS is unknown but it is known that genetics play a key role. Most individuals who have AS also had a gene that produces a “genetic marker” – in this case protein – called HLA-B27. This marker is found in over 95% of people but is also noted that HLA-B27 does not need to be positive to have AS.

•AS is a rheumatic disease that causes arthritis of the spine and sacroiliac joints and can cause inflammation of the eyes, lungs and heart valves. The onset of the disease is gradual and characterized by aseptic inflammation at the sacroiliac joints. As the disease progresses it moves cephalad up the vertebral column. In advanced cases the stiffness progresses into spinal fusion and the normal lumbar lordosis is flattened and the thoracic kyphosis becomes exaggerated. This disease can vary from intermittent episodes of back pain that occur throughout life to a severe chronic disease that attacks the spine, peripheral joints and other body organs, resulting in severe joint and back stiffness, loss of motion and deformity as life progresses.

•AS afflicts an estimated 129 out of 100,000 people in the United States and the onset of AS is most often between the ages of fifteen and thirty-five with the mean age of twenty-six years and is more common in the male population. The male to female ratio is 4-10:1.

•The twins have a condition called Ankylosing Spondylitis. Athlete 1 was diagnosed first by multiple physicians suggesting that she has AS. The diagnosis was determined by her multiple MRI’s, her bone scan and other physical examinations. She has recently decided to devote her positive efforts to herself and help out the team in a different way than being on the active roster.

•Athlete 2 was diagnosed by one of the physicians that suggested her sister has AS. She recently decided because of how bad her sister’s condition is, to devote her efforts to a non-contact sport, Track and Field.

• Ankylosing Spondylitis – American College of Rheumatology. Available at: www.rheumatology.org• Ankylosing Spondylitis (AS). Available at: www.spondylitis.org• Ankylosing Spondylitis – Genetics Home Reference. Available at: http://ghr.nlm.nih.gov• Ankylosing Spondylitis. Interview with Athlete 1 and Athlete 2. 2008.• Ankylosing Spondylitis: Copy of Athlete 1 and Athlete 2 Medical Records. 2008.• French, T. Leading Article: The Treatment of Ankylosing Spondylitis. Current Medical Literature:

Rheumatology. 2007; 65-69• Keiser, V., & Robbin, M. Musculoskeletal Imaging Teaching Files: Case Fifty Eight – Ankylosing

Spondylitis. Available at: www.uhrad.com• Kenneth, S. Standard of Care: Ankylosing Spondylitis. The Brigham and Women’s Hospital, Inc.

Department of Rehabilitation Services. 2007; 1-13.• Khan, M. A. Ankylosing Spondylitis: An Update From EULAR 2007. EULAR 2007: The Annual

European Congress of Rheumatology. 2007; 1-12• Musculoskeletal Imaging: Ankylosing Spondylitis. Available at: www.medcyclopaedia.com • Shaikh, S. A. Ankylosing Spondylitis: recent breakthroughs in diagnosis and treatment. Journal of the

Canadian Chiropractic Association. 2007; 51(4)• Shiel, W. C. Ankylosing Spondylitis. Available at: www.medicinenet.com• Spencer, D. G., Sturrock, R. D., & Buchanan, W. W. Ankylosing Spondylitis: Yesterday and Today.

Medical History. 1980; 24, 60-69.• Starkey, C. Evaluation of Orthopedic and Athletic Injuries (2nd edition). 2002.• Wilfred, C. G. Ankylosing Spondylitis. Available at: www.emedicine.com

REHABILITATION•Rehabilitation for A’ 1 consisted of wearing an SI girdle, a Handloom brace, compression shorts, bone stimulator treatment and completing water and land rehab.

•Some water exercises include:• Treading water• Leg lifts• Running

•Some land exercises include:• Abdominal coordination program• Resistance bands• Electrical stimulation and Ice

•Rehabilitation for A’ 2 is a lot less complex because she never used any take home devices or braces. Her condition is not as developed as her sister’s.

•Some exercises include:• Abdominal coordination program• Single leg heel slides• Electrical stimulation and Ice