Sonographic evaluation of the tendons in familial Mediterranean fever and Behçet’s disease

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.

Sonoelastographic Assessment of the Achilles Tendon in Familial Mediterranean Fever Patients: Comparison With Healthy Subjects

Introduction and objective: This study aims at using sonoelastography as a novel technique to evaluate the stiffness and thickness of Achilles tendons in familial Mediterranean fever (FMF) patients.

Methods: Achilles tendons of 26 FMF patients and 23 control subjects were assessed with ultrasound and real-time sonoelastography. The Achilles tendons were divided into the distal, middle, and proximal thirds for elastographic image evaluation. Tendons were classified into three main types according to their elasticity features: grade 1 blue (hardest tissue) to green (hard tissue); grade 2, yellow (soft tissue); and grade 3, red (softest tissue). Tendons of the groups were compared in terms of thickness and stiffness.

Results: There were no significant differences in thickness and stiffness of the Achilles tendon between FMF patients and controls (p>0.05). Sonoelastography of Achilles tendons of FMF patients displayed no relationship between FMF and tendinopathy. 

Conclusion: This issue should be explored in prospective studies in larger groups. 

Ultrasonographic Measurement of the Femoral Cartilage Thickness in Patients with Behçet's Disease

OBJECTIVE

To evaluate femoral cartilage thickness in patients with Behçet's disease (BD) by using ultrasonography.

METHODS

Thirty-one patients with BD (18 M, 13 F; mean age: 32.87 ± 8.5 years) and 31 age-, gender- and body mass index-matched healthy subjects were enrolled. Demographic features and medications of the patients were recorded. The femoral cartilage thicknesses of both knees were measured with a 7-12 MHz linear probe while subjects' knees were held in maximum flexion. Three mid-point measurements were taken from both knees: lateral femoral condyle (LFC), intercondylar area (ICA) and medial femoral condyle (MFC).

RESULTS

Cartilage measurements of BD patients were significantly thinner at the ICA (p = 0.009) and LFC (p = 0.007) on the left knee, and at the MFC on both sides (both p < 0.05). Left knee cartilage thickness value at MFC (p = 0.005) was decreased in BD patients with arthritis compared to the healthy control group.

CONCLUSION

These preliminary findings of decreased femoral cartilage thickness in BD patients with arthritis should be complemented with future studies. However, the possibility of early knee joint degeneration and eventual osteoarthritis in BD should also be kept in mind.

Increased enthesopathy in patients with familial Mediterranean fever: evaluation with a new sonographic enthesitis index

OBJECTIVES

The aim of this study was to determine the frequency of enthesopathy in familial Mediterranean fever by using a newly developed sonographic method, the Madrid Sonographic Enthesitis Index (MASEI).

METHODS

The study included 50 consecutive patients with familial Mediterranean fever and 57 healthy sex- and age-matched control participants. Six entheseal sites (olecranon tuberosity, superior and inferior poles of the patella, tibial tuberosity, and superior and inferior poles of the calcaneus) on both lower limbs were evaluated. All sonographic findings were identified according to MASEI. Validity was analyzed by receiver operating characteristic curves. P < .05 was considered significant.

RESULTS

Mean total enthesitis scores ± SD were 7.54 ± 4.99 for patients and 3.63 ± 3.03 for controls (P < .001). No statistically significant correlation was found between the MASEI score and familial Mediterranean fever duration or colchicine treatment duration. There was no difference between the MASEI score and the presence or absence of arthritic involvement among the patients. The area under the receiver operating characteristic curve was 0.74 (95% confidence interval, 0.649-0.839). When analyzed by sex, men with familial Mediterranean fever had significantly higher MASEI scores than women (P < .05).

CONCLUSIONS

This study showed significant enthesopathy in patients with familial Mediterranean fever. The findings support the hypothesis that familial Mediterranean fever and spondyloarthropathy may have common inflammatory mechanisms and suggest that the MASEI scoring system can be incorporated into clinical protocols for studying patients with familial Mediterranean fever in daily practice.

Conditioning of the Achilles tendon via ankle exercise improves correlations between sonographic measures of tendon thickness and body anthropometry

Although conditioning is routinely used in mechanical tests of tendon in vitro, previous in vivo research evaluating the influence of body anthropometry on Achilles tendon thickness has not considered its potential effects on tendon structure. This study evaluated the relationship between Achilles tendon thickness and body anthropometry in healthy adults both before and after resistive ankle plantarflexion exercise. A convenience sample of 30 healthy male adults underwent sonographic examination of the Achilles tendon in addition to standard anthropometric measures of stature and body weight. A 10-5 MHz linear array transducer was used to acquire longitudinal sonograms of the Achilles tendon, 20 mm proximal to the tendon insertion. Participants then completed a series (90-100 repetitions) of conditioning exercises against an effective resistance between 100% and 150% body weight. Longitudinal sonograms were repeated immediately on completion of the exercise intervention, and anteroposterior Achilles tendon thickness was determined. Achilles tendon thickness was significantly reduced immediately following conditioning exercise (t = 9.71, P < 0.001), resulting in an average transverse strain of -18.8%. In contrast to preexercise measures, Achilles tendon thickness was significantly correlated with body weight (r = 0.72, P < 0.001) and to a lesser extent height (r = 0.45, P = 0.01) and body mass index (r = 0.63, P < 0.001) after exercise. Conditioning of the Achilles tendon via resistive ankle exercises induces alterations in tendon structure that substantially improve correlations between Achilles tendon thickness and body anthropometry. It is recommended that conditioning exercises, which standardize the load history of tendon, are employed before measurements of sonographic tendon thickness in vivo.

Musculoskeletal sonography use in physiatry: a single-center one-year analysis

OBJECTIVE

To document the musculoskeletal ultrasonography experience in a physiatry clinic for 1 yr and to find out whether its use decreased time, cost, and radiation exposure with regard to musculoskeletal imaging.

DESIGN

All patients who underwent musculoskeletal ultrasonography examination (n = 309) in our physiatry department during the whole year of 2007 were enrolled. The same physiatrist, experienced in musculoskeletal ultrasonography, performed all of the evaluations by using 5-10 MHz and 8-16 MHz linear probes (Diasus Dynamic Imaging Ltd., Scotland, UK). At the end of the year, each patient was retrospectively considered on an individual basis, and the answers to the following three questions were recorded in case he/she had not been evaluated by musculoskeletal ultrasonography: (1) How long would the patient have waited (i.e., for further radiologic appointments)? (2) What would the extra cost have been? (3) What would the radiation exposure have been? Cumulative numbers were calculated for the whole year concerning time, cost, and radiation dose.

RESULTS

According to the calculations, the total waiting period was estimated as 7620 days if musculoskeletal ultrasonography had not been used for imaging. Similarly, the total cost and the radiation dose were estimated to be euro8128 ($16,256 US) and 20 Sievert (2000 cGy), respectively.

CONCLUSIONS

Musculoskeletal ultrasonography provides a significant amount of gain regarding time and cost in physiatry clinics. We call the attention of physiatrists to this issue and advocate that a standardized international approach to musculoskeletal ultrasonography training and assessment is definitely awaited.

Achilles tendon problems: not just an orthopaedic issue

PURPOSE

To review the current concepts on Achilles tendon involvement in various pathological conditions.

METHOD

A literature search was conducted to trace relevant literature on Achilles tendon problems in general pathologies.

RESULTS

The Achilles tendon can be involved in inflammatory and autoimmune conditions, genetically determined collagen abnormalities, infectious diseases, tumours, and neurological conditions which are not of a primary surgical nature.

CONCLUSIONS

Although Achilles tendon problems are classically considered frequent in active individuals from overuse or a single acute episode, problems in the Achilles tendon can be a consequence of several conditions.

Increased enthesopathy among Behçet's syndrome patients with acne and arthritis: an ultrasonography study

OBJECTIVE

Behçet's syndrome is characterized by clusters of disease expression, one of which is the coexistence of acne and arthritis. The aim of this study was to test the hypothesis that enthesopathy is increased in this cluster, having features reminiscent of acne-associated arthritis.

METHODS

The study group comprised 35 patients with Behçet's syndrome who had acne and arthritis (BS-AA), 38 patients with Behçet's syndrome who did not have arthritis (BS-WA), 37 patients with ankylosing spondylitis (AS), 25 patients with rheumatoid arthritis (RA), and 25 healthy control subjects. Five entheseal sites (the superior and inferior poles of the patella, the tibial tuberosity, and the superior and inferior poles of the calcaneus) on both lower extremities were examined by 2 independent observers, using ultrasonography. A previously validated composite score was calculated for each patient. The numbers of entheseal sites giving a positive power Doppler signal in each group were also compared.

RESULTS

Patients with AS had the highest enthesopathy score (mean +/- SD 4.1 +/- 2.4; F [4df] = 8.43, P < 0.001) followed by BS-AA patients (3.0 +/- 1.9; F [3df] = 3.63, P = 0.015). The mean +/- SD enthesopathy scores among the remaining 3 groups were similar (for BS-WA, 1.8 +/- 1.4; for RA, 2.2 +/- 1.6; for healthy controls, 2.0 +/- 1.5 [F (2df) = 0.65, P = 0.53]). Power Doppler scores were highest for the BS-AA group (mean +/- SD 3.0 +/- 1.5; F [4df] = 15.54, P < 0.001) followed by the AS group (2.7 +/- 1.8; F [3df] = 14.38, P < 0.001), the RA group (2.6 +/- 1.8; F [2df] = 13.88, P < 0.001), the BS-WA group (1.2 +/- 1.3; F [1df] = 4.48, P = 0.038), and the control group (0.5 +/- 1.1). There was 87% agreement between the 2 observers (kappa = 0.55, intraclass correlation coefficient 0.71).

CONCLUSION

The increased presence of enthesopathy among BS-AA patients compared with that among BS-WA patients further supports the hypothesis that patients with Behçet's syndrome who also have arthritis and acne form a distinct cluster.