Psoriatic arthritis affecting the hip is an inflammatory autoimmune disease like rheumatoid arthritis.(1) Joint inflammation results from hyperactivity of immune cells causing destruction of healthy cells and tissue such as joint synovial membrane and cartilages. Hyperactive immune cells damage normal joint tissue as a result of continuous activated inflammation of soft tissue and cartilage. In psoriatic skin disease, hyperactive immune system induces overproduction of skin cells and in 10% of cases with skin lesion may cause destruction of joint.
Psoriatic hip joint arthritis is associated with inflammation of synovial membrane, tendon and cartilage of hip joint.(2) Inflammation activated by immune system may spread in other organs and tissue like eyes, lungs, kidney and aorta. In United States 2% of Caucasians suffer with skin psoriasis and 0.2% suffers with psoriatic joint disease. Psoriatic arthritis is often difficult to treat. Young or middle age patient may end up as a disabled individual.
Causes of Hip Joint Psoriatic Arthritis
- Autoimmune Disease– Involves skin and joint.
- Hereditary Disease- Often seen in family.
- Genetic Causes– Several researches have indicated genetic marker associated with psoriatic arthritis and hip joint disease, genetic marker often observed with psoriatic arthritis is HLA–B27.
- Environmental Factors– Hyperactivity of immune system may be induced by environmental factors and climates.
- Bacterial or Viral Infection– Research has indicated psoriatic arthritis is often associated or followed by viral or bacterial infection.(3)
Symptoms and Signs of Hip Joint Psoriatic Arthritis
Symptoms of Hip Joint Psoriatic Arthritis
- Sex– More common among male.
- Age– Between 30 and 50 years.
- Skin Lesion– Precedes arthritis in 80% cases and in 15% cases arthritis is not associated or preceded by skin lesion. In few cases skin lesion is absent for several years and joint arthritis is often diagnose as osteoarthritis or rheumatoid arthritis.
- Pain– Multiple joint pain, hip joint pain often bilateral or unilateral.
- Joint Stiffness– Symptoms of joint stiffness is observed during active movement.
- Fatigue and Exhaustion– Psoriatic arthritis causes systemic effects like fatigue and exhaustion.
- Remission– Pain is often absent or less severe during period of remission.
Signs of Hip Joint Psoriatic Arthritis
- Skin Lesions– Topped with discolored or erythematous silvery scales of skin.
- Joint Stiffness– Observed during examination and passive movement of hip joint.
- Hip Joint Swelling– Swelling is secondary to inflammation of synovial membrane and collection of synovial fluid within joint, hip joint subluxation or dislocation is rare compared to rheumatoid arthritis.
- Multiple Small Joint Swelling– Joint swelling observed in hand and feet.
- Joint Temperature– Skin over hip joint is warm.
- Dactylitis– Sausage like swelling in the fingers or toes.
- Spondylitis– Back pain caused by inflammatory joint disease of facet joint and ligaments of the vertebral column.
- Sacroiliitis- Inflammatory sacroiliac joint disease.
- Spondyloarthropathies– Hip joint psoriatic arthritis associated with sacroilitis, spondylitis and arthritis of several joints of hands and feet.
- Nail- Pitting nail bed.
- Tendon Inflammation– Inflammation of Plantar fascia causes Plantar Fasciitis and Achilles tendon causes Achilles Tendonitis.
Diagnosis and Investigation for Hip Joint Psoriatic Arthritis
Diagnosing Hip Joint Psoriatic Arthritis
- Psoriasis– Skin lesion and skin scaling associated with hip joint pain.
- Dactylitis– Sausage-like swelling in the fingers or toes.
- Nail- Pitting nail bed.
- Spondyloarthropathies- Hip joint psoriatic arthritis associated with sacroilitis, spondylitis and arthritis of several joints of hands and feet.
- Arthritis of Tip of Finger– distal interphalangeal joint arthritis observed with hip joint arthritis. Arthritis of distal finger is often not seen in osteoarthritis or rheumatoid arthritis.
Investigation for Hip Joint Psoriatic Arthritis
- Blood Examination– Negative rheumatoid factor.
- X-Ray– Findings are as follows
- Irregular broken cartilage linings.
- Joint space is narrowed or wide (collection of synovial fluid).
- Bone spurs are not seen.
- Unilateral lesion.
- MRI-Findings are as follows
- Uneven cartilage linings and surface of the joint observed.
- Joint space is narrowed or wide.
- Bone spurs around edges not seen as observed in osteoarthritis.
- Synovial membrane thickening are seen.
Joint Fluid Analysis (Arthrocentesis)-
- Rule-out Gout– Uric acid crystals are observed in gout.
- Septic Arthritis– Bacterial cells, red blood cells and pus cells are observed in septic arthritis.
Blood Examination for Hip Joint Psoriatic Arthritis
Specific Blood Test
- HLA-B27 Genetic Marker– Test is positive in inflammatory joint diseases like Psoriatic hip joint disease, Ankylosing Spondylitis and Reiter’s syndrome.1
- ESR (Erythrocyte Sedimentation Rate) – ESR is increased in Psoriatic arthritis. ESR study is performed to monitor the progress of the disease and prognosis. Erythrocyte sedimentation rate (ESR) is increased during active inflammation. ESR is non-specific test and used to diagnose inflammatory joint disease and prognosis of the disease. ESR is elevated in rheumatoid hip joint disease, osteoarthritis of hip joint and psoriatic hip joint arthritis.
- ANA Blood Test– ANA is a non-specific antibody test, which is often positive as in all autoimmune disease.
Blood Tests To Rule Out Other Hip Joint Diseases
- Rheumatoid Factors (RF) – RF is negative in patients suffering with psoriatic hip joint disease. RF is a protein molecule known as antibodies. Blood examination of 70% to 90% of patients suffering with rheumatoid arthritis show presence of RF. RF may also present in patients suffering with autoimmune disorders and no joint pain. Symptoms of Rheumatoid arthritis are less severe in patients with absence of RF antibodies.
- Citrulline Modified Proteins (anti-CCP)– Anti-CCP blood test is negative in psoriatic arthritis. Test is specifically used in early stages to rule our rheumatoid arthritis. Anti-CCP is specific antibodies produced in rheumatoid disease prior to symptoms and during symptoms binds to citrulline. The test is specific and diagnoses even cases which do not show positive rheumatoid factors. Anti-CCP predict severity of Rheumatoid disease (RD) and also subclinical RD-
- Antineutrophil Cytoplasmic Antibodies (ANCA) – ANCA is an abnormal antibody seen in patients with history of hip joint pain caused by Wegener’s granuloma. Blood examination for ANCA level is performed to rule out Wegener’s granuloma as a cause of hip joint pain.
- Serum Cytokines – Cytokins and related protein factors are elevated in early stages of rheumatoid disease. Cytokiin factors are used as a marker to diagnosed early stage of rheumatoid arthritis.
Treatment for Hip Joint Psoriatic Arthritis
Conservative Treatment for Psoriatic Arthritis of Hip Joint
- Rest or restricted activities in advanced disease to prevent fall or dislocation until inflammation is control with medications.
- Exercise. Swimming and Yoga therapy as tolerated,
- Heat or cold therapy,
- Cane, walker or wheel chair for ambulation and to assist activities,
- Weight loss if associated with obesity
Specific Treatment for Psoriatic Arthritis of Hip Joint
- Hip Pain Due to Psoriatic Arthritis is treated with one of the following medications
- Opioids- if NSAIDs are not effective to relieve pain.
- Antidepressant Analgesics- Treats neuropathic pain and pain not responding to opioids.
- Antiepileptic Analgesics- Treats neuropathic pain and pain not responding to opioids.
- Hip Joint Inflammation– Inflammation of the Hip Joint is treated with following anti-inflammatory medications-
- NSAIDs– Ibuprofen, Naproxen, Daypro or Celebrex, Corticosteroids.
- Muscle Spasm– Muscle relaxants such as baclofen, flexeril, skelaxin or robaxin are prescribed with anti-inflammatory medications.
- Advanced Treatment of Severe Arthritis– Psoriatic arthritis of the Hip if not treated can cause disability as result of pain and joint malfunction. Inflammation causing arthritis of the hip if not responding to NSAIDs then following medications are tried-
- Methotrexate (Rheumatrex, Trexall).
- Disease-Modifying Anti-Rheumatic Drugs (DMARDs).
- TNF-Alpha Inhibitors2
- Antimalarial medications (Hydroxychloroquine or Plaquenil)
Physical Therapy for Psoriatic Arthritis of Hip Joint
- Muscle Spasm
- Joint Stiffness
- Joint Instability
- Abnormal Gait
Interventional Therapy for Psoriatic Arthritis of The Hip Joint
Corticosteroid injection of the hip joint.
Surgery for Psoriatic Arthritis of The Hip Joint
- Hip Joint Replacement– Head of the femur, neck of the femur and acetabulum is replaced with artificial metal prosthesis.
- Partial Hip Joint Replacement- Head of the femur or neck of the femur or acetabulum is replaced with artificial metal prosthesis.
- Resurfacing of Hip Joint- The surface of the head of the femur and acetabulum is replaced and covered with cobalt metal cap.
- Hip Sprain: Causes, Symptoms, Treatment, Exercises
- Post Traumatic Osteoarthritis of the Hip Joint: Causes, Signs, Treatment, Exercises
- Q&A: Hip Joint Pain Treatment Approach and Options–Everything You Need To Know
- Hip Joint Rheumatoid Arthritis: Causes, Signs, Symptoms, Treatment
- Hip Joint Septic Arthritis: Causes, Symptoms, Treatment, PT, Surgery
- Enthesopathy of Hip: Causes, Symptoms, Treatment
- Analysis of 6 genetic loci for disease susceptibility in psoriatic arthritis.
Alenius GM, Friberg C, Nilsson S, Wahlström J, Dahlqvist SR, Samuelsson L.
J Rheumatol. 2004 Nov;31(11):2230-5.
Department of Public Health and Clinical Medicine, Rheumatology, University Hospital, Umeå, Sweden. [email protected]
- Pharmacoeconomic issues in psoriatic arthritis.
Olivieri I, D’Angelo S, Palazzi C, Padula A, Lubrano E, Mantovani LG.
J Rheumatol Suppl. 2012 Jul;89:103-5. doi: 10.3899/jrheum.120258.
Rheumatology Department of Lucania, San Carlo Hospital, Potenza, Italy. [email protected]