Heel pain in spondyloarthropathy

NewsBot · Jun 1, 2010

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A randomised, multicentre, double-blind, placebo-controlled trial of etanercept in adults with refractory heel enthesitis in spondyloarthritis: the HEEL trial.
Dougados M, Combe B, Braun J, Landewé R, Sibilia J, Cantagrel A, Feydy A, van der Heijde D, Leblanc V, Logeart I.
Ann Rheum Dis. 2010 May 28. [Epub ahead of print]

OBJECTIVE: Inflammation at the entheses is a distinguishing feature of spondyloarthritis (SpA). Enthesitis at the heel is the most common location and is often chronic, refractory to standard treatment and may have socioeconomic consequences. The objective of this study was to investigate the efficacy of etanercept in refractory heel enthesitis related to SpA.

METHODS: The present work was a 12-week, randomised, double-blind, placebo-controlled study compared etanercept with placebo in patients with SpA according to Amor's criteria, and heel enthesitis proven by MRI. The primary efficacy end point was the normalised net incremental area under the curve (AUC) between randomisation and week 12 for the patient's global assessment (PGA) of disease activity. Secondary end points included change from baseline in PGA, heel pain, the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) function subscale and improvement in enthesitis as measured by MRI.

RESULTS: A total of 24 patients were randomised. Mean normalised net incremental AUC for PGA of disease activity over 12 weeks was significantly greater in the etanercept versus placebo group: -28.5 versus -11.1, respectively (p=0.029). Significant improvements were also reported in the etanercept versus placebo group for PGA, -37.6 versus -11.6 (p=0.007); heel pain, -36.7 versus -13.1 (p=0.022); and WOMAC function, -23.2 versus -7.8 (p=0.024). No significant changes were observed in the MRI findings between groups. No unexpected adverse events or changes in laboratory values or vital signs.

CONCLUSIONS: This trial is the first randomised placebo-controlled study of an anti-tumour necrosis factor (TNF) agent in refractory heel enthesitis in patients with SpA. It demonstrates that etanercept has a statistically significant and clinically relevant benefit in such patients
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Admin2 · Jun 1, 2010

Related threads:
Heel raise for enthesitis?
Varied presentations of enthesopathy
'Inflammatory' vs 'mechanical' plantar fasciitis

NewsBot · May 29, 2011

Enthesitis in an inception cohort of enthesitis-related arthritis.
Arthritis Care Res (Hoboken). 2011 May 25. doi: 10.1002/acr.20508. [Epub ahead of print]

OBJECTIVE:
To describe an enthesitis-related arthritis (ERA) inception cohort and determine which entheses and joints are most commonly affected.

METHODS:
Retrospective inception cohort study of children with ERA diagnosed and treated at the Children's Hospital of Philadelphia between November 2007 and December 2009. RESULTS.: During the study period there were 32 newly diagnosed ERA patients. Fifty-nine percent were male, and the median age at the date of initial evaluation was 12.5 (IQR: 10.2, 14.3) years. The median number of tender entheses at presentation was 2 (IQR: 0, 5), and 21 subjects (66%) had at least 1 tender enthesis. The most prevalent tender entheses were the patellar ligament insertion at the inferior pole of the patella, the plantar fascial insertion at the calcaneus, the Achilles tendon insertion at the calcaneus, and the plantar fascial insertion at the metatarsal heads. Enthesitis was most often symmetric. The median number of active joints was 2 (IQR: 0, 4). The most commonly affected joints were the sacroiliacs, knees, and ankles. Sacroiliitis, which was defined clinically, was most often symmetric while peripheral arthritis was most frequently asymmetric. The odds of having active enthesitis at 6 months increased significantly with each additional tender enthesis at initial evaluation.

CONCLUSIONS:
Among pediatric patients with ERA, lower extremity enthesitis is prevalent at the time of diagnosis and is likely to persist 6-months later. Future studies should address standardization of the enthesitis exam, the pattern of enthesitis over time, enthesitis response to therapy, and the impact of enthesitis on quality of life.
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NewsBot · Sep 1, 2011

Clinical and ultrasonography assessment of peripheral enthesitis in ankylosing spondylitis.
Spadaro A, Iagnocco A, Perrotta FM, Modesti M, Scarno A, Valesini G.
Rheumatology (Oxford). 2011 Aug 28.

Objective. The aim of this study was to compare clinical examination with power Doppler US (PDUS) in the detection of entheseal abnormalities in patients with AS.

Methods. Thirty-six AS patients underwent clinical and PDUS examination of the following bilateral entheseal sites: common extensor tendon at its insertion at the lateral humeral epicondyle; gluteus tendons at their insertion at the greater trochanter; quadriceps tendon at its insertion at the superior pole of the patella; patellar tendon at its proximal insertion at the inferior pole of the patella; patellar tendon at its distal insertion at the tibial tuberosity; Achilles tendon at its insertion at the calcaneus; and plantar aponeuroses at its insertion at the calcaneus.

Results. Clinical and PDUS examination revealed at least one abnormal enthesis in 23 (63.9%) and 35 (97.2%) AS patients, respectively. Furthermore, of 432 entheses examined in our 36 AS patients, 64 (14.8%) were considered abnormal by clinical examination and 192 (44.4%) by PDUS. US abnormalities most commonly found were enthesophytes (31.7%), calcifications (33.7%), thickening (29.8%) and hypoechogenicity (26.6%). We found erosions and PD signals in 9.7 and 6% of examined entheseal sites, respectively. The evidence of entheseal abnormalities by clinical examination has a poor likelihood ratio (LR) for the presence of US abnormalities with vascularization (LR = 1.61), without vascularization (LR = 1.24) or erosions (LR = 1.51) at all sites.

Conclusions. PDUS permits detection of structural and inflammatory abnormalities of the enthesis in AS and may complement the physical examination in order to better evaluate
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NewsBot · Sep 13, 2011

Efficacy and safety of ultrasound-guided local injections of etanercept into entheses of ankylosing spondylitis patients with refractory Achilles enthesitis.
Huang Z, Cao J, Li T, Zheng B, Wang M, Zheng R.
Clin Exp Rheumatol. 2011 Jul-Aug;29(4)

OBJECTIVES:
Enthesitis is one of the most common and specific manifestations of ankylosing spondylitis (AS). However, the treatment of enthesitis is still a challenge for rheumatologist so far, especially to those AS patients with serious enthesitis. This study aimed to evaluate the efficacy and safety of ultrasound (US)-guided local injection of etanercept into entheses of AS patients with refractory Achilles enthesitis.

METHODS:
Twelve AS patients with severe unilateral refractory Achilles enthesitis were enrolled. Among them, 5 patients received US-guided local injection of etanercept and the other 7 received betamethasone. BASDAI, BASFI, VAS of the affected heel, the percentage of ASAS20 responders, CRP, ESR and any adverse events were recorded at baseline, 2, 4, 8 and 12 weeks after the treatment. US was also used to evaluate the corresponding entheses at baseline and every follow-up visit.

RESULTS:
The BASDAI, BASFI, VAS of the affected heel, CRP, ESR, the percentage of ASAS20 responders and the regional blood flow signals detected by colour Doppler were all improved in both the etanercept group and the betamethasone group, at each follow-up visit compared to the baseline data (p<0.05). There were no significant differences in the improvements of any of the above parameters between the two groups (p>0.05). In addition, there were no adverse events from the etaner- cept group, except for the mild acid bilges feeling during the injection procedure, while 1 patient from the betamethasone group developed mild local atrophoderma since the week 4 follow-up visit and the atrophoderma kept stable at the 2 subsequent visits.

CONCLUSIONS:
US-guided local injection of etanercept might be a highly effective, safe and well tolerated treatment for Achilles enthesitis in patients with AS.
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NewsBot · Sep 29, 2011

Comparative study of MRI and power Doppler ultrasonography of the heel in patients with spondyloarthritis with and without heel pain and in controls.
Feydy A, Lavie-Brion MC, Gossec L, Lavie F, Guerini H, Nguyen C, Rannou F, Drapé JL, Dougados M.
Ann Rheum Dis. 2011 Sep 26. [Epub ahead of print]

Introduction
Imaging of heel enthesopathy in spondyloarthritis (SpA) could potentially be useful for diagnosis and monitoring. The aim of this study was to assess the diagnostic capacities of MRI and power Doppler ultrasonography (PDUS) of the heel to distinguish patients with SpA from controls and to distinguish between patients with SpA with and without enthesopathy.

METHODS:
A cross-sectional single-centre study was performed in 51 patients (102 heels) with definite SpA according to Amor's criteria. Patients with degenerative non-inflammatory low back pain (n=24, 48 heels) were included as controls. Bilateral heel MRI and PDUS were performed by two senior musculoskeletal radiologists blinded to the clinical and biological data on the same day as the clinical evaluation. The data were analysed by patient and by heel.

RESULTS:
Neither MRI nor PDUS could discriminate between patients with SpA and controls; bone oedema on MRI was the only abnormality specific to SpA (94%), but with a poor sensitivity (22%). However, among patients with SpA, painful heels had more inflammatory abnormalities (81% by MRI, 58% by PDUS) than heels with no pain (56% at MRI, 17% at PDUS).

CONCLUSION:
Heel MRI and PDUS frequently show inflammatory lesions in SpA, particularly in painful heels. However, they were also often abnormal in controls. These results suggest that heel MRI and PDUS cannot be used for the diagnosis of SpA. However, PDUS and MRI may be useful for the depiction and assessment of enthesis inflammatory lesions in patients with SpA with heel pain.
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NewsBot · Apr 19, 2012

Heel pain in spondyloarthritis: results of a cross-sectional study of 275 patients.
Koumakis E, Gossec L, Elhai M, Burki V, Durnez A, Fabreguet I, Meyer M, Payet J, Roure F, Paternotte S, Dougados M.
Clin Exp Rheumatol. 2012 Apr 17

OBJECTIVES:
Heel pain is a common but poorly studied feature of spondyloarthritis (SpA). The aims of this study were to assess the prevalence and clinical features of heel pain in a cohort of patients with SpA.

METHODS:
This was a retrolective single centre observational study in 2010. Patients with SpA as defined by Amor's criteria were recruited. The data collected were: demographic and disease characteristics, history of heel pain, age at first heel pain, localisation, nature and intensity of pain and treatments. The analyses were descriptive.

RESULTS:
A total of 275 SpA patients (mean age 44.6±13.5 yrs, mean disease duration 16.7±11.8 yrs, 61.5% men) were assessed. A history of heel pain was reported in 130 patients (47.1%), and was the first symptom of SpA in 15.7% of all patients. Heel pain was frequent in both axial (89/201, 44.3%) and peripheral disease (27/56, 48.2%). Distribution was more frequently inferior (88, 69.3%) than posterior (61, 48.0%) (p<0.0001), and frequently bilateral: simultaneously (41.9%) rather than alternatively (29.1%) (p=0.03). Main clinical symptoms were: morning pain on weight bearing (83.6%), but also night pain (34.4%), and/or patient-described swelling (24.2%). Heel pain was frequently recurrent (74.2%), intense (70.3%), source of a limp (71.6%), and often resistant to non-steroidal anti-inflammatory drugs (NSAIDs) (54/108, 50%). Tumour necrosis factor blockers were efficacious on heel pain in 72/94 (76.6%) of cases.

CONCLUSIONS:
This study confirmed heel pain as a frequent symptom in both axial and peripheral SpA. It occurred early in the disease course and it was frequently recurrent and resistant to NSAIDs.
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NewsBot · May 9, 2012

Comparative study of MRI and power Doppler ultrasonography of the heel in patients with spondyloarthritis with and without heel pain and in controls.
Feydy A, Lavie-Brion MC, Gossec L, Lavie F, Guerini H, Nguyen C, Rannou F, Drapé JL, Dougados M.
Ann Rheum Dis. 2012 Apr;71(4):498-503.

INTRODUCTION:
Imaging of heel enthesopathy in spondyloarthritis (SpA) could potentially be useful for diagnosis and monitoring. The aim of this study was to assess the diagnostic capacities of MRI and power Doppler ultrasonography (PDUS) of the heel to distinguish patients with SpA from controls and to distinguish between patients with SpA with and without enthesopathy.

METHODS:
A cross-sectional single-centre study was performed in 51 patients (102 heels) with definite SpA according to Amor's criteria. Patients with degenerative non-inflammatory low back pain (n=24, 48 heels) were included as controls. Bilateral heel MRI and PDUS were performed by two senior musculoskeletal radiologists blinded to the clinical and biological data on the same day as the clinical evaluation. The data were analysed by patient and by heel.

RESULTS:
Neither MRI nor PDUS could discriminate between patients with SpA and controls; bone oedema on MRI was the only abnormality specific to SpA (94%), but with a poor sensitivity (22%). However, among patients with SpA, painful heels had more inflammatory abnormalities (81% by MRI, 58% by PDUS) than heels with no pain (56% at MRI, 17% at PDUS).

CONCLUSION:
Heel MRI and PDUS frequently show inflammatory lesions in SpA, particularly in painful heels. However, they were also often abnormal in controls. These results suggest that heel MRI and PDUS cannot be used for the diagnosis of SpA. However, PDUS and MRI may be useful for the depiction and assessment of enthesis inflammatory lesions in patients with SpA with heel pain.
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NewsBot · Jun 30, 2012

Quantitative MRI measurements of the Achilles tendon in spondyloarthritis using ultrashort echo times.
Hodgson RJ, Menon N, Grainger AJ, O'Connor PJ, McGonagle D, Helliwell P, Emery P, Robson MD.
Br J Radiol. 2012 Jul;85(1015):e293-9.

Objectives: Tendon involvement is common in spondyloarthritis. The MRI signal from the Achilles tendon has been used to quantify mechanical tendinopathy; however, conventional MRI is limited by the short T(2) of normal tendon. Short and ultrashort echo time (UTE) MRI have the potential to better measure signal intensity reflecting changes in T(2) or gadolinium enhancement. Furthermore, UTE images could be used for normalisation to reduce variability. The aim of this work was to investigate such techniques in patients with spondyloarthritis (SpA).

Methods: The Achilles tendons of 14 healthy volunteers and 24 patients with symptomatic spondyloarthritis were studied. Combined UTE (TE=0.07 ms) and gradient echo (TE=4.9 ms) images were acquired before and after intravenous gadolinium together with pre-contrast gradient echo images (TE=2 ms). The signal intensity from a region of interest in the Achilles tendon above the calcaneus was measured. The relative enhancement at echo times of 0.07 ms (RE(0.1)) and 4.9 ms (RE(5)) were calculated. The ratios of the signal intensities from both 4.9 ms and 2 ms gradient echo images to the signal intensity from the UTE image were calculated (RTE(5) and RTE(2) respectively).

Results: Interobserver intraclass correlation coefficients were excellent (≥0.97). The contrast-to-noise ratio was higher for enhancement on UTE images than on gradient echo images. RE(0.1), RTE(5) and RTE(2) were significantly higher in SpA patients than controls.

Conclusion: Signal intensity ratios using UTE images allow quantitative measurements to be made which are sensitive to tendon T(2) or contrast enhancement and which are increased in spondyloarthritis. They therefore have the potential for use as measures of tendon disease in spondyloarthritis.
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NewsBot · Nov 12, 2012

Ultrasonographic evaluation of lower limb enthesis in patients with early spondyloarthropathies
Yasser Ezzat, Wafaa Gaber, Sherif F. Abd EL-Rahman, Marwa Ezzat, Mohammad El Sayed
The Egyptian Rheumatologist; 7 November 2012

Introduction

The enthesopathy of seronegative spondyloarthropathies (SpA) is the hallmark of these diseases, the ultrasound examination of these entheses confirms the frequency of their involvement.
Aim of the work

To detect entheseal abnormalities with ultrasound (US) in the lower limb of patients with early spondyloarthropathy (SpA) and to evaluate US as a valuable tool in detecting early enthesis.
Patients and methods

A total of 45 patients with early disease duration of 11.7 ± 8.5 months, including 10 patients with psoriatic arthritis (PsA), 10 patients with ankylosing spondylitis (AS), 10 patients with reactive arthritis (ReA), eight patients with ulcerative colitis (UC) and seven patients with Crohn’s disease and 20 healthy controls of matched age and sex underwent ultrasonographic evaluation of Achilles, quadriceps, patellar entheses and plantar aponeurosis. Ultrasonographic findings were scored according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS).
Results

On US examination a total of 290/450 (64.4%) of the entheseal sites were abnormal. Mean GUESS score was significantly higher in patients with SpA as compared with controls (p < 0.001), with a higher mean value in patients with PsA, ReA and AS. The mean thickness of all tendons examined was significantly higher in SpA patients than in controls (p < 0.0001) as well as the mean number of enthesophytes and bursitis in all sites examined (p = 0.002, p = 0.003), with a higher prevalence amongst patients with PsA and ReA. The GUESS score was correlated to duration of the disease and the anti-tumour necrosis factor alpha medications.

Conclusion
Enthesis involvement occurs early in spondyloarthritis, the enthesis US score appears to be reliable and useful for improving the diagnostic accuracy of early SpA, further studies are needed as US is an evolving technique.
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NewsBot · Mar 8, 2013

Achilles enthesis ultrasound: the importance of the bursa in spondyloarthritis.
Falcao S, de Miguel E, Castillo-Gallego C, Peiteado D, Branco J, Martín Mola E.
Clin Exp Rheumatol. 2013 Mar 7.

OBJECTIVES:
This paper aims to assess the prevalence and relevance of the bursa-synovial lesion in spondyloarthritis (SpA).

METHODS:
A transversal blind and controlled two-dimensional (2D) and three-dimensional (3D) ultrasound (US) study of Achilles enthesis bursa in early SpA was undertaken. Clinical outcome measures were collected.

RESULTS:
Bilateral Achilles enthesis of 66 early SpA patients (34 women) and 46 control patients (23 asymptomatic healthy subjects and 23 rheumatoid arthritis [RA] patients) were analysed. Mean BASDAI, BASFI and BASRI-spine were 4.55±2.08, 2.16±1.95 and 0.65±0.77, respectively. Mean erythrocyte sedimentation rate (ESR) was 10.93±12.35 mm/h and C-reactive protein (CRP) was 6.46±10.09 mg/l. The κ-values for intra-reader agreement for 2D and 3D images and bursa measurement were 0.82 and 0.98, respectively. Bursas were visualised in 89/132 SpA enthesis (67.4%) vs. 27/46 enthesis (58.7%) of healthy controls (p<0.01), and 10/46 enthesis (21.7%) of RA controls (p<0.01). When the thicknesses of the bursas were analysed, the SpA group had a mean of 1.52±1.47 mm versus 0.76±0.76 mm in the healthy control group (p<0.0001), and 0.38±0.62 mm in the RA control group (p<0.0001). A positive likelihood ratio of 4.6 with a cut-off point of bursa >2 was found. No Doppler signal was detected in controls, but 6.6% of SpA Achilles enthesis had Doppler bursitis. Heel pain was more frequent when bursa was present (p<0.05). When Doppler was present, male predominance, HLA B27 positive, heel pain, and higher number of swollen joints, CRP levels, disease activity by the patient and BASDAI questions 2 and 3 achieved statistical significance (p<0.01).

CONCLUSIONS:
The presence of bursa and Doppler signal at retrocalcaneal bursa level could have a relevant contribution to differentiate SpA patients, and were correlated with clinical outcomes of SpA disease activity.
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NewsBot · Apr 12, 2016

Achilles tendinitis as a rare extraintestinal manifestation of ulcerative colitis
Takahiro Zenda , Ichiro Araki, Otoyuki Nakamiya, Yuji Tokuumi, Yuka Shimada, Keigo Komai, Yukie Taniuchi
Clinical Journal of Gastroenterology 08 April 2016

Patients with inflammatory bowel disease often have extraintestinal manifestations (EIMs) involving almost all organ systems, but little has been reported on Achilles tendinitis. Herein, we present a unique case of Achilles tendinitis, which manifested shortly after initiation of mesalazine therapy for ulcerative colitis. A 26-year-old Japanese woman with bloody diarrhea and abdominal cramps lasting for 7 days was referred to our hospital. The Lichtiger clinical activity index (CAI) score was 9 at the first visit. Based on the clinical symptoms and examination results, she was diagnosed with ulcerative pancolitis in the active phase, and treatment with mesalazine (2.4 g/day) and probiotics was initiated. Her symptoms resolved within 7 days of treatment (CAI 3). However, she then developed bilateral Achilles tendinitis without any apparent cause. The Achilles tendinitis subsided with conservative management within 2 weeks, despite continuation of mesalazine therapy. This case instructively suggests that Achilles tendinitis should be noted as an EIM of ulcerative colitis.
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NewsBot · Aug 4, 2016

Functional limitations due to foot involvement in spondyloarthritis
Nihal Ozaras et al
Journal of Physical Therapy Science
Vol. 28 (2016) No. 7 July p. 2005-2008

[Purpose] Spondyloarthritis is a major inflammatory disease followed-up in the rheumatology clinics, foot involvement in spodyloarthritis is common. The functional states of patients with spondyloarthritis are usually evaluated globally. The aim of this study was to assess the foot involvement-related functional limitations in patients with spondyloarthritis.
[Subjects and Methods] Patients with ankylosing spondylitis and psoriatic arthritis with foot pain more than 4 weeks who underwent anteroposterior and lateral feet radiography were enrolled into the study. A clinical findings score was calculated by assigning 1 point for every finding of swelling, redness, and tenderness. C-reactive protein and erythrocyte sedimentation rate were used as serum markers for disease activity. Foot radiograms were evaluated using the spondyloarthropathy tarsal radiographic index and the foot-related functional state of patients was determined by the Turkish version of the Foot and Ankle Outcome Score.
[Results] There were no relationships between Foot and Ankle Outcome Score subscales and clinical findings score, serum markers, or radiologic score. Pain and symptoms subscale scores were result positively correlated with activity of daily living, sport and recreation, and quality of life subscale scores.
[Conclusion] Pain and symptoms are the main determinants of foot-related functional limitations in spondyloarthritis.
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NewsBot · Nov 14, 2017

Involvement of foot in patients with spondyloarthritis: prevalence and clinical features
Hana Sahli, et al
Foot and Ankle Surgery; Article in Press

Highlights
•Foot involvement is more frequent in spondyloarthritis with peripheral localization.
•Foot involvement was associated with late onset of the disease.
•Foot involvement was associated with comorbidities and blood inflammation.
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Background
The purpose of this study was to evaluate the foot involvement in a group of patients with spondyloarthritis in regard to symptoms, type and frequency of deformities, location and radiological changes.

Methods
We conducted a cross sectional study including 60 patients with spondyloarthritis over a period of six months. Anamnesis, clinical examination, podoscopic examination, biological tests and X-rays of feet were done for each patient.

Results
Foot involvement was found in 31 patients (52%). It was symptomatic in 35% of cases and inaugural in 42% of cases. The most frequent site was the hindfoot (22 patients/31). Radiological findings were: erosion (17%), reconstruction (33%), erosion and reconstruction (50%). Forefoot involvement was found in 18/31 patients. Forefoot deformities were found in 9 patients. Two patients had sausage toe and feet skin abnormalities were observed in 12 patients. At podoscopic examination, 23 patients had abnormal footprints. Foot involvement was more frequent in peripheral spondyloarthritis (p = 0.008). Patients with foot involvement had an advanced age of disease onset (p = 0.05), a shorter disease duration (p = 0.038) and more comorbidities (p = 0.039). Foot involvement was correlated with C Reactive protein (p = 0.043).

Conclusion
In our study, foot involvement and foot symptoms were seen frequently in spondyloarthritis and it is associated with late onset of the disease and with higher inflammation in blood tests.
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NewsBot · May 6, 2018

Association of neuropathic-like pain characteristics with clinical and radiographic features in patients with ankylosing spondylitis
Jung-Hye ChoiSang-Heon LeeHae-Rim KimKyung-Ann Lee
Clinical Rheumatology: 30 April 2018

Ankylosing spondylitis (AS) is a chronic, progressive, and inflammatory disorder and causes chronic back pain. It is not unusual for patients with AS to have symptoms similar to neuropathic pain. We aimed to investigate the neuropathic pain (NeP) component in patients with AS using the painDETECT questionnaire (PD-Q) and to assess the relation between NeP and the disease characteristics of AS. A single-center prospective study was performed, including 105 patients. Patients with AS completed three questionnaires: PD-Q, Beck Depression Inventory (BDI), and Euro Quality of Life (EQ-5D) questionnaires. Patients were classified into three groups according to the PD-Q scores: nociceptive pain (NoP) (score ≤ 12), mixed pain (MP) (score 13–18), and NeP pain (score ≥ 19). Fifteen patients (14.2%) were classified into the NeP group, 22 (21.0%) in the MP group, and 68 (64.8%) in the NoP group. The questionnaires and clinical and radiographic findings were analyzed. Patients with NeP and MP scored worse on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI); BDI; modified Stoke Ankylosing Spondylitis Spine Score; pain-visual analog scale (VAS); and EQ-5L index and showed an increased prevalence of enthesitis and peripheral arthritis. There were no differences in objective inflammatory markers. PD-Q scores were positively correlated with pain-VAS, BASDAI, BDI, and inversely correlated with EQ-5D index. Age, BASDAI, presence of current enthesitis, and BDI score were independently associated with PD-Q scores. The findings showed that NeP component in AS was associated with age, high disease activity, presence of current enthesitis, and depression.
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NewsBot · Sep 11, 2018

Radiologic features in symptomatic/asymptomatic heels of patients with ankylosing spondylitis
Tae‐Hwan Kim Jin Kyu Lee Hyo‐Kyung Sung Bo‐Hyun Kim Young‐Sik Song Il‐Hoon Sung
The International Journal of Rheumatic Diseases: 05 September 2018

Aim
Most heel pain occurs at the posterior or plantar aspect, where main entheses of the heel are located. However, simple radiographs as basic work‐up tools, their features based on their association with local symptoms in the heel in ankylosing spondylitis (AS) patients, have rarely been described.

Method
Forty patients with AS and unilateral heel pain were enrolled to evaluate radiographic differences between symptomatic and asymptomatic heels. The two groups were assessed according to symptom location: posterior (group PS) or plantar (group PL). Typical abnormalities in bone and/or soft tissue on the heel due to inflammation were compared.

Results
In group PS (20 cases), 19 (95%) symptomatic feet and 7 (35%) asymptomatic feet showed abnormal findings on the posterior heel and symptomatic feet showed 6 (30%) plantar abnormalities. Erosion of the posterior calcaneal tuberosity, obliteration of the retrocalcaneal recess (RR), and swelling shadows with increased thickness on posterior soft tissue were observed more frequently and significantly in symptomatic feet in group PS (P < 0.05). In group PL (20 cases), 11 (55%) symptomatic feet and 8 (40%) asymptomatic feet showed abnormalities on the plantar heel and symptomatic feet showed 14 (70%) posterior abnormalities, and none showed significant differences between symptomatic and asymptomatic feet.

Conclusion
Among simple radiographic alterations on heels with AS, such changes around the enthesis of the Achilles as bony erosion and RR obliteration with swollen posterior soft tissue are strongly related to current painful posterior heels. Assessment of enthesitis of the Achilles tendon in AS using plain radiography seems to be valid.
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NewsBot · Sep 17, 2020

Evaluation Effects of Laser Therapy and Extracorporeal Shock Wave Therapy with Clinical Parameters and Magnetic Resonance Imaging for Treatment of Plantar Fasciitis in Patients with Spondyloarthritis: A Randomized Controlled Trial
Kezban Armagan Alpturker et al
Int J Rheumatol. 2020 Aug 27;2020

Objective: Low-level laser therapy (LLLT) and extracorporeal shock wave therapy (ESWT) is applied in the conservative treatment of inflammatory plantar fasciitis, which is also a characteristic feature of spondyloarthritis (SpA) (Gill, 1997 and Roxas, 2005). We determined and compared the effectiveness of LLLT and ESWT using magnetic resonance imaging (MRI).

Methods: This study is a prospective, randomized, comparative, single-blind clinical study. Voluntarily followed 40 patients with the diagnosis of SpA and having pain at the heels at least for 6 months. Patients were divided randomly into two treatment groups. One group undertook 14 sessions of infrared Ga-Al-As LLLT, and the other group undertook 3 sessions ESWT. Feet functions of the patients were evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) and Roles and Maudsley Scoring; VAS was evaluated for foot pain and function. In clinical assessment, disease activity was carried out by applying the BASDAI, the functional assessment was evaluated through the BASFI, and the patient quality of life was evaluated through the ASQoL; enthesitis was scored according to MASES assessment, performed before and at 1 month after treatment. The thickness of the plantar fascia was measured with MRI before and 1 month after treatment.

Results: Compared with the pretherapy, progress in the feet function by AOFAS and Roles-Maudsley scoring and decrease in VAS levels were statistically significant in both groups (p < 0.001). Only the VAS exercise score was superior to LLLT (p < 0.05). The thickness of the plantar fascia had decreased significantly on MRI in all two groups.

Conclusion: The treatment of plantar fasciitis with LLLT and ESWT was more successful in pain improvement and functional outcomes with the dose, frequency, and duration used in our study.
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NewsBot · Sep 29, 2020

Efficacy of local injection therapy for heel pain in rheumatic inflammatory diseases: A systematic review
K. B. Abdelghani, L. Rouached MD, A. Fazaa, S. Miladi, K. Ouenniche, L. Souabni, S. Kassab, S. Chekili & A. Laatar
Zeitschrift für Rheumatologie (2020)

Heel pain or achillodynia is one of the most common manifestations in patients with rheumatic inflammatory diseases (RID) and particularly spondyloarthritis (SpA). It can be associated with inflammation at the bone insertion of tendon, ligament, bursa or fascia. However, treatment is still a challenge for rheumatologists. Several findings highlighted the proven benefit of nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and recently, tumor necrosis factor (TNF)-α inhibitors. However, only limited data about the efficacy of local therapy such as glucocorticoid and anti-TNF injections are available. The aim of this systematic review was to assess the efficacy and safety of local therapies in heel pain and to make recommendations for further studies. Five studies discussing the effectiveness of local treatments of heel pain in RID were included. All studies recognized that the ultrasonography (US)-guided local corticosteroid or etanercept injections were effective and safe modalities for the treatment of inflammatory heel enthesitis, tendinitis, and retrocalcaneal bursitis (RCB) in patients with RID. Pain relief at the local site was associated with a reversion of the acute inflammatory changes in the heel. Furthermore, US-guided injection in RCB with a lateral approach was beneficial in terms of preventing side effects
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NewsBot · Feb 6, 2022

The efficacy and safety of extracorporeal shock wave therapy on plantar fasciitis in patients with axial spondyloarthritis: a double-blind, randomized controlled trial
Özgür Can Caner et al
Rheumatol Int. 2022 Feb 5

The efficacy and safety of extracorporeal shock wave therapy (ESWT) on chronic plantar fasciitis (PF) in patients with axial spondyloarthritis (axSpA) remain unclear. To investigate the efficacy and tolerability of ESWT in patients with PF in axSpA. In this double-blind, randomized controlled trial, 22 axSpA patients with PF who had heel pain above 5 according to visual analog scale (VAS) over 3 months were randomly divided into 2 groups: ESWT and sham-ESWT. Both groups received a total of three treatments at 1-week intervals. All patients were assessed by the VAS, heel pressure algometry, Foot Function Index (FFI), and plantar fascia ultrasonography (thickness and morphology) at baseline, 1 week after each session, 4th and 8th week after the last therapy. The mean ± SD ages of the ESWT and sham-ESWT groups were 43.8 ± 8.2 and 48.5 ± 7.6 years, respectively. Significant time effects between the time points were observed in both groups in terms of VAS, pressure algometry, and FFI. There was a statistically significant decrease in pain, an increase in perceived pressure algometry values, and an improvement in activity restriction in the ESWT group compared to the sham-ESWT group. There was not a change in the plantar fascia thickness before and after the intervention in both groups. No side effects were observed during the treatment and follow-up. ESWT appears to be a safe and well-tolerated physical therapy modality for improving chronic refractory heel pain due to PF in patients with axSPA.
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NewsBot · Sep 13, 2022

Ultrasonography of heel entheses in axial spondyloarthritis patients: frequency and assessment of associated factors
Maroua Slouma et al
J Ultrasound. 2022 Sep 6

Purpose: Foot entheses involvement is a common manifestation of spondyloarthritis. The superiority of ultrasonography examination in foot entheses damages detection has been reported. We aimed to compare the ultrasonography findings of foot entheses between spondyloarthritis patients. and healthy controls and to identify factors associated with enthesitic heel involvement.

Methods: We conducted a cross-sectional study including 37 patients with axial spondyloarthritis (G1) and 37 healthy subjects matched by age and gender (G0). The following pro-inflammatory cytokines were measured: Interleukin (IL-)1, IL-6, IL-17, and IL-23. A blind ultrasonography of foot entheses was performed to examine calcaneal tendon (CT) and plantar fascia (PF).

Results: The mean age was 44.62 ± 12.31 years. Non-steroidal anti-inflammatory drugs were taken in 92% of patients. Clinical heel enthesopathy was noted in 10 patients (27%) of G1. No participant has enthesitic pain in G0. Ultrasonography changes in CT and PF were more frequent in G1 than G0 (p = 0.001 and p = 10-3, respectively). In the PF, tendon thickening was significantly higher in G1 than G0 (p = 0.03). Power Doppler in both enthesitic sites was exclusively observed in G1 (p = 10-3). Regarding associated factors, CT enthesophytes were less frequent in patients taking non-steroidal anti-inflammatory drugs continuously or having regular physical activity. PF structural damages were associated with higher erythrocyte sedimentation rate (p = 0.02), higher IL-23 level (p = 0.01), and higher disease activity (p = 0.04).

Conclusion: Ultrasonography lesions of heel entheses were frequent in spondyloarthritis. Disease activity and inflammatory markers were higher in patients with heel enthesitis. Non-steroidal anti-inflammatory drugs intake and regular physical activity may prevent enthesophytes' occurrence.
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NewsBot · Oct 30, 2023

The association between refractory plantar fasciitis and insertional Achilles tendinopathy and peripheral spondyloarthritis: a report of human leukocyte antigen B-27 investigation and treatment outcome
Young Ho Jung et al
Int Orthop. 2023 Oct 28

Purpose: This study aimed to determine the presence of peripheral spondyloarthritis and investigate the clinical characteristics of patients with concurrent peripheral spondyloarthritis in those presenting with refractory plantar fasciitis and Achilles tendinopathy by conducting human leukocyte antigen B-27 (HLA-B27) testing.

Methods: This retrospective study aimed to investigate patients who complained of persistent pain and significant limitations in daily activities due to their respective foot pain, despite receiving conservative treatment for over one year under the diagnosis of plantar fasciitis or insertional Achilles tendinopathy. The study included 63 patients who underwent HLA-B27 testing. The patients were classified into two groups based on the presence or absence of HLA-B27 positivity. The Mann-Whitney U test assessed significant relationships between continuous variables, and the chi-square test was used to compare categorical variables.

Results: Among the 63 included patients, HLA-B27 positivity was confirmed in 11 patients (17.5%), which was significantly associated with a lower average age (22.8 years versus 31.7 years, P = 0.01) and a substantially lower proportion of females compared to HLA-B27-negative patients (9.1% vs. 25.0%, P = 0.001). Ten of the 11 patients initiated treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) combined with oral steroids as the first-line medication after being diagnosed as HLA-B27 positive. Six patients experienced pain relief with the first-line medication (60%). Four patients who did not achieve pain control with the first-line medication received tumour necrosis factor-alpha inhibitors as the second-line medication. Two patients experienced pain relief, while two experienced reduced but persistent pain.

Conclusions: Among the patients with "refractory" plantar fasciitis and insertional Achilles tendinopathy, 17.5% were diagnosed with peripheral spondyloarthritis. Patients diagnosed with peripheral spondyloarthritis had a higher proportion of men and relatively younger mean age compared to those without the diagnosis. Approximately 70% of these patients achieved symptom improvement in foot and ankle joints by taking conventional synthetic DMARDs, TNF-α inhibitors, or both appropriate for spondyloarthritis.
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