What is the next step in management for a 30-year-old female with Achilles tendon pain and sacroiliac joint pain, and would you order HLA-B27 (Human Leukocyte Antigen B27) testing to rule out ankylosing spondylitis?

From the Guidelines

The next step in management for a 30-year-old female with Achilles tendon pain and sacroiliac joint pain should include a comprehensive musculoskeletal evaluation, physical therapy, and anti-inflammatory medication, while HLA-B27 testing would be appropriate to help evaluate for ankylosing spondylitis. I would recommend starting with naproxen 500mg twice daily or ibuprofen 600mg three times daily with food for 2-3 weeks to reduce inflammation, as suggested by recent guidelines 1. Physical therapy focusing on stretching and strengthening exercises for both the Achilles tendon and sacroiliac joint should be initiated concurrently. For the Achilles tendon, eccentric heel drop exercises and gentle stretching would be beneficial. For sacroiliac joint pain, core strengthening and pelvic stabilization exercises are recommended. HLA-B27 testing is warranted in this case because the combination of Achilles tendinitis (enthesitis) and sacroiliac joint pain in a young adult raises suspicion for a spondyloarthropathy like ankylosing spondylitis, as noted in the Assessment of SpondyloArthritis international Society (ASAS) classification system 1. While HLA-B27 positivity alone is not diagnostic (it's present in 8% of the general population), it can support the diagnosis when combined with clinical findings. Additional imaging such as sacroiliac joint X-rays or MRI would also be appropriate if symptoms persist, as imaging plays a critical role in the diagnosis of axSpA 1. The patient should be advised to avoid high-impact activities temporarily and to use proper footwear with adequate arch support. It's also important to consider the patient's quality of life and functional impairment, as axSpA can impose substantial physical and social burdens on patients, and can interfere with work and schooling 1. Treatment algorithms should focus on controlling disease activity and improving quality of life, with the use of biologic agents such as tumor necrosis factor (TNF)–a antagonists considered for patients with active disease despite nonsteroidal anti-inflammatory drugs 1.

Some key points to consider in the management of this patient include:

• The importance of early diagnosis and treatment to prevent long-term disability and improve quality of life 1
• The use of HLA-B27 testing as a screening tool to help evaluate for ankylosing spondylitis, while also considering other clinical and imaging findings 1
• The role of physical therapy and anti-inflammatory medication in reducing symptoms and improving functional impairment 1
• The potential need for additional imaging and referral to a specialist if symptoms persist or worsen over time 1

From the Research

Next Steps in Management

• The patient's symptoms of Achilles tendon pain and sacroiliac joint pain could be indicative of ankylosing spondylitis (AS), a type of axial spondyloarthritis (axSpA) 2, 3.
• Given the association between HLA-B27 and AS, testing for HLA-B27 may be considered to support the diagnosis 2, 4, 5.
• However, it is essential to note that HLA-B27 is not exclusive to AS and can be present in healthy individuals, and its presence does not necessarily confirm the diagnosis 2, 4.
• A comprehensive clinical evaluation, including medical history, physical examination, and imaging studies, is necessary to determine the underlying cause of the patient's symptoms 3.

HLA-B27 Testing

• HLA-B27 testing may be ordered to support the diagnosis of AS, but it should be interpreted in the context of the patient's overall clinical presentation 2, 4, 5.
• The presence of HLA-B27 can increase the suspicion of AS, but it is not a definitive diagnostic test 2, 4.
• The patient's symptoms, such as Achilles tendon pain and sacroiliac joint pain, should be evaluated in conjunction with the HLA-B27 test results to determine the best course of management 3.

Treatment Considerations

• If the patient is diagnosed with AS, treatment options may include tumor necrosis factor inhibitors (TNFi), which have been shown to be effective in reducing disease activity 6.
• The patient's HLA-B27 status may be considered when selecting treatment options, as some studies suggest that HLA-B27-positive patients may respond better to certain treatments 6.
• A multidisciplinary approach, including rheumatology and physical therapy, may be necessary to manage the patient's symptoms and improve functional outcomes 3.