Features of the Achilles tendon, paratenon, and enthesis in inflammatory rheumatic diseases: A clinical and ultrasonographic study

The value of different involvement patterns of the knee "synovio-entheseal complex" in the differential diagnosis of spondyloarthritis, rheumatoid arthritis, and osteoarthritis: an MRI-based study

OBJECTIVES

To explore the different involvement patterns of the knee "synovio-entheseal complex (SEC)" on MRI in patients with spondyloarthritis (SPA), rheumatoid arthritis (RA), and osteoarthritis (OA).

METHODS

This study retrospectively included 120 patients (male:female, 55:65) with a mean age of 39.20 years diagnosed with SPA (n = 40), RA (n = 40), and OA (n = 40) at the First Central Hospital of Tianjin between January 2020 and May 2022. Six knee entheses were assessed by two musculoskeletal radiologists according to the SEC definition. Bone marrow lesions associated with entheses include bone marrow edema (BME) and bone erosion (BE), which were classified as entheseal or peri-entheseal based on their relationship to the entheses. Three groups (OA, RA, and SPA) were established to characterize the location of enthesitis and the different SEC involvement patterns. Inter-group and intra-group differences were analyzed using the ANOVA or chi-square tests, and the inter-class correlation coefficient (ICC) test was used to determine inter-reader agreement.

RESULTS

The study contained a total of 720 entheses. The SEC-based analysis revealed different involvement patterns in three groups. The OA group had the most abnormal signals in tendons/ligaments (p = 0.002). The RA group had considerably greater synovitis (p = 0.002). The majority of peri-entheseal BE was identified in the OA and RA groups (p = 0.003). Furthermore, entheseal BME in the SPA group was significantly different from those in the other two groups (p < 0.001).

CONCLUSIONS

SEC involvement patterns differed in SPA, RA, and OA, which is important for differential diagnosis. SEC should be used as a whole evaluation method in clinical practice.

KEY POINTS

• The "synovio-entheseal complex (SEC)" explained differences and characteristic alterations in the knee joint in patients with spondyloarthritis (SPA), rheumatoid arthritis (RA), and osteoarthritis (OA). • The various SEC involvement patterns are crucial for differentiating SPA, RA, and OA. • When "knee pain" is the only symptom, a detailed identification of characteristic alterations in the knee joint of SPA patients may help timely treatment and delay the structural damage.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Explaining Variability in the Prevalence of Achilles Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals

OBJECTIVE

To estimate the prevalence of, and factors associated with, Achilles tendon abnormalities observed on imaging in asymptomatic individuals.

DESIGN

Systematic review with stratified meta-analysis and meta-regression.

LITERATURE SEARCH

Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science were searched from 1980 to August 2020.

STUDY SELECTION CRITERIA

We included studies that reported the prevalence of Achilles tendon abnormalities, observed with any imaging modality, in an asymptomatic population. We excluded studies if participant mean age was younger than 12 years or if participants had current/previous lower-limb tendon injuries/symptoms or other systemic conditions.

DATA SYNTHESIS

Random-effects proportion meta-analysis was used to estimate prevalence. We used meta-regression for continuous variables (mean age and body mass index [BMI], sample size, proportion of female participants) and stratified categorical variables (imaging modality and participation in physical activity) to explain between-study heterogeneity.

RESULTS

We included 91 studies (10 156 limbs, 5841 participants). The prevalence of Achilles tendon abnormalities on imaging ranged from 0% to 80% per participant. Between-study heterogeneity was high (I²>90%, P<.001), precluding data pooling. Between-study heterogeneity was partly explained by participant mean BMI (slope, 2.8% per 1-unit increase in BMI; 95% confidence interval: 0.57%, 5.03%; P = .015) and participation in physical activity per limb, and mean age of 40 years old or older (P = .022) per participant.

CONCLUSION

There was substantial variability in the prevalence of Achilles tendon abnormalities on imaging in asymptomatic individuals. Higher prevalence of abnormalities was associated with older age (40 years old or older), higher BMI, and participation in physical activity. A large proportion of heterogeneity remains unaccounted for, likely due to variations in abnormality definitions and study design. J Orthop Sports Phys Ther 2021;51(5):232-252. Epub 28 Mar 2021. doi:10.2519/jospt.2021.9970.

A Systematic Review of the Inclusion of Non-Inflammatory Ultrasonographic Enthesopathy Findings in Enthesitis Scoring Indices

Ultrasound has advanced the diagnosis and management of patients with inflammatory rheumatic conditions. It can be used to identify and monitor enthesitis, a cardinal feature of spondyloarthropthies. Several enthesitis scoring systems utilizing ultrasound to determine entheseal involvement have been developed. These scoring systems generally rely on determining the presence or absence of erosions, tendon enlargement, power Doppler signal, or enthesophytes. This systematic review identified ultrasound scoring systems that have been utilized for evaluating enthesitis and what key components derive the score. Review of these scoring systems, however, demonstrated confounding as some of the score components including enthesophytes may be seen in non-inflammatory conditions and some components including erosions can be seen from chronic damage, but not necessarily indicate active inflammatory disease. What is furthermore limiting is that currently there is not an agreed upon term to describe non-inflammatory enthesopathies, further complicating these scoring systems. This review highlights the need for a more comprehensive ultrasound enthesopathy scoring index.

Updating the use of the Madrid Sonographic Enthesis Index (MASEI): a systematic review of the literature

OBJECTIVE

To perform a systematic review of the literature to evaluate the use of the enthesis ultrasound Madrid Sonographic Entesis Index (MASEI) from its publication.

METHODS

A systematic search of MEDLINE, EMBASE, and Cochrane Central Register databases was performed. The search strategy was constructed to identify publications containing terms related to enthesis and ultrasound. The only applied filter was studies conducted in humans. One reviewer systematically screened the search. A second reviewer verified the selection. The data extraction was focused on study characteristics, including population and components of the OMERACT filter.

RESULTS

Sixty-eight of the 1581 identified studies had used MASEI, including 41 (60%) abstracts and 27 (40%) articles. Of the 27 articles, MASEI was mainly used for spondyloarthritis and related diseases in 12 (44%) articles, followed by both psoriatic arthritis and rheumatoid arthritis in five (19%) articles; however, it was also used in diseases such as Behçet disease, FM, familiar Mediterranean fever, SS, crystal arthropathies and systemic sclerosis. The feasibility of MASEI was reported in three (11%) articles, and the reliability in 12 (44%) with good to excellent values. No article evaluated the responsiveness to treatment. The construct validity of MASEI was assessed using biomarkers in seven (26%) articles, clinical examination in 13 (48%) and imaging procedures (only X-rays) in two (7%). The discriminative validity was assessed in 16 (59%) articles, not only in SpAs.

CONCLUSION

MASEI is a feasible, reliable and valid ultrasound score for the study of enthesis in spondyloarthritis, psoriatic arthritis and other diseases.

Achilles Tendon Thickness Is an Independent Predictor of Carotid Atherosclerosis and Is Associated With a Carotid Plaque Burden

The aim of the study was to research the relationship between carotid atherosclerosis markers and ultrasound parameters of Achilles tendons (AT). The study included 150 patients at high and very high cardiovascular risk (CVR). All patients underwent a carotid ultrasound scanning. We evaluated carotid plaque, carotid plaque score (cPS), carotid total plaque area (cTPA), and the percentage of stenosis. All patients underwent AT ultrasound with an assessment of thickness (Achilles tendon thickness [ATT]), width (Achilles tendon width), and cross-sectional area. An increase in the ATT ≥5.07 mm was associated with a 4.55-fold increase in the relative risk of carotid atherosclerosis (sensitivity 68.3% and specificity 62.5%). Direct correlations between the ATT and carotid stenosis (r = 0.277; P = .004), cPS (r = 0.225; P = .035), and cTPA (r = 0.305; P = .004) were determined. An increase in the mean ATT by 1 mm was associated with an increase in cTPA by 8.09 mm² (95% CI: 2.26-13.9; P = .007) and carotid stenosis by 4.11% (95% CI: 0.64-7.60; P = .021). Thus, in patients with high and very high CVR, an increase in ATT is an independent predictor of carotid atherosclerosis. The ATT directly correlates with the markers of carotid plaque burden.

Ultrasonographic evaluation of Achilles tendon: Is there any difference between ankylosing spondylitis, non-radiographic axial spondyloarthropathy and controls?

PURPOSE

The aim is to evaluate Achilles tendon enthesopathy with ultrasound (US) in ankylosing spondylitis (AS) and non-radiographic axial SpA (nr-axSpA) patients and controls, and compare these groups in terms of associations between disease activity parameters and ultrasonographic Achilles enthesitis signs.

METHODS

A total of 24 AS and 20 nr-axSpA patients fulfilling the Assessment in Spondyloarthritis International Working Group criteria for axSpA and 30 controls were enrolled. Demographic characteristics, erythrocyte sedimentation rate, C-reactive protein (CRP), human leukocyte antigen (HLA)-B27, Bath AS Disease Activity Index, Bath AS Functional Index, Bath AS Metrology Index, Maastricht AS Enthesitis Score (MASES), AS Disease Activity Score-CRP, modified Stoke AS Spine Score (m-SASSS) scores and ultrasonographic findings were noted.

RESULTS

HLA-B27 positivity, extra-articular and peripheral involvement, disease activity, functional status, mean m-SASSS, ultrasonographic gray scale (GS) and total scores were similar between AS and nr-axSpA groups. In GS, tendon echotexture scores were significantly different across all groups (0.812 ± 0.384 in AS, 0.575 ± 0.466 in nr-axSpA, 0.017 ± 0.091 in controls; P < .001). Entheseal calcification scores were similar in AS and nr-axSpA patients, and higher than controls (P = .001). Bone profile scores were similar in patients with AS and nr-axSpA, and higher than controls (P = .010). When the correlations between US findings and disease activity and functional status were considered, power Doppler US (PDUS) and MASES total scores were positively correlated in the AS group (P = .045; r = .41).

CONCLUSION

AS and nr-axSpA patients were found to be similar in various clinical, functional, and US findings indicating that these 2 entities are different phenotypic reflections of the same disease spectrum. The positive correlation between PDUS and MASES scores in AS patients substantiate the performance of MASES in evaluation of entheseal activity.