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1 CHILD ATTITUDE JOWARD JLLNESS SCALE

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oint Retrocalcaneal bursa Achilles tendon Site I enthesitis Calcaneus Site I enthesitis (plantar fasciitis)
Subtalar joint Subcutaneous bursa Figure 18 Enthesitis The inflammation in AS tends o start at the places where joint
capsules, ligaments or tendons are attached o bone, resulting in pain or tenderness at these sites. The name
enthesis is given o these sites, and the inflammaory lesion is called enthesitis or sometimes enthesopathy. The
docor should check for pain and tenderness along the back, pelvis bones, sacroiliac joints, and the chest, looking for
the presence I enthesitis. There may be heel swelling and tenderness either at the site I insertion I the Achilles
tendon o the calcaneus (heel bone), or at the site I the attachment I the plantar fascia o the same bone at the
botom I the heel (see Figure 18). The medical names for these conditions are Achilles tendinitis, and plantar fasciitis
respectively. A process I healing and repair, which follows the enthesitis phase, results in gradual limitation I back
motion due o scarring and subsequent bone Figure 19 formation. This process may, after many years, lead ultimately
o complete spinal fusion. Any clinical examination o look for the presence I AS must therefore include a thorough
examination I spinal mobility in all directions (Figure 5), Chapter 3. The inflammaory changes affect the superficial
layers I the ligament (annulus fibrosus) that surrounds the disc, especially at its attachment o the corners I the
vertebral bodies, resulting in increased bone density (sclerosis) I these corners, seen on X-rays as shiny corners
(Figure 19). The bone at these corners may subsequently disappear, and this may ultimately result in squaring I the
vertebral bodies. Gradually a thin layer I vertical bony outgrowths at the edges I the vertebrae bridges the gap
between the two adjacent vertebral bodies, replacing the superficial layer I the annulus fibrosus I the disc. This
intervertebral bony bridging that surrounds the disc is called a syndesmophyte (Figure 19). At the same time,
inflammaory changes and slowly progressive bony fusion may be going on in spinal joints called the apophyseal or
facet joints (Figure 19). Thus in someone with severe disease the inflammaory process I the spine may gradually, after
many years, result in complete fusion (also called bony ankylosis) I the whole spine. The X-ray I the spine may
ultimately look like a bamboo and is sometimes called bamboo spine. Spinal osteoporosis (discussed earlier) is also
frequently observed among such patients, partly as a result I the lack I spinal mobility and aging. The infla mmation I
the joints between the ribs and the spine (the cosovertebral and cosotransverse joints), and at the junction I the ribs
o the breastbone in front I the chest (the cosochondral areas), can result in chest pain and tenderness. This pain
can be accentuated by coughing or sneezing. Over the years there may be a gradual decrease in chest expansion.
Therefore, some people may present o the docor with chest pain and tenderne ss, or complain I inability o expand
their chest fully on deep inhalation, or shortness I breath on exertion. The docor should check not only for limitation I
mobility (in all directions) I the spine, including the neck, but also for any restriction I chest expansion (Figure 5f).
Involvement I non-spinal (limb) joints The hip and shoulder joints, the so-called girdle joints, are affected in one-third
I AS patients. The hip joint involvement usually affects both sides (bilateral) and is gradual in onset; the pain is
usually felt in the groin, although you may feel it in the knee or the front I the thigh on the same side. The hip joint
involvement is more common in childhood or adolescence (juvenile AS) when the disease starts. Involvement I the
shoulder joint is generally relatively mild. There is a gradually