Working Diagnosis:
Enthesitis related arthritis

Treatment:
Because of his severe pain, he completed a three week steroid taper to rapidly halt his inflammatory arthritis. Due to his axial spine involvement and long-standing arthritis as evidenced by erosions, we initiated etanercept, an anti-tumor necrosis factor biologic agent, as non-biologic disease-modifying anti-rheumatic drugs (DMARDs) do not adequately treat axial disease. He restarted physical therapy to increase lumbar hamstring and flexibility and increase core strength.

Outcome:
His pain resolved and flexibility improved upon medication initiation. He returned to multiple sports after completion of physical therapy. Since he did not have any anklyosis on imaging, we did not limit his participation in athletics. However, there are no formal return to play guidelines in patients with juvenile idiopathic arthritis, and future investigation should better define criteria necessary to safely return this population to play.

Author's Comments:
Enthesitis related arthritis is a type of juvenile idiopathic arthritis chararacterized by arthritis and enthesitis (inflammation at sites of tendon insertion); or arthritis or enthesitis with at least 2 of the following: sacroiliac tenderness or inflammatory lumbosacral pain, HLA B27 positive, onset of arthritis in a male greater than 6 years of age, acute (symptomatic) anterior uveitis, history of ankylosing spondylitis, enthesitis relatated arthritis, sacroiliitis with inflammatory bowel disease, reactive arthritis, or acute anterior uveitis in a first degree relative.

Editor's Comments:
Juvenile idiopathic arthtiis (JIA) is a chronic, inflammatory disease. One category is enthesitis-related arthritis (ERA). ERA makes up 10%–20% of JIA. Presentation often include arthritis, enthesitis, and acute anterior uveitis, and axial disease.
Patients in the ERA category tend to have worse outcomes. ERA is associated with worse function, quality of life, and pain. Active disease 1 year after treatment is more likely. In addition, at 5 years less than 20% of children with ERA are in remission.

References:
Bowyer et al: Pediatric rheumatology clinic populations in the United States: Results of a 3 year survey. Pediatric Rheumatology Database Research Group. J Rheumatology 1996, 23(11): 1968-1974
Petty et al: International league of associations for rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton. J Rheumatology 2004, 31 (2): 390-392.
Weiss PF et al: Enthesitis-related arthritis is associated with higher pain intensity and poorer health status in comparison with other categories of juvenile idiopathic arthritis: the Childhood Arthritis and Rheumatology Research Alliance Registry. J Rheumatology 2012, 39(12):2341-2351.
Weiss P. Diagnosis and treatment of enthesitis-related arthritis. Adolesc Health Med Ther. 2012; 3: 67–74.

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