Varied presentations of enthesopathy

NewsBot · Dec 21, 2007

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Varied presentations of enthesopathy.
Slobodin G, Rozenbaum M, Boulman N, Rosner I.
Semin Arthritis Rheum. 2007 Oct;37(2):119-26.

BACKGROUND: The concept of "enthesis organ" allows a new look at the nature of enthesis involvement in some rheumatic and nonrheumatic systemic disorders.

OBJECTIVES: To describe the various presentations of enthesopathy in the course of systemic medical disorders using the available literature data.

METHODS: Review of relevant articles from 1996 to 2006 retrieved by a Medline search utilizing the index terms "enthesis," "enthesitis," and "tendonitis." The list of articles reviewed herein is not exhaustive, with preference given, where possible, to studies and surveys over case reports as well as the most recent literature reflecting new developments on the subject.

RESULTS: Enthesis is defined as the site of insertion of a tendon, ligament, fascia, or articular capsule into bone. Pain originating in the free nerve endings enriched entheses (enthesalgia) may represent a potential cause of chronic musculoskeletal pain in some individuals. Enthesis involvement in the disease process is well appreciated in spondyloarthropathies and in rheumatoid arthritis, though overshadowed by synovitis in the latter. Calcium deposition diseases may constitute the most significant articular cause of enthesopathies in the general population. New data may shed light on the possible pathophysiologic role of enthesopathy in the development of osteoarthritis. Various metabolic and endocrine conditions may manifest with enthesopathy features. The pathogenic mechanisms of enthesis involvement are not uniform and differ in the diverse disorders.

CONCLUSIONS: The concept of enthesopathy as a variety of syndromes in the course of many rheumatic, metabolic, and endocrine disorders should be appreciated. Exercise of a high level of suspicion toward enthesopathic involvement, and greater knowledge of enthesopathy's characteristic patterns and diagnostic possibilities, may allow better management of many patients in rheumatology practice.
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NewsBot · Jul 16, 2008

Evidence for a distinctive pattern of bone formation in enthesophytes.
Benjamin M, Toumi H, Suzuki D, Hayashi K, McGonagle D.
Ann Rheum Dis. 2008 Jul 14. [Epub ahead of print]

OBJECTIVES: The mechanism of new bone formation at entheses in spondyloarthritis (SpA) is poorly understood, but it is a key factor contributing to disability in disease. As bony spur development is also an age-related phenomenon, we studied spurs in elderly dissecting room cadavers in order to establish general principles relating to their development.

METHODS: Spurs of different sizes were studied by routine histology at 26 different entheses (a total of 76 specimens) from the upper limb, lower limb and spine. The percentage of bone marrow was compared in the posterior part of the calcaneus in cadavers with and without Achilles spurs to ascertain the relationship between spurs and immediately adjacent trabecular bone.

RESULTS: Bony spur formation was a common age related phenomena and typically occurred in the most fibrous part of an enthesis. Paradoxically, it was often heralded by the initial appearance of a thick zone of calcified fibrocartilage that subsequently developed bony nodules within it. Uncalcified fibrocartilage was more prominent around large spurs. Endochondral, intramembranous and chondroidal ossification all contributed to spur formation and growth, but cell hypertrophy and florid vascular invasion of a cellular calcified cartilage, typical of endochondral ossification, were not conspicuous features.

CONCLUSION: Entheseal new bone formation occurs by a combination of 3 methods of ossification. However, endochondral ossification was atypical and differed from that seen in the normal development of cartilage bones or during fracture healing. How the inflammatory process modulates these processes could lead to a better understanding of entheseal new bone formation in SpA.
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NewsBot · Oct 12, 2013

Detection of enthesitis in children with Enthesitis-related arthritis: Dolorimeter examination compared to ultrasonography.
Weiss PF, Chauvin NA, Klink AJ, Localio R, Feudtner C, Jaramillo D, Colbert RA, Sherry DD, Keren R.
Arthritis Rheum. 2013 Sep 24. doi: 10.1002/art.38197.

Objective. To evaluate the distribution of enthesitis and accuracy of physical examination (PE) with a dolorimeter for the detection of enthesitis in children, using ultrasound (US) assessment as the reference standard.

Methods. We performed a prospective cross-sectional study of 30 enthesitis-related arthritis (ERA) subjects and 30 controls. The following tendon insertion sites were assessed by standardized PE with a dolorimeter and US: common extensor on lateral humerus epicondyle, common flexor on medial humerus epicondyle, quadriceps at superior patella, patellar ligament at inferior patella, Achilles, and plantar fascia at the calcaneus.

Results. Abnormal US findings were detected most commonly at the insertions of the quadriceps (30%; N= 18/60 sites), common extensor (12%; N=7/60), and Achilles (10%; N=6/60) tendons. The intra-and inter-rater reliability of US (kappa) were 0.78 (95% CI: 0.63, 0.93) and 0.81 (95% CI: 0.67, 0.95), respectively. Tenderness detected by standardized dolorimeter exam had poor positive predictive value for US-confirmed enthesitis. In comparison to controls, ERA subjects reported more pain and had lower pain thresholds at every site, including control sites (all p-values <0.01). Inter-rater reliability of dolorimeter exam for detection of enthesitis was low (kappa 0.49, 95% CI: 0.33, 0.65).

Conclusions. Compared to US, standardized dolorimeter examination for the detection of enthesitis in children has poor accuracy and reliability. The decreased pain threshold of ERA subjects likely contributed to the limited accuracy of PE. Future research is warranted regarding the utility of US for identifying enthesitis at JIA diagnosis, accurately predicting disease progression, and guiding therapeutic decisions
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NewsBot · Oct 26, 2013

Defining enthesitis in spondyloarthritis by ultrasound: Results of a Delphi process and of a reliability reading exercise
L. Tersle et al
Arthritis Care & Research; Accepted Article

Objective: To standardize ultrasound (US) in enthesitis.

Methods: An Initial Delphi exercise was undertaken to define US detected enthesitis and its core components. These definitions were subsequently tested on static images taken from Spondyloarthritis (SpA) patients in order to evaluate their reliability. Results: High-good agreement (>80%) was obtained for including hypoechogenicity, increased thickness of the tendon insertion, calcifications, enthesophytes, erosions and Doppler activity as core elementary lesions of US detected enthesitis. US definitions were subsequently obtained for each elementary component.

On static images the intra-observer reliability showed a high degree of variability for the detection of elementary lesions with kappa coefficients ranging from 0.14 – 1. The inter-observer kappa value was variable with the lowest kappa for enthesophytes (0.24) and the best for Doppler activity at the enthesis (0.63).

Conclusion: This is the first consensus based definition of US enthesitis and its elementary components and the first step performed to ensure a higher degree of homogeneity and comparability of results between studies and in daily clinical work. Defining Enthesitis By Ultrasound
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NewsBot · Nov 10, 2013

Correlations among enthesitis, clinical, radiographic and quality of life parameters in patients with ankylosing spondylitis
Aylin Rezvani et al
Modern Rheumatology November 5, 2013. (doi:10.3109/14397595.2013.850182)

Objectives. To investigate the relationship between enthesitis and disease activity, functional status, fatigue, joint mobility, radiological damage, laboratory parameter and quality of life in patients with ankylosing spondylitis (AS).

Methods. A total of 421 patients with AS (323 male and 98 female) who were included in the Turkish League Against Rheumatism Registry were enrolled in the study. The Bath AS Disease Activity Index (BASDAI), fatigue, the Bath AS Functional Index (BASFI), the Bath AS Metrology Index (BASMI), the Maastricht AS Enthesitis Score (MASES), AS quality of life (ASQoL), the Bath AS Radiology Index (BASRI) and erythrocyte sedimentation rate (ESR) were evaluated.

Results. Enthesitis was detected in 27.3% of patients. There were positive correlations between MASES and BASDAI, BASFI and fatigue (p < 0.05). MASES was not correlated with BASRI, BASMI, ASQoL and ESR. The mean MASES score was 1.1 ± 2.4. The most frequent regions of enthesopathies were right iliac crest, spinous process of L5 and proximal to the insertion of left achilles tendon, respectively.

Conclusions. Enthesitis was found to be associated with higher disease activity, higher fatigue, worse functional status and lower disease duration. As enthesitis was correlated with BASDAI, we conclude that enthesitis can reflect the disease activity in patients with AS.
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NewsBot · Nov 13, 2013

Assessment of enthesopathy in patients with fibromyalgia by using new sonographic enthesitis index.
Ozkan F, Bakan B, Inci MF, Kocturk F, Cetin GY, Yuksel M, Sayarlioglu M.
Rev Bras Reumatol. 2013 Aug;53(4):335-340.

OBJECTIVE:
The aim of the present study is to determine the frequency of enthesopathy in fibromyalgia (FM) by using a newly developed ultrasonography (US) method, the Madrid Sonography Enthesitis Index (MASEI).
METHODS:
This study was conducted on 38 consecutive patients with FM and 48 healthy sex- and age-matched controls. Six entheseal sites (olecranon tuberosity, superior and inferior poles of patella, tibial tuberosity, superior and inferior poles of calcaneus) on both lower limbs were evaluated. All US findings were identified according to MASEI. Scores of patients and controls were compared by Student's t-test and Mann-Whitney U-test. Validity was analysed by receiver operating characteristic curve. Values of P < 0.05 were considered significant.
RESULTS:
Total enthesitis score was 7.39 ± 4.99 (mean ± SD) among FM patients and 3.7 ± 3.22 among healthy controls (P < 0.001). The receiver operating characteristic curve established an ultrasound score of > 3.5 in the FM group as the best cut-off point to differentiate between cases and controls. No statistically significant correlation was found between the MASEI score and the FM disease duration, and the location of the tender points.
CONCLUSIONS:
Misdiagnoses of FM are harmful to patients and the community, and the presence of enthesopathy among FM patients increases. Its detection with the MASEI score may help to discriminate FM patients presenting with ill-defined symptoms and signs, in order to prevent mistreatment.
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NewsBot · Jan 9, 2014

Enthesitis in patients with psoriatic arthritis, axial spondyloarthritis and healthy subjects assessed by ‘head-to-toe’ whole-body MRI and clinical examination
René Panduro Poggenborg et al
Ann Rheum Dis doi:10.1136/annrheumdis-2013-204239

Objectives To investigate the ability of whole-body MRI (WBMRI) to detect axial and peripheral enthesitis in patients with psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), and in healthy subjects (HS). Furthermore, to develop MRI enthesitis indices based on WBMRI and validate these by use of clinical measures of disease activity.

Methods Prospective cross-sectional study of patients with PsA (n=18) and axSpA (n=18) with moderate to high disease activity, and HS (n=12). Enthesitis at 35 individual sites located at upper and lower limbs, chest and pelvis were evaluated by WBMRI and clinical examination, and compared. Three new WBMRI enthesitis indices were developed.

Results WBMRI allowed evaluation of 888 (53%) of 1680 sites investigated, and 19 (54%) of 35 entheses had a readability >70%. The percentage agreement between WBMRI and clinical enthesitis was 49–100%, when compared at the level of the individual entheses. Enthesitis on WBMRI was observed in 148 (17%) of the entheseal sites, and was frequently present at greater trochanters (55%) and Achilles (43%) and supraspinate (23%) tendon insertions in patients and HS. At the first mentioned two locations enthesitis often appeared without clinical signs of enthesitis. Patients and HS differed significantly in one of the new WBMRI enthesitis scores. Patients and HS differed significantly in one of the new WBMRI enthesitis scores, and this score correlated weakly with BASDAI question 4 (tenderness in relation to entheses), BASDAI and patient global (ρ=0.29–0.31, p<0.05).

Conclusions WBMRI is a promising new imaging modality for evaluation of enthesitis in patients with PsA and axSpA, but requires further investigation before clinical use.
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NewsBot · Sep 2, 2014

A STUDY OF ENTHESITIS IN SPONDYLOARTHROPATHY IN PATIENTS FROM A TERTIARY CARE SERVICE HOSPITAL
Surajit Ghatak, K. Shanmuganandan
Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 28, July 14; Page: 7822-7830,

INTRODUCTION: The enthesis is defined as the site of insertion of a tendon, ligament, joint capsule, or fascia to bone. A variety of anatomical sites can be symptomatically affected in Spondyloarthropathy. The spectrum of Spondyloarthropathy consists of Primary Ankylosing spondylitis, Reiter's syndrome/ reactive arthritis, Psoriatic arthropathy and arthropathy associated with Inflammatory Bowel Disease. One of the pathologic hallmarks of the disease is entheseal involvement with insertional tendonitis at different locations. AIM: To study the distribution of involved enthesis in patients with spondyloarthropathy.

MATERIAL AND METHODS: The study group included 54 patients from diverse age groups and from different geographic areas in India and was carried out in a tertiary care service hospital. All these patients had historical evidence of sacroiliitis in the form of Inflammatory Back Pain and were diagnosed as Spondyloarthropathy according to ESSG criteria. RESULT: The male to female ratio in this study is 8.2:1. The distribution of enthesitis in our study showed a maximum incidence of heel and costosternal joint. The other enthesis involved were greater trochanter, anterior superior iliac spine and ischial tuberosity. MRI was compared against Plain radiography of Sacroiliac joints for detecting sacroiliitis changes.

CONCLUSION: The disease expression has been considered different in males and females. The males with Ankylosing spondylitis have more often had radiological spinal changes and hip involvement than their female counterparts. MRI was compared against Plain radiography of Sacroiliac joints for detecting sacroiliitis changes. MRI was found to be better as compared to Plain radiography in detecting early sacroiliitis with a P value <0.05.
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NewsBot · Jan 23, 2015

Enthesitis in the context of spondyloarthritides.
Haibel H, Sieper J.
Z Rheumatol. 2015 Jan 23.

Enthesitis is a frequent manifestation in spondyloarthritis (SpA) and psoriatic arthritis (PsA) and can be found in up to 40 % of patients with SpA. Because of the pathognomonic relevance the classification criteria for SpA and PsA use enthesitis as an entrance or secondary criterion. Enthesitis is most frequently localized at the heel but it can occur at any insertion of an enthesis into the bone. When diagnosing enthesitis differential diagnoses should be considered, mechanical-degenerative causes and fibromyalgia in particular should be excluded. The imaging techniques power Doppler ultrasound (PDUS) and magnetic resonance imaging (MRI) are most helpful in making the diagnosis. The therapeutic options for enthesitis are limited. Nonsteroidal antirheumatic drugs (NSARD) and local injections of corticosteroids are recommended. In small clinical trials no efficacy of disease modifying antirheumatic drugs (DMARD) could be demonstrated. In contrast, tumor necrosis factor alpha (TNF-alpha) blockers were shown to be highly effective in randomized controlled trials for SpA and PsA but they are not currently approved for enthesitis only.
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NewsBot · Feb 14, 2015

Spectrum of ultrasound pathologies of achilles tendon, plantar aponeurosis and flexor digiti brevis tendon heel entheses in patients with clinically suspected enthesitis.
Sudoł-Szopińska I, Zaniewicz-Kaniewska K, Kwiatkowska B.
Pol J Radiol. 2014 Nov 9;79:402-8. doi: 10.12659/PJR.890803. eCollection 2014

BACKGROUND:
Enthesitis is considered a characteristic presentation of the second most common group of rheumatoid disorders, i.e. spondyloarthropathies (SpAs), particularly peripheral spondyloarthropathies. At the initial stages, enthesitis may be the only symptom of SpA, particularly in patients lacking the HLA-B27 receptor.
MATERIAL/METHODS:
In light of diagnostic difficulties with detecting enthesitis in clinical examinations and laboratory investigations, many studies point out the high specificity of imaging studies, and particularly ultrasonography.
RESULTS:
A total of 20% Achilles tendon entheses, 45% plantar aponeurosis entheses and 89.5% of flexor digiti brevis tendon entheses were unremarkable. In the remaining cases, the presentation of pathological lesions was not specific to enthesitis and might more likely correspond to degeneration or microinjuries of the entheses, beside the most obvious cases of achillobursitis or Kager's fat pad inflammation.
CONCLUSIONS:
The studies demonstrated that ultrasound scans rarely confirm the clinical diagnosis of enthesitis
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NewsBot · Apr 18, 2015

Ultrasound study of entheses in psoriasis patients with or without musculoskeletal symptoms: A prospective study
Emilie Acquacalda et al
Joint Bone Spine; 13 April 2015

Objective
To estimate the prevalence of ultrasonographic enthesitis in psoriasis patients with or without musculoskeletal symptoms and to investigate their evolution under systemic treatments given for the cutaneous symptoms.

Patients and methods
Prospective bi-centre (rheumatology and dermatology) study over 6 months, including psoriasis pts requiring systemic treatment, with or without musculoskeletal symptoms and/or psoriatic arthritis (PsA). Clinical assessment (M0 and M6) included: BASDAI, HAQ, SPARCC, PASI and nail disease. US assessment (M0 and M6) with Grey Scale and PD of 10 entheses was performed by one trained rheumatologist blinded to clinical and biological data, scoring morphological, structural lesions and PD signal.

Results
Complete data were obtained on 340 entheses in 34 patients. Twenty-two were asymptomatic (PsO) and 12 symptomatic (PsA). They received conventional treatment and/or biologics.

At baseline
US abnormalities were found in 97.1% total population and in 86.4% PsO patients. 95/340 enthesitis were observed, 57/220 in PsO vs 38/120 in PsA (P = 0.258). Neither group had PD signal. Presence of 24/90 enthesitis in patients with nail disease vs 33/130 without (P = 0.831).

At M6
Twenty-three patients were assessed. US morphological (thickness and hypoechogenicity) abnormalities were improved in PsO (n = 13) (P = 0.021) and PsA patients (n = 10) (P = 0.164) with a significant decrease of BASDAI, HAQ, SPARCC.

Conclusion
We observed a high frequency of US enthesitis in psoriasis patients, with or without musculoskeletal symptoms, requiring systemic treatment. At 6 months, US morphological abnormalities were likely to improve. Further studies would be interesting to validate our data and to assess their potential impact on PsA development.
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NewsBot · Apr 26, 2015

The assessment of lesions of the Achilles tendon by ultrasound imaging in inflammatory arthritis: A systematic review and meta-analysis.
Carroll M, Dalbeth N, Boocock M, Rome K.
Semin Arthritis Rheum. 2015 Mar 18.

OBJECTIVE:
Ultrasound (US) is a highly sensitive, reliable and non-invasive tool, which allows for the assessment of lesions of tendons and entheseal sites. The aim of this systematic review and meta-analysis is to identify differences in US lesions of the Achilles tendon (AT) between people with inflammatory arthritis (IA) and healthy controls.
METHODS:
An electronic literature search was performed on Medline, CINAHL, SportDiscus and The Cochrane Library. Methodological quality was assessed using a modified Quality Index. Odds ratios with 95% confidence intervals (CI) were determined. Meta-analysis was conducted on those studies that were considered to be homogenous.
RESULTS:
A total of 13 high-to-medium quality studies met the inclusion criteria. The majority of studies reported US lesions in spondyloarthropathy (SpA), with limited evidence for other forms of IA. US lesions were not consistently defined with regard to Outcome Measures in Rheumatology Clinical Trials (OMERACT) definitions, and numerous scoring systems were used across the majority of studies. The mean AT thickness at the enthesis in people with SpA was 0.54mm thicker (95% CI: 0.10-0.97mm) with more frequent erosions in people with SpA (odds ratio = 7.43, 95% CI: 1.99-27.77, P = 0.003) and rheumatoid arthritis (RA) (odds ratio = 9.60, 95% CI: 1.23-74.94, P = 0.03), compared to controls. There was no significant difference in the frequency of enthesophyte formation in people with SpA compared to the controls (odds ratio = 2.48, 95% CI: 0.64-9.70, P = 0.19).
CONCLUSIONS:
The systematic review identified that a majority of studies reporting US lesions were in SpA, but limited evidence relating to other forms of IA. Consistent application of the OMERACT US definitions and scoring of US lesions is required in future studies of AT disease in IA. Further work is also required to distinguish between US lesions reflective of inflammation and structural damage.
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NewsBot · May 1, 2015

Enthesitis im Rahmen von Spondyloarthritiden.
Haibel H, Sieper J.
Orthopade. 2015 Apr 29

Enthesitis is a frequent manifestation in spondyloarthritis (SpA) and psoriatic arthritis (PsA) and can be found in up to 40 % of patients with SpA. Because of the pathognomonic relevance the classification criteria for SpA and PsA use enthesitis as an entrance or secondary criterion. Enthesitis is most frequently localized at the heel but it can occur at any insertion of an enthesis into the bone. When diagnosing enthesitis differential diagnoses should be considered, mechanical-degenerative causes and fibromyalgia in particular should be excluded. The imaging techniques power Doppler ultrasound (PDUS) and magnetic resonance imaging (MRI) are most helpful in making the diagnosis. The therapeutic options for enthesitis are limited. Nonsteroidal antirheumatic drugs (NSARD) and local injections of corticosteroids are recommended. In small clinical trials no efficacy of disease modifying antirheumatic drugs (DMARD) could be demonstrated. In contrast, tumor necrosis factor alpha (TNF-alpha) blockers were shown to be highly effective in randomized controlled trials for SpA and PsA but they are not currently approved for enthesitis only.
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NewsBot · Sep 15, 2015

Development of ultrasound enthesitis score to identify patients with enthesitis having spondyloarthritis: prospective, double-blinded, controlled study.
Milutinovic S, Radunovic G, Veljkovic K, Zlatanovic M, Zlatkovic Svenda M, Perovic Radak M, Pavlov Dolijanovic S, Stojic B, Damjanov N
Clinical and Experimental Rheumatology [2015]

OBJECTIVES: To distinguish patients (pts) with enthesitis having spondyloarthritis (SpA) from pts with enthesitis without SpA by ultrasound (US) enthesitis score.

METHODS: The study sample included 127 pts with enthesitis (76 pts with SpA, 26 pts with rheumatoid arthritis, 25 pts with mechanically-related enthesitis). The entheses of plantar fascia, Achilles, patellar, quadriceps and common extensor tendon on lateral epicondyle were examined by US. Two operators, blinded to clinical diagnosis and enthesitis symptoms, assessed enthesis thickness, echogenicity, enthesophytes, power Doppler signal and erosions. Logistic regression and receiver operating characteristic (ROC) curve analysis were used to determine the predictive value of each enthesitis lesion for diagnosis of SpA. The best predictive value for SpA was accomplished when absence and presence of increased thickness, hypoechogenicity and enthesophytes were scored as 0 and 1; absence and presence of PD and erosions were scored as 0 and 4. Belgrade Ultrasound Enthesitis Score (BUSES) represents a cumulative score of derived enthesitis lesion scores at examined entheses. Independent-samples t-test was used for BUSES comparison between pts with and without SpA. Validity of BUSES for SpA diagnosis was evaluated by sensitivity and specificity. Cut-off point was chosen as the smallest value with specificity of at least 90%. The reliability was analysed by intra-class-correlation coefficient (ICC).
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NewsBot · Sep 17, 2015

Entheseal involvement in systemic disorders
Gleb Slobodin , Doron Rimar, Nina Boulman, Lisa Kaly, Michael Rozenbaum, Itzhak Rosner, Majed
Clinical Rheumatology; 10 September 2015

The objective of this study is to review the data on entheseal involvement in systemic disorders. A Pubmed search utilizing the indexing terms “enthesis” and “enthesitis” was conducted and the data pertinent to the aim of the review was extracted and organized in accordance with the preplanned structure of the manuscript. A number of cadaver-based studies, as well as studies using ultrasonography and magnetic resonance imaging, have detailed new distinct aspects of enthesis physiology and pathology in a variety of rheumatic and non-rheumatic systemic disorders. Major progress has been done in characterization of separate components of the enthesis organ, imaging of entheses, elaboration of the role and features of entheseal disease in spondyloarthropathies, juvenile idiopathic arthritis, osteoarthritis, familial Mediterranean fever, hyperuricemia, and other systemic conditions. The knowledge acquired and summarized herein shows that entheses can be affected in various ways in variety of medical disorders with different pathogenesis. Better understanding of the risk factors, mechanisms and natural history of enthesopathies is warranted. The current progress in the understanding of entheseal involvement in systemic disorders represents just the first step in resolving the entheses-related enigmas.
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NewsBot · Oct 13, 2015

Incidence and risk factors of calcaneal enthesophytes in spondyloarthritis and trauma patients.
Kamo K, Yahiro KI
Mod Rheumatol. 2015 Oct 12:1-14

OBJECTIVE:
Achilles enthesitis and plantar fasciitis are features of spondyloarthritis (SpA). Enthesophytes may indicate enthesitis, but their incidence is also high in elderly individuals and in athletes. This study aimed to clarify the incidences and risk factors of Achilles enthesophyte (AE) and plantar entesophye (PE) in SpA and trauma patients.
METHOD:
We retrospectively surveyed radiographs of the feet of SpA and trauma patients in our hospital. The SpA group included 17 patients (33 feet), and the trauma group included 33 patients (37 feet) who had undergone surgery between April 2013 and March 2014.
RESULTS:
The incidence of AEs was 63.6% (21 feet) in the SpA group and 54.1% (20 feet) in the trauma group (p = 0.45). The incidence of PEs was 48.9% (16 feet) in the SpA group and 16.2% (6 feet) in the trauma group. The SpA group had a higher prevalence of PEs than the trauma group (p < 0.01). The multivariate analysis shows that the risk factors for AEs and PEs were SpA and age.
CONCLUSION:
The risk factors for AEs and PEs were found to be advanced age and the presence of SpA.
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NewsBot · Nov 19, 2015

Discriminant validity study of ultrasound Achilles enthesis.
Exp?sito Molinero MR, de Miguel Mendieta E
Reumatol Clin. 2015 Nov 10. pii: S1699-258X(15)00149-7. doi: 10.1016/j.reuma.2015.08.006

OBJECTIVE:
We want to know if the ultrasound examination of the Achilles tendon in spondyloarthritis is different compared to other rheumatic diseases.
MATERIAL AND METHODS:
We studied 97 patients divided into five groups: rheumatoid arthritis, spondyloarthritis, gout, chondrocalcinosis and osteoarthritis, exploring six elementary lesions in 194 Achilles entheses examined.
RESULTS:
In our study the total index ultrasonographic Achilles is higher in spondyloarthritis with significant differences. The worst elementary spondyloarthritis lesions for discriminations against other pathologies were calcification.
CONCLUSIONS:
This study aims to demonstrate the discriminant validity of Achilles enthesitis observed by ultrasound in spondyloarthritis compared with other rheumatic diseases that may also have ultrasound abnormalities such enthesis level.
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NewsBot · Feb 1, 2016

Sonologic enthesitis in children with enthesitis-related arthritis.
Shenoy S, Aggarwal A
Clin Exp Rheumatol. 2016 Jan 12

OBJECTIVES:
Enthesitis is an important clinical manifestation and is a diagnostic criterion for juvenile idiopathic enthesitis-related arthritis (JIA-ERA). Ultrasound (US) is a highly sensitive method of detection of enthesitis in adult spondyloarthropathies. However, since the data on JIA and the preformance of US compared to clinical examination is limited, we aimed to compare the accuracy of US and clinical examination in JIA-ERA.
METHODS:
Patients with JIA-ERA (ILAR criteria) were enrolled in the study after consent. Besides data on disease variables, enthesitis was evaluated clinically as well as by ultrasound. Six entheseal sites (iliac crest, superior pole patella, inferior pole patella, tibial tuberosity, tendoachilles and plantar fascia) on both sides of the body were examined in each patient. Features of acute and chronic enthesitis were noted.
RESULTS:
360 entheseal sites in 30 male patients (26 positive for HLA-B27), with a median age of 16 years and median disease duration of 4 years were evaluated. Median Madrid Sonology Enthesitis Index (MSEI) was 2.0 (MSEI-Acute) (IQR 0-3) and 1.0 (MSEI-Chronic) (IQR 0-1). Ultrasound enthesitis was seen in 25 of 30 patients whereas clinical enthesitis was present in 15 patients only. USG picked up 20 (47 vs. 27) more sites of enthesitis as compared to clinical examination. The concordance rate was 89.4%. Discordance was more at tibial tuberosity, superior pole patella and tendoachilles entheses.
CONCLUSIONS:
Ultrasonography detects subclinical enthesitis in a proportion of patients with JIA-ERA. It can be a useful, cost-effective and safe diagnostic tool in the workup of JIA patients.
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NewsBot · Feb 4, 2016

Comparison of Clinical Examination versus Whole-body Magnetic Resonance Imaging of Enthesitis in Patients with Early Axial Spondyloarthritis during 3 Years of Continuous Etanercept Treatment.
Althoff CE et al
J Rheumatol. 2016 Feb 1. pii: jrheum.150659.

OBJECTIVE:
To compare clinical examination versus whole-body magnetic resonance imaging (WB-MRI) of enthesitis in patients with early axial spondyloarthritis during 3 years of continuous etanercept (ETN) treatment.
METHODS:
Forty-one patients underwent clinical and WB-MRI examinations for enthesitis at baseline and after 2 and 3 years of treatment. Twenty-one sites were assessed in 4 anatomic regions - anterior chest wall, pelvis, knee, and foot.
RESULTS:
Clinical examination at baseline detected enthesitis in 57% of the patients (85 lesions, mean 2.1 lesions, SD 2.9), most of them in the pelvis (42 lesions in 17 patients) and anterior chest wall (19 lesions in 10 patients). The proportion of patients with clinically detected enthesitis decreased to 19% at Year 2 (mean 0.5, SD 1.5) and 14% at Year 3 (mean 0.7, SD 1.8). WB-MRI detected enthesitis at baseline in 21% of patients (22 lesions, mean 0.5 lesions, SD 1.1), also most frequently in the pelvis (12 lesions) and anterior chest wall (7 lesions). MRI-positive enthesitis decreased to 13% at Year 2 (mean 0.2 lesions, SD 0.5) and 14% at Year 3 (mean 0.2 lesions, SD 0.5). There was positive correlation of clinical and MRI findings at baseline at the anterior chest wall (p = 0.001) and the pelvis (p = 0.0001). No correlation was found at the knee and foot at baseline and for all regions at followup.
CONCLUSION:
Both clinical examination and WB-MRI show a decrease in enthesitis after 2 and 3 years of ETN treatment, but correlation was limited to the pelvis and anterior chest wall at baseline.
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NewsBot · Mar 24, 2016

The effect of foot position on Power Doppler Ultrasound grading of Achilles enthesitis.
Zappia M et al
Rheumatol Int. 2016 Mar 22

The aim of this study was to determine whether foot position could modify power Doppler grading in evaluation of the Achilles enthesis. Eighteen patients with clinical Achilles enthesitis were studied with power Doppler ultrasound (PDUS) in five different positions of the foot: active and passive dorsiflexion, neutral position, active and passive plantar flexion. The Doppler signal was graded in any position and compared with the others. The Doppler signal was higher with the foot in plantar flexion and decreased gradually, sometimes till to disappear, while increasing dorsiflexion. The Doppler signal was always less during the active keeping of the position of the joint, than during the passive. The PDUS examination of the Achilles enthesis should be performed also with the foot in passive plantar flexion, in order not to underestimate the degree of vascularization.
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NewsBot · Sep 8, 2016

An ultrasonographic study of enthesis in early psoriatic arthritis patients naive to traditional and biologic DMARDs treatment.
Perrotta FM et al
Rheumatol Int. 2016 Sep 6

The aim of this study was to evaluate the rate of power Doppler ultrasound (PDUS) abnormalities at entheseal sites in patients with early psoriatic arthritis (PsA) na?ve to traditional and biologic DMARDs and to compare the PDUS findings with clinical examination. PsA patients with early disease and na?ve to traditional and biologic DMARDs were consecutively enrolled in this study. Patients underwent PDUS examination of the following bilateral entheseal sites: common extensor tendon at its insertion at the lateral humeral epicondyle; quadriceps tendon at its insertion at the superior pole of the patella; patellar tendon at its insertion at the tibial tuberosity; medial collateral ligament at its proximal insertion and Achilles tendon at its insertion at the calcaneus. The Leeds enthesitis index (LEI) was used to assess clinical entheseal involvement. Twenty-one early PsA patients completed the clinical and PDUS examinations. Clinical entheseal involvement was found in 9 (42.9 %) and PDUS abnormalities in 20 (95.5 %) of the 21 early PsA patients. Achilles tendon insertion was the site with the major entheseal abnormalities. Active (power Doppler positive) entheseal lesions were found in 4.7, 9.5, 14.3 and 14.3 % of patients at the lateral humeral epicondyle; quadriceps tendon, patellar tendon insertions, and Achilles tendon insertions, respectively. Concordance between clinical (LEI) and PDUS was poor. The present study confirms that PDUS allows detecting structural and inflammatory abnormalities of enthesis in early PsA patients. Our study shows that, in early disease, active abnormalities seem to have a low prevalence.
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NewsBot · Nov 28, 2016

Gut microbiome in children with enthesitis-related arthritis in a developing country, and the effect of probiotic administration
Amita Aggarwal et al
Clin & Exp Immun 9 Nov

In Asia, enthesitis-related arthritis (ERA) is the most-frequent category of juvenile idiopathic arthritis. ERA has a strong association with HLA-B27 and subclinical gut inflammation. In a HLA-B27 transgenic rat model, presence of Bacteroides bacteria in the gut appears to cause spondyloarthropathy (SpA). Thus, we studied gut microbiota in children with ERA. Stool specimens from 33 patients with ERA and 14 age-matched healthy controls were studied; none had any gastrointestinal symptom, or had received a drug known to affect gut motility or microbiota in the preceding 6 weeks. From each specimen, a cDNA library for V3 region of bacterial 16S rRNA was subjected to high-throughput, massively-parallel sequencing. Relationship of specimens was studied using principal co-ordinate analysis (PCoA), and abundances of various bacterial taxa and alpha diversity were compared between groups. In 8 patients, a repeat fecal specimen was studied after 12 weeks of probiotic therapy. The 55 specimens yielded a median (range) of 397315 (102093 – 1502380) high-quality reads each. In PCoA, gut microbiota from ERA showed a wider dispersion than those from controls. In patients, families Bacteroidaceae and Enterobacteriaceae were more abundant and Prevotellaceae were less abundant than in controls. Also, genera Bacteroides, Entercoccus and Klebsiella were overrepresented, and genus Prevotella was under-represented in ERA patients. Probiotic therapy led to a non-significant increase in Prevotellaceae. Patients with ERA have a dysbiosis in the gut, with increased abundance of Bacteroides and reduction of Prevotella. Probiotic supplementation in a subset of patients did not significantly reverse these changes. This article is protected by copyright. All rights reserved.
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NewsBot · Dec 21, 2016

Clinical enthesitis in a prospective longitudinal psoriatic arthritis cohort: Incidence, prevalence, characteristics and outcome.
Polachek A et al
Arthritis Care Res (Hoboken). 2016 Dec 20. doi: 10.1002/acr.23174.

OBJECTIVES:
The aim of our study was to evaluate the incidence, prevalence, characteristics, disease associations, risk factors and outcome of clinical enthesitis in patients with PsA.
METHODS:
The study included patients with PsA followed prospectively. Enthesitis was defined as the presence of at least one tender enthesis at one of the 18 entheseal sites of the Spondyloarthritis Research Consortium of Canada enthesitis index.
RESULTS:
Between 2008 and 2014, 281 of 803 patients had enthesitis providing a prevalence of 35%. 192 patients developed enthesitis during the course of follow-up, with an annual incidence of 0.9%. Most of the patients had 1 (48.4%) or 2 (32.2%) tender entheseal sites and the mean (s.d.) number of sites per visit was 2.03 (1.6). The 3 most common sites were at the insertions of the Achilles tendons and plantar fascia on the calcaneus, and the lateral epicondyles (24.2%, 20.8% and 17.2%, respectively). More active disease (higher actively inflamed joint count, tenosynovitis and dactylitis), more pain and less clinical damage were associated with enthesitis. Higher BMI, more actively inflamed joints and younger age were risk factors for developing this condition. Enthesitis resolved in most patients without changing treatment.
CONCLUSION:
Clinical enthesitis is common with a period prevalence of 35% of PsA patients. It usually involves only 1 or 2 sites simultaneously. The most common tender sites are at the insertions of the Achilles tendon, plantar fascia and the lateral epicondyles. More active disease and more pain are associated with enthesitis.
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NewsBot · Dec 24, 2016

Ultrasound Features of the Posterior Tibialis Tendon and Peroneus Brevis Tendon Entheses: A Comparison Study between Healthy Adults and Inflammatory Arthritis
Ian M. Ward MD et al
Arthritis Care Res (Hoboken). 2016 Dec 24. doi: 10.1002/acr.23174.

Objectives: Limited literature exists on the sonographic appearance of the posterior tibialis (PTT) and the peroneus brevis (PBT) tendon entheses. We determined the anatomic features and best imaging techniques of normal PTT and PBT using musculoskeletal ultrasound and compared these findings to subjects with inflammatory arthritis.

Methods: Adult subjects were enrolled as: healthy controls (HC), rheumatoid arthritis (RA), and spondyloarthropathy (SpA). Bilateral PTT and PBT entheses were imaged longitudinally, comparing two angles of insonation: perpendicular to the skin surface and 45˚ cephalad. Images were scored on semi-quantitative scales assessing pathology.

Results: Eighty-eight subjects were enrolled: HC (n=37), RA (n=21), and SpA (n=20). Complete enthesis visualization was achieved more frequently in the perpendicular than in the cephalad view for the PBT (76.3% versus 58.7%), but more frequently in the cephalad view for the PTT (58.0% versus 19.6%). RA and SpA subjects had higher rates of PTT fiber disruption (p< 0.001), PTT tenosynovial effusion (p< 0.001), and Doppler signal (p< 0.001) than HC. No significant differences existed at the PBT enthesis. Multivariate analysis demonstrated that RA and SpA subjects were 5.1 times (p< 0.001) and 3.6 times (p< 0.001) more likely to exhibit ultrasound detected pathology than healthy controls.

Conclusions: Perpendicular transducer aim is optimal for imaging the PBT, while cephalad transducer orientation was more effective for evaluation of the PTT. Unlike distal PBT imaging, PTT imaging distinguished HC from disease state, with both RA and SpA patients showing features of PTT enthesopathy. Distal PTT imaging is a useful technique for musculoskeletal ultrasound.
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NewsBot · Jan 4, 2017

Enthesitis in a 16-Year-Old Boy with M694V Mutation.
Nienhuis SL, Westerbeek RE
Case Rep Med. 2016;2016:5869250.

Introduction. FMF (Familial Mediterranean Fever) is characterized by recurrent attacks of fever and articular pain. Enthesitis is the hallmark of pain in spondyloarthropathy. Literature suggests association of M694V mutation and enthesitis. We report a case of a 16-year-old boy with enthesitis and FMF. Case Presentation. A 16-year-old boy of Turkish origin with a history of FMF presented with localized tenderness of the heel and severe disability. MRI showed an enthesitis of the plantar fascia. Standard treatment of FMF and enthesitis was not successful. After referral to a university hospital and expert opinion of a professor in rheumatology, this enthesitis should be treated as an enthesitis related arthritis. With this treatment, our patient fully recovered 8 months after the onset of the disease symptoms. Conclusion. M694V mutation related enthesitis should be considered in FMF patients with enthesitis. We would suggest treatment for enthesitis related arthritis in similar cases. This is of clinical importance because the treatment is different from treatment of enthesitis or articular pain caused by FMF.
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NewsBot · Mar 18, 2017

Subclinical enthesopathy in patients with psoriasis and its association with other disease parameters: a power Doppler ultrasonographic study
Abdelhafeez Moshrif et al
Eur J Rheumatol. 2017 Mar; 4(1): 24–28.

Objective
This study aimed to determine the prevalence of subclinical enthesopathy in patients with psoriasis using power Doppler ultrasonography (PDUS) and its association with other disease parameters.

Material and Methods
A total of 50 patients with psoriasis (31 females) aged 19–70 years underwent a thorough clinical examination that included assessment of body mass index (BMI) and psoriasis area and severity index (PASI) score. Measurements of inflammatory markers, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), serum uric acid, and plain radiography of the heels, knees, and sacroiliac joints were performed for all patients. Patients without clinical evidence of arthritis or enthesitis underwent an ultrasonographic (US) examination. According to the US examination, patients were classified into group I (patients with enthesitis) and group II (patients without enthesitis).

Results
In group I, Achilles enthesis was the most common site of US enthesitis (33.3%), followed by distal patellar enthesis (22.2%), proximal patellar enthesis (16.7%), quadriceps enthesis (16.7%), and plantar aponeurosis enthesis (11.1%). There was a statistically significant positive correlation between the occurrence of enthesitis and the patient’s age, disease duration, PASI score, BMI, and hyperuricemia (p<0.05 for each). In contrast, there was no significant correlation between enthesitis and sex or radiographic sacroiliitis (p>0.05 for each).

Conclusion
In addition to the importance of PDUS as a complimentary tool for examining enthesis in patients with psoriasis, the presence of high PASI score, increased BMI and hyperuricemia, and a long disease duration can be considered as predictive parameters for the presence of psoriatic enthesitis.
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NewsBot · Mar 22, 2017

Ultrasound Evaluation of the Entheses in Daily Clinical Practice during Tumor Necrosis Factor-α Blocking Therapy in Patients with Ankylosing Spondylitis
Fréke Wink, George A. Bruyn, Fiona Maas, Ed N. Griep, Eveline van der Veer, Hendrika Bootsma, Elisabeth Brouwer, Suzanne Arends and Anneke Spoorenberg
The Journal of Rheumatology March 2017, jrheum.160584; DOI: https://doi.org/10.3899/jrheum.160584

Objective To assess structural and inflammatory ultrasound (US) lesions of entheses in ankylosing spondylitis (AS) patients with active disease and to evaluate inflammatory lesions after 6 months of tumor necrosis factor (TNF-α) blocking therapy, in daily clinical practice.

Methods Consecutive patients with AS were clinically evaluated and underwent US examination of 9 bilateral entheses before and after 6 months of TNF-α blocking therapy. US examination included the following as inflammatory lesions: bone erosions/cortical irregularities, enthesophytes, calcifications as structural lesions; adjacent bursitis, effusion, increased tendon hypoechogenicity or thickness; and positive power Doppler (PD) signal.

Results At baseline, 105 (95%) of 111 included patients showed US abnormalities. Structural lesions were seen in 74 patients (67%) and inflammatory lesions in 88 (79%). Enthesophytes and positive PD signal were the most prevalent structural and inflammatory lesions, respectively. Most lesions were found at the lower extremities. Additionally, inflammatory lesions occurred at the lateral epicondyle of the elbow. Patients with structural lesions at baseline were significantly older, had longer disease duration, higher modified Stoke AS Spine score, and higher C-reactive protein. Individually, there was a great diversity in changes of inflammatory entheseal lesions during treatment, but on the group level no significant decrease was found.

Conclusion This prospective observational cohort study in daily clinical practice shows a high prevalence of structural and inflammatory US lesions in AS patients with longstanding and active disease. Positive PD signal was the most common inflammatory feature. No significant change in inflammatory US lesions was found after 6 months of TNF-α blocking therapy.
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NewsBot · Mar 22, 2017

Performance of 3 Enthesitis Indices in Patients with
Peripheral Spondyloarthritis During Treatment with
Adalimumab
Philip J. Mease, Filip Van den Bosch, Joachim Sieper, Yinglin Xia, Aileen L. Pangan,
and In-Ho Song
The Journal of Rheumatology; March 21, 2017

Objective. To evaluate the validity of enthesitis indices in patients with peripheral spondyloarthritis
(pSpA).
Methods. The ABILITY-2 study evaluated the efficacy of adalimumab (ADA) versus placebo (PBO)
in patients with active pSpA over 12 weeks. Patients received open-label ADA for an additional
144 weeks. Twenty-nine enthesitis sites used in 3 enthesitis scoring systems [Leeds Enthesitis Index
(LEI), Spondyloarthritis Research Consortium of Canada (SPARCC) Enthesitis Index, Maastricht
Ankylosing Spondylitis Enthesitis Score (MASES)] were assessed; discriminatory capacity and
treatment response at Week 12 were calculated by standardized mean difference (SMD) and Guyatt’s
effect size (ES). Sites showing resolution or new-onset enthesitis from baseline to Week 12 were
analyzed.
Results. Overall, 165 patients (ADA, n = 84; PBO, n = 81) were randomized; 143 had ≥ 1 enthesitis
site at baseline. The LEI (SMD –0.73, ES –1.07) and SPARCC (SMD –0.56, ES –0.99) enthesitis
indices showed higher discriminatory ability and treatment response than MASES (SMD –0.32, ES
–0.81). At Week 12, among sites that were positive at baseline, significantly more (p < 0.05) showed
resolution among patients treated with ADA versus PBO in the Achilles tendon (60.4% and 36.5%,
respectively), medial epicondyle (73.2%, 48.7%), lateral epicondyle (80.6%, 52.8%), and iliac crest
(73.5%, 47.2%). Among negative sites at baseline, significantly less (p < 0.05) new-onset enthesitis
was observed with ADA versus PBO for Achilles tendon (3.6% and 10.9%, respectively), greater
trochanter (3.4%, 14.4%), lateral epicondyle humerus (4.7%, 15.1%), medial femoral condyle (1.6%,
9.2%), and quadriceps insertion superior patella (1.5%, 7.0%).
Conclusion. The LEI and SPARCC enthesitis indices showed better discriminatory capacity and
treatment response in patients with pSpA versus MASES, likely because these indices contain more
peripheral sites. Trial registration number: ClinicalTrials.gov NCT01064856. (J Rheumatol First
Release March 15 2017; doi:10.3899/jrheum.160387)
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NewsBot · Apr 22, 2017

Case-control Study on Dactylitis, Enthesitis, and Anterior Uveitis in Spondyloarthritis Associated with Inflammatory Bowel Diseases: Role of Coexistent Psoriasis
Fabrizio Cantini, Laura Niccoli, Carlotta Nannini, Emanuele Cassarà, Olga Kaloudi, Fernando Rizzello and Paolo Gionchetti
The Journal of Rheumatology April 2017, jrheum.161518; DOI: https://doi.org/10.3899/jrheum.161518

Objective To evaluate the frequency of dactylitis, enthesitis, and anterior uveitis (AU) in spondyloarthritis (SpA) associated with inflammatory bowel disease (IBD-SpA) compared with other SpA, and to assess the role of associated psoriasis in the occurrence of dactylitis and enthesitis.

Methods In a 12-month case-control study, the frequency of dactylitis and enthesitis in 29 patients with ulcerative colitis (UC) and 59 with Crohn disease (CD) who satisfied the Spondyloarthritis international Society criteria for axial or peripheral SpA was compared with 176 controls, including 97 (55.1%) with psoriatic arthritis (PsA), 47 (26.7%) with ankylosing spondylitis (AS), and 32 (18.2%) with nonradiographic axial SpA (nr-axSpA). The occurrence of these features in IBD-SpA with and without psoriasis was also evaluated.

Results Axial, peripheral, or mixed involvement was observed in 46 (52%), 29 (33%), and 13 (15%) patients, respectively; and 14/88 (16%) had psoriasis. Dactylitis was recorded in 4/88 patients (4.5%) with IBD-SpA and in 30 controls (17.4%; p = 0.008), enthesitis in 16 cases (18.1%) and in 78/176 controls (44.3%; p < 0.001), and AU in 3 patients (3.4%) with IBD-SpA and in 26 controls (14.7%; p = 0.01). No significant differences were found between patients with UC-SpA and those with CD-SpA. Dactylitis and enthesitis were significantly more common in patients with IBD-SpA who also had psoriasis compared to those without skin disease (p = 0.009 and 0.003, respectively).

Conclusion Dactylitis, enthesitis, and AU are significantly less frequent in IBD-SpA compared with other types of SpA. Given the frequent association of psoriasis and IBD, overlooking coexistent skin disease may lead to overestimating the frequency of these features.
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NewsBot · Apr 29, 2017

Ultrasonographic evaluation of enthesitis in patients with ankylosing spondylitis
Huayong Zhang,Jun Liang,Junlan Qiu, et al.
Journal of Biomedical Research, 2017, 31(2): 162-169.

The aim of this study was to assess sensitivity and responsiveness of power Doppler ultrasound (PDUS) in detecting enthesitis for ankylosing spondylitis (AS) patients compared to clinical examinations. Twenty AS patients initiating etanerceptunderwent clinical and PDUS examinations of six bilateral entheseal sites at baseline and after 1, 2 and 3 months of treatment. Clinical and PDUS examinations identified at least one entheseal lesion in nine (45%) and 19 (95%) patients, respectively. Furthermore, of 240 entheseal sites examined in these 20 patients, PDUS detected 123 entheseal lesions (51.3% of sites), compared with only 47 entheseal lesions (19.6%) detected by clinical examination (P<0.05). The entheseal lesions found on PDUS were most commonly identified by calcification (33.3%), tendon edema (29.2%), abnormal blood flow (25.8%), a thickened tendon (22.1%), cortical irregularity (12.9%), bony erosions (9.6%) and bursitis at the tendon insertion to the bone cortex (7.1%). Improvements in clinical symptoms and laboratory parameters, and significant decreases in PDUS scores were observed following treatment with etanercept. Improvements in PDUS scores continued during follow-up in patients who entered remission following treatment. In conclusion, PDUS improves detection of structural and inflammatory abnormalities of the enthesis in AS compared to physical examination. In addition, PDUS may be useful inascertaining medications.
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NewsBot · Jun 26, 2017

Ultrasonography assessment of heel entheses in patients with spondyloarthritis: a comparative study with magnetic resonance imaging and conventional radiography.
Aguila Maldonado R et al
Clin Rheumatol. 2017 Jun 25. doi: 10.1007/s10067-017-3723-5.

The aim of the present study was to determine the agreement between ultrasonography (US), magnetic resonance imaging (MRI), and conventional radiography (CR) in the detection of findings indicative of enthesopathy in spondyloarthritis (SpA) patients. A cross-sectional study was performed in 40 SpA patients. Heel entheses (Achilles tendon and plantar fascia) were bilaterally examined by US, MRI, and CR. The three imaging modalities were carried out by three independent operators blinded to the other imaging modality data. Soft tissue abnormalities indicative of enthesopathy as thickening, structural changes, and bursitis were assessed by both US and MRI, and cortical bone abnormalities indicative of enthesopathy as erosions and enthesophytes were assessed by the three imaging modalities. The unweighted kappa values between US and MRI were 0.80, 0.66, 0.69, 0.70, and 0.70 for thickening, structural changes, bursitis, enthesophytes, and bone erosions, respectively. With respect to the detection of enthesophytes, the unweighted kappa values between CR and both US and MRI were 0.78 and 0.76, respectively. At last, for the recognition of bone erosions, the unweighted kappa values between CR and both US and MRI were 0.38 and 0.45, respectively. Using MRI as standard reference method, US was more sensitive with respect to CR revealing bone erosions. The present study provides evidence about the high overall agreement between US and MRI for all abnormal comparable findings at entheseal level and between US, MRI, and CR for the detection of enthesophytes in SpA patients.
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NewsBot · Jul 1, 2017

Presence of enthesopathy in patients with primary Sjogren's syndrome: ultrasonographic study of a local cohort.
Sag S et al
J Med Ultrason (2001). 2017 Jun 23. doi: 10.1007/s10396-017-0802-9

BACKGROUND:
Musculoskeletal findings in Sjögren's syndrome are arthralgia, arthritis, myalgia, myositis, fibromyalgia, and chronic fatigue. Enthesis zones are important in the formation of pain in the musculoskeletal system. Musculoskeletal ultrasound (US) may show subclinical enthesitis in the synovial joints and in the axial skeleton before joint swelling in inflammatory diseases characterized by arthritis.
OBJECTIVE:
In this study, we aimed to determine the presence of enthesopathy using the Madrid sonographic enthesitis index (MASEI) in patients with primary Sjögren's syndrome (PSS).
PATIENTS AND METHODS:
Consecutive patients with PSS and age-matched healthy controls were included in this study. All the patients met the 2002 American College of Rheumatology/European League against Rheumatism classification criteria for PSS. The demographic characteristics of the patients were recorded. Six enthesis sites were evaluated using gray-scale and Doppler US with a linear transducer, and they were scored using the MASEI. They were assessed by the EULAR Sjögren's syndrome disease activity index (ESSDAI).
RESULTS:
We evaluated 40 patients with PSS (average age 48.67 ± 11.23 years) and 30 healthy controls (average age 45.40 ± 8.24 years). Patients with PSS had significantly higher MASEI scores than the healthy controls. Plantar fascia, Achilles tendon, and distal patellar tendons were significantly thicker in the PSS group than in the healthy controls. The MASEI total score had a positive correlation with age. There was no correlation between MASEI total score and BMI and ESSDAI.
CONCLUSION:
In this study, it was shown that the MASEI scores assessed by US were significantly higher in patients with PSS than in healthy controls. Plantar fascia, Achilles tendon, and distal patellar tendon were significantly thicker in the PSS group than in the healthy controls. This result suggests that PSS may be one of the causes of musculoskeletal pain that can be seen in patients with PSS. Our study was the first study to use an enthesis index ultrasonographically in patients with PSS. In addition, it is the first study to investigate the relationship between the presence of enthesopathy and disease activity by means of US.
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NewsBot · Jul 23, 2017

Enthesis as a target organ in rheumatic diseases: an expanding frontier
Gleb Slobodin, Itzhak Rosner
Editorial
Clinical Rheumatology 17 July 2017 (full text)

Enthesopathy refers to the involvement of the entheses in any pathological process, whether inflammatory, metabolic, traumatic, or degenerative, and has been well recognized as a feature of a variety systemic rheumatic disorders [1]. In clinical practice, enthesopathy is frequently a secondary or subordinate issue. Recent data cast a new light on the role of enthesopathy in the large body of rheumatic disorders.
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NewsBot · Aug 2, 2017

Evaluation of peripheral enthesitis in spondyloarthritis: Ultrasonography versus clinical examination
Anupam Wakhlu, Saumya Ranjan Tripathy, Archana Wakhlu, Durgesh Srivastava, Rasmi Ranjan Sahoo
Ind J Rheumatology

Background: Enthesitis is an important feature of spondyloarthritis but may often be subclinical. Data is sparse, especially from India, on the ultrasonography (USG) detection of enthesitis in these patients. The present study aimed to find the prevalence and pattern of entheseal involvement assessed clinically and by USG. Methods: Fifty-two spondyloarthritis, 26 rheumatoid arthritis, and 26 healthy controls were evaluated for enthesitis by clinical examination and by USG using 2014 OMERACT consensus group definitions at bilateral Achilles insertion on the calcaneus, plantar fascia attachment on the calcaneus, quadriceps tendon insertion on the patella, patellar tendon origin from the inferior pole of the patella, and patellar tendon insertion on the tibial tuberosity. At least one ultrasonographic finding at any of the above sites was considered positive for enthesitis. Results: The number of entheseal sites screened in spondyloarthritis patients was 520 and 260 each in rheumatoid arthritis and healthy controls. USG (sensitivity - 94.2%) was better in detecting enthesitis than clinical examination (sensitivity - 69.2%). Clinical examination was highly specific (100%) compared to USG (55.7%) in differentiating from rheumatoid arthritis and healthy controls. USG alone without clinical findings was positive at 23.8% of sites while clinical examination alone without USG findings was positive at 5.2% of sites. Frequency of enthesitis in rheumatoid arthritis was not more than healthy controls (6.1% vs. 8.1%, respectively) and was much less than spondyloarthritis (34%). Conclusion: USG is a good screening tool for detection of enthesitis but cannot replace clinical examination completely.
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NewsBot · Aug 5, 2017

Ultrasonic Features of Enthesitis: a Comparison Between Patients with Psoriasis Vulgaris and Patients with Psoriatic Arthritis
Tang YJ et al
Sichuan Da Xue Xue Bao Yi Xue Ban. 2017 Jul;48(4):589-594.

OBJECTIVE:
To compare the ultrasonic features of enthesitis between psoriatic arthritis and psoriasis vulgaris.
METHODS:
A total of 39 patients with psoriatic arthritis (PsA group), 60 with psoriasis vulgaris (non-PsA group) and 60 healthy people (control group) participated in this study. They were examined by two-dimensional and color Doppler ultrasound on the entheses of bilateral femoral quadriceps tendons, patella tendons, Achilles tendons, plantar fasciae, common flexor tendons and common extensor tendons.
RESULTS:
About 45% (27 cases) healthy controls had enthesitis, with Achilles tendons and femoral quadriceps tendons being most likely affected. No blood flow signal was observed on the affected sites. About 63% (38 cases) of non-PsA patients had enthesitis, with Achilles tendons and femoral quadriceps tendons being most likely affected. Blood flow signals were observed on 4 affected sites. More than 84% (33 cases) PsA patients had enthesitis, with all locations being likely affected but mostly on Achilles tendons, femoral quadriceps tendons, and plantar fasciae. Blood flow signals were observed on 18 affected sites. The differences in prevalence of enthesitis were statistically significant (PsA group>non-PsA group>control group, all P<0.01), although the differences in tendon hypoechogenicity and enthesophytes among the groups showed no statistical significance. PsA and non-PsA patients were more likely to have tendon thickening than the controls (both P<0.01); but no difference appeared between PsA and non-PsA patients. PsA patients had higher prevalence of intratendinous calcifications, bony erosions and color Doppler signals than non-PsA patients and the controls (all P<0.01).
CONCLUSION:
Enthesitis in healthy people and non-PsA patients are most likely to affect Achilles tendon and femoral quadriceps tendons. By contrast, Achilles tendons, femoral quadriceps tendon and plantar fascia are more likely to be affected in patients with PsA. PsA patients have high prevalence of enthesitis and are more likely to have intratendinous calcifications, bony erosions and color Doppler signals.
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NewsBot · Sep 23, 2017

Ultrasonographic Enthesopathy and Disease Activity in Psoriatic Arthritis.
Ahmed MM et al
Open Access Maced J Med Sci. 2017 Aug 11;5(5):651-656.

BACKGROUND:
To our knowledge, the correlation between ultrasonographic enthesopathy and severity in psoriatic arthritis (PsA) has been done before. However, the correlation between ultrasonography of enthesopathy and the Psoriatic Arthritis Disease Activity Score (PASDAS) have not been done.
AIM:
To compare the results of ultrasonographic enthesopathy of foot and PASDAS in PsA.
MATERIALS AND METHODS:
A total of 65 PsA patients were involved and divided into two groups. The first group of 35 active PsA and the second group of 30 ages and sex matched inactive PsA as a control group were recruited in this study. Both groups were evaluated by examination, radiological findings and ultrasonography.
RESULTS:
Of 70 entheses in 35 active PsA patients, the most entheseal abnormalities were tender plantar fascia (18.5%), tender Achilles tendon (37.8%). PASDAS was a direct highly significant correlated with plantar fascia and Achilles tendon thickness in in active PsA (r = 0.823 and r = 0.796, p < 0.001 respectively).
CONCLUSION:
Musculoskeletal US is an accurate and low-cost method for assessment of enthesopathy with significant correlation to disease activities in psoriatic arthritis.
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NewsBot · Nov 26, 2017

Clinical and ultrasonographic enthesopathy in inflammatory rheumatic diseases Is MASEI or only calcaneal enthesitis sufficient?

NewsBot · Feb 13, 2018

Chronic but not inflammatory changes at the Achilles' tendon differentiate patients with peripheral spondyloarthritis from other diagnoses - Results from a prospective clinical trial.
Baraliakos X et al
RMD Open. 2017 Dec 22;3(2):e000541. doi: 10.1136/rmdopen-2017-000541. eCollection 2017.

BACKGROUND:
Imaging has an essential role in the new spondyloarthritis (SpA) classification criteria for axial but not for peripheral manifestations. We evaluated the impact of imaging findings for identification and treatment decisions in patients with peripheral spondyloarthritis (pSpA) and controls (non-SpA).

METHODS:
Patients with pSpA (Assessment of SpA international Society criteria, n=30) and non-SpA (n=30), aged <45 years, with painful heels or knees, were recruited. Conventional radiography, grey-scale ultrasound including power Doppler (US/PDUS) and MRI of symptomatic areas were performed to assess inflammatory and structural changes. Mann-Whitney U test was used for group comparisons.

RESULTS:
In total, 105 painful entheses (71 heels, 34 knees) in 60 patients were examined. Differences between diagnoses were found for symptom duration (pSpA: 17.2±27.5 vs non-SpA: 4.4±4.3 months), human leucocyte antigen B27 prevalence (67% vs 13%) and gender distribution (53.3% vs 20% male, respectively), all P<0.05. Logistic regression analysis for baseline differences showed that chronic changes (erosions and calcification) in the heel were more frequent in pSpA versus non-SpA by US/PDUS (62.5% vs 28.6% patients and 59.5% vs 26.5% entheses, P<0.05). Inflammatory changes in heel or knee by US/PDUS and MRI could not differentiate between non-SpA and pSpA.

CONCLUSIONS:
Differentiation between pSpA and non-SpA was only possible based on structural but not inflammatory changes in the heels and knees of symptomatic patients. US/PDUS was superior to MRI for this purpose. These findings imply that pSpA is associated with erosive changes at enthesitic sites, while inflammation and susceptibility are of minor influence for the development of erosions and calcification to pSpA.
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NewsBot · Jun 6, 2018

Options for Assessing Joints and Entheses in Psoriatic Arthritis by Ultrasonography and Magnetic Resonance Imaging: How to Move Forward
Lihi Eder, Sibel Z. Aydin, Gurjit S. Kaeley, Walter P. Maksymowych and Mikkel Østergaard
The Journal of Rheumatology Supplement June 2018, 94 44-47; DOI: https://doi.org/10.3899/jrheum.180140

Psoriatic arthritis (PsA) is a heterogeneous disease with various manifestations of musculoskeletal inflammation. Recent advances in imaging, including ultrasound (US) and magnetic resonance imaging (MRI), allow for the accurate evaluation of the extent of inflammation and damage in the peripheral joints, spine, and entheses. The development and validation of outcome measures are critical steps in creating standardized evaluations of musculoskeletal inflammation and damage in psoriatic patients. At the 2017 meeting of the Group for Research and Assessment of Psoriasis and PsA (GRAPPA), recent work on outcome measures from the GRAPPA US and MRI working groups was summarized. The GRAPPA US group has been developing and validating a sonographic enthesitis scoring system in PsA. The GRAPPA MRI group focuses on the evaluation of whole-body MRI for the assessment of musculoskeletal inflammation in the joints and entheses in patients with PsA.
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NewsBot · Jun 6, 2018

Entheseal involvement in asymptomatic human immunodeficiency virus infected patients: preliminary results of a clinical and ultrasonographic study.
Ciancio G et al
Clinical and Experimental Rheumatology [24 May 2018]

As a strong association between human immunodeficiency virus (HIV) infection and spondyloarthritis (SpA) has been hypothesised, our main objective was to explore by power Doppler ultrasonography (PDUS) the presence of subclinical enthesitis in asymptomatic HIV patients. The presence of subclinical synovitis was also evaluated.Consecutive asymptomatic HIV patients were studied and compared with asymptomatic HCV patients and healthy controls (HC). All subjects underwent a clinical and PDUS bilateral examination of the following entheses and joints: epicondyle, quadriceps, patellar, Achilles and plantar fascia; wrists, II and III metacarpo-phalangeal, knee and ankle.Twenty-nine HIV, 32 HCV and 25 HC were recruited; 1.032 entheses and 860 joints were examined. Clinical diagnosis of enthesitis was made in 10.3% HIV patients, 6.2% HCV patients (p=0.66) and none HC (p=0.24). PDUS enthesitis was found in 72.4% HIV, 28.1% HCV (p=0.0008) and 12% HC (p<0.0001). Clinical diagnosis of synovitis was made in 3.4% HIV patients, 9.3% HCV patients (p=0.61) and none HC (p=1). PDUS abnormalities were documented in 24.1% HIV patients, 71.8% HCV patients (p=0.0003) and none HC (p=0.0001). In detecting enthesitis and synovitis, PDUS was more sensitive than clinical examination both in HIV and HCV patients.Our preliminary study shows the high frequency of PDUS enthesitis in asymptomatic HIV patients, which highlights the close link between HIV and SpA. Further studies are desirable on a larger number of HIV patients to confirm these results. PDUS proved to be more sensitive than clinical examination in detecting subclinical involvement of entheses and joints.
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