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Jung YH, Suh JS, Choi JY. The association between refractory plantar fasciitis and insertional Achilles tendinopathy and peripheral spondyloarthritis: a report of human leukocyte antigen B-27 investigation and treatment outcome. INTERNATIONAL ORTHOPAEDICS 2024; 48:711-718. [PMID: 37897545 DOI: 10.1007/s00264-023-06019-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/19/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE This study aimed to determine the presence of peripheral spondyloarthritis and investigate the clinical characteristics of patients with concurrent peripheral spondyloarthritis in those presenting with refractory plantar fasciitis and Achilles tendinopathy by conducting human leukocyte antigen B-27 (HLA-B27) testing. METHODS This retrospective study aimed to investigate patients who complained of persistent pain and significant limitations in daily activities due to their respective foot pain, despite receiving conservative treatment for over one year under the diagnosis of plantar fasciitis or insertional Achilles tendinopathy. The study included 63 patients who underwent HLA-B27 testing. The patients were classified into two groups based on the presence or absence of HLA-B27 positivity. The Mann-Whitney U test assessed significant relationships between continuous variables, and the chi-square test was used to compare categorical variables. RESULTS Among the 63 included patients, HLA-B27 positivity was confirmed in 11 patients (17.5%), which was significantly associated with a lower average age (22.8 years versus 31.7 years, P = 0.01) and a substantially lower proportion of females compared to HLA-B27-negative patients (9.1% vs. 25.0%, P = 0.001). Ten of the 11 patients initiated treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) combined with oral steroids as the first-line medication after being diagnosed as HLA-B27 positive. Six patients experienced pain relief with the first-line medication (60%). Four patients who did not achieve pain control with the first-line medication received tumour necrosis factor-alpha inhibitors as the second-line medication. Two patients experienced pain relief, while two experienced reduced but persistent pain. CONCLUSIONS Among the patients with "refractory" plantar fasciitis and insertional Achilles tendinopathy, 17.5% were diagnosed with peripheral spondyloarthritis. Patients diagnosed with peripheral spondyloarthritis had a higher proportion of men and relatively younger mean age compared to those without the diagnosis. Approximately 70% of these patients achieved symptom improvement in foot and ankle joints by taking conventional synthetic DMARDs, TNF-α inhibitors, or both appropriate for spondyloarthritis.
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Affiliation(s)
- Young Ho Jung
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-Ro, Ilsanseo-Gu, Goyang-Si, Gyeonggi-Do, South Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-Ro, Ilsanseo-Gu, Goyang-Si, Gyeonggi-Do, South Korea
| | - Jun Young Choi
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170 Juhwa-Ro, Ilsanseo-Gu, Goyang-Si, Gyeonggi-Do, South Korea.
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Østergaard M, Maksymowych WP. Advances in the Evaluation of Peripheral Enthesitis by Magnetic Resonance Imaging in Patients With Psoriatic Arthritis. J Rheumatol 2023; 50:18-22. [PMID: 37419626 DOI: 10.3899/jrheum.2023-0518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/09/2023]
Abstract
Enthesitis is a key disease manifestation in patients with psoriatic arthritis (PsA) that considerably contributes to pain, lower physical function, and reduced quality of life. Clinical assessment of enthesitis lacks sensitivity and specificity, and therefore better methods are urgently needed. Magnetic resonance imaging (MRI) allows detailed assessment of the components of enthesitis, and consensus-based validated MRI scoring systems exist. These include the Outcome Measures in Rheumatology (OMERACT) Heel Enthesitis MRI Scoring System (HEMRIS) method, which assesses the entheses of the heel region in a detailed manner, and the OMERACT MRI Whole-Body Score for Inflammation in Peripheral Joints and Entheses (MRI-WIPE) method, which provides an overall assessment of the inflammatory burden in the peripheral entheses and joints in the entire body using whole-body MRI. At an MRI workshop at the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2022 meeting in Brooklyn, the MRI appearances of peripheral enthesitis were described, as were the scoring methods. The utility of MRI for improved assessment of enthesitis was demonstrated with examples of patient cases. Clinical trials in PsA that evaluate enthesitis by MRI as a key endpoint should include the presence of MRI enthesitis as an inclusion criterion, and apply validated MRI outcomes to assess the effect of therapeutics on enthesitis are recommended.
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Affiliation(s)
- Mikkel Østergaard
- M. Østergaard, MD, PhD, DMSc, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, and Department of Clinical Medicine, Faculty for Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark;
| | - Walter P Maksymowych
- W.P. Maksymowych, MD, MB ChB, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Hamitouche F, Lopez-Medina C, Gossec L, Perrot S, Dougados M, Moltó A. Evaluation of the agreement between the ACR 1990 fibromyalgia tender points and an enthesitis score in patients with axial spondyloarthritis. Rheumatology (Oxford) 2023; 62:2757-2764. [PMID: 36573318 DOI: 10.1093/rheumatology/keac683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 11/24/2022] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVES Coexistence of FM represents a challenge in the evaluation of enthesitis in patients with axial spondyloarthritis (axSpA) due to a possible overlap between the tender points (TP) due to enthesitis and those of FM. The objective was to assess the agreement between the MASES enthesitis score and the tender points of the ACR 1990 criteria in patients with axSpA. METHODS This was a cross-sectional ancillary analysis of the Predict-SpA study (NCT03039088). Patients had a diagnosis of axSpA according to their rheumatologist and an indication to start a TNFα blocker. All patients were screened for FM according to the FiRST questionnaire. A physician was asked to assess 31 anatomically described sites in a random order without knowing to which instrument the site belonged (i.e. the 18 ACR 1990 TP and the 13 MASES sites). Agreement between the MASES and the ACR 1990 TPs by the intraclass correlation coefficient (ICC), also stratified by the presence/absence of concomitant FM according to the FiRST. RESULTS Among the 526 patients, 53% were men and 202 (38%) had FM. Radiographic sacroiliitis and MRI sacroiliitis were present in 56% and 68% patients, respectively. Patients were mostly men (53.4%) with radiographic and MRI sacroiliitis in 56% and 68% patients, respectively. Mean number of ACR 1990 TP was 5.4 (s.d. 4.6) and mean MASES was 4.2 (s.d. 3.6). ICC between both scores was 0.7 [95% CI (0.6, 0.8)]. ICC between both scores was 0.6 [95% CI (0.3, 0.8)] and 0.7 [95% CI (0.6, 0.7)] for patients with and without FM, respectively. CONCLUSION These results suggest a significant overlap between both scores in patients with axSpA, including in those without concomitant FM. TRIAL REGISTRATION clinicaltrials.gov, https://clinicaltrials.gov, NCT03039088.
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Affiliation(s)
- Faten Hamitouche
- Rheumatology Department, Cochin Hospital, AP-HP. Centre, Paris, France
| | - Clementina Lopez-Medina
- INSERM U1153, CRESS, Université Paris-Cité, Paris, France
- Rheumatology Department, Reina Sofia Hospital, IMIBIC, University of Cordoba, Spain
| | - Laure Gossec
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, Paris, France
- Rheumatology Department, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Maxime Dougados
- Rheumatology Department, Cochin Hospital, AP-HP. Centre, Paris, France
- INSERM U1153, CRESS, Université Paris-Cité, Paris, France
| | - Anna Moltó
- Rheumatology Department, Cochin Hospital, AP-HP. Centre, Paris, France
- INSERM U1153, CRESS, Université Paris-Cité, Paris, France
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Wu X, Liu D, Li Y, Xie Y, Tu L, Zhang Y, Zhang X, Fang L, Luo X, Lin Z, Liao Z, Rong L, Ren J, Zhou Y, Yang N, Xu J, Zhang H, Xu B, Wu Z, Zhan F, Li Z, Xiao W, Liu S, Zhou Y, Ye S, Lv Q, Zhang L, Zhao D, He S, Zhao L, Wu L, Lin H, Zhu Y, Guo D, Yang Z, Liu B, Yang K, Gu J. A clinical practice guideline for the screening and assessment of enthesitis in patients with spondyloarthritis. Front Immunol 2022; 13:978504. [PMID: 36172360 PMCID: PMC9510351 DOI: 10.3389/fimmu.2022.978504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The aim of this review is to provide guidance on the selection of approaches to the screening and assessment of enthesitis in patients with spondyloarthritis (SpA). Methods Twenty-four questions regarding the approaches to the screening and assessment of enthesitis and the implementation details were devised, followed by a systemic literature review. The Grading of Recommendations Assessment, Development, and Evaluation methodology was employed in the development of this guideline, with modifications to evaluate non-interventional approaches under comprehensive consideration of costs, accessibility, and evidence strength. A consensus from the voting panel was required for the inclusion of the final recommendations and the strength of each recommendation. Results Seventeen recommendations (including five strong recommendations) were included in this guideline. The voting panel expressed unequivocal support for the necessity of screening and assessment of enthesitis in patients with SpA. It was agreed unanimously that symptom evaluation and physical examination should serve as the initial steps to the recognition of enthesitis, whereas Maastricht Ankylosing Spondylitis Enthesitis Score is a reliable tool in both clinical trials and daily medical practice. Ultrasound examination is another reliable tool, with power Doppler ultrasound as an informative addition. Notwithstanding its high resolution, MRI is limited by the costs and relatively low accessibility, whereas radiographs had low sensitivity and therefore should be rendered obsolete in the assessment of enthesitis. PET/CT was strongly opposed in the detection of enthesitis. Conclusion This guideline provides clinicians with information regarding the screening and assessment of enthesitis in patients with SpA. However, this guideline does not intend on dictating choices, and the ultimate decisions should be made in light of the actual circumstances of the facilities.
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Affiliation(s)
- Xinyu Wu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dong Liu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanfei Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Ya Xie
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liudan Tu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanli Zhang
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xi Zhang
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Linkai Fang
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiqing Luo
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhiming Lin
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zetao Liao
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Limin Rong
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jie Ren
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuqi Zhou
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou>, China
| | - Niansheng Yang
- Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian Xu
- Department of Internal Medicine, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hua Zhang
- Department of Rheumatology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Baijie Xu
- Department of Rheumatology, Jieyang People's Hospital, Jieyang, China
| | - Zhenbiao Wu
- Department of Rheumatology, Tangdu Hospital of Air Force Military Medical University, Xian, China
| | - Feng Zhan
- Department of Rheumatology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zhenbin Li
- Department of Rheumatology, Bethune International Peace Hospital, People's Liberation Army, Shijiazhuang, China
| | - Weiguo Xiao
- Department of Rheumatology, The First Hospital of China Medical University, Shenyang, China
| | - Shengyun Liu
- Department of Rheumatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yi Zhou
- Department of Rheumatology and Immunology, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shanhui Ye
- Department of Rheumatology and Immunology, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing Lv
- Department of Rheumatology, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Lijun Zhang
- Department of Rheumatology, Shenzhen Hospital, The University of Hong Kong, Shenzhen, China
| | - Dongbao Zhao
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shanzhi He
- Department of Rheumatology, Zhongshan People's Hospital, Zhongshan, China
| | - Like Zhao
- Department of Rheumatology and Immunology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Lijun Wu
- Department of Rheumatology and Immunology, The People's Hospital of the Xinjiang Uygur Autonomous Region, Urumqi, China
| | - He Lin
- Department of Rheumatology, Fujian Provincial Hospital, Fuzhou, China
| | - Yunxiao Zhu
- Department of Medical Ultrasonics, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Donggeng Guo
- Department of Rheumatology and Immunology, Ningxia Clinical Institute of Bone and Joint Research, The Affiliated People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, China
| | - Zehong Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Budian Liu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Jieruo Gu
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Ventura-Ríos L, Cazenave T, Hernández-Díaz C, Gallegos-Nava S, Gómez-Ruiz C, Rosemffet M, Silva-Luna K, Rodríguez-Henríquez P, Vázquez-Mellado J, Casasola-Vargas J, Cruz-Arenas E, de Miguel EM. Entheseal Involvement in Spondyloarthritis (SpA) and Gout: An Ultrasound Comparative Study. Front Med (Lausanne) 2022; 9:871760. [PMID: 35685413 PMCID: PMC9170994 DOI: 10.3389/fmed.2022.871760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To compare the assessment of entheses in subjects with spondyloarthritis (SpA) with patients with gout by the Madrid Sonographic Enthesis Index (MASEI). Method This cross-sectional study includes videos of entheses evaluated by ultrasound (US) of 30 patients with SpA diagnosed according to the ASAS criteria and 30 patients with gout established by the presence of monosodium urate crystals. Entheses were evaluated for MASEI in 2 Institutes located in two different countries. Demographic and clinical data were registered. Total MASEI score, MASEI-inflammatory, and MASEI-chronic damage were analyzed. Comparisons between groups were obtained by chi-square test and Student's t-test. An inter-reading US reliability was realized. Results Patients with gout were older and had significantly more comorbidities than those with SpA. The total MASEI score was not significantly different among diseases (p = 0.07). MASEI-inflammatory was significantly more prevalent at the Achilles tendon in SpA, while the proximal patellar tendon was in gout. Power Doppler was higher in SpA compared to gout (p = 0.005). MASEI-chronic damage related to calcification/enthesophytes predominated in gout (p = 0.043), while calcaneal erosions did in SpA (p = 0.008). The inter-reader concordance was excellent (0.93, CI 95% 0.87–0.96, p = 0.001). Conclusions SpA and gout similarly involve entheses according to MASE, however, some inflammatory and chronic lesions differ significantly depending on the underlying disease and tendon scanned.
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Affiliation(s)
- Lucio Ventura-Ríos
- Laboratorio de Ultrasonido Musculoesquelético y Articular, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Tomas Cazenave
- Department of Rheumatology, Instituto de Rehabilitación Psicofísica, Buenos Aires, Argentina
| | - Cristina Hernández-Díaz
- Laboratorio de Ultrasonido Musculoesquelético y Articular, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | - Selma Gallegos-Nava
- Department of Rheumatology, Hospital General Dr. Darío Fernández Fierro, Mexico City, Mexico
| | | | - Marcos Rosemffet
- Department of Rheumatology, Instituto de Rehabilitación Psicofísica, Buenos Aires, Argentina
| | - Karina Silva-Luna
- Service of Rheumatology, Hospital Universitario "Dr. JoséEleuterio González", Monterrey, Mexico
| | | | | | | | - Esteban Cruz-Arenas
- Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Unidad de Vigilancia Epidemiológica Hospitalaria-Investigación Sociomédica, México City, Mexico
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Ultrasound of the Heel Improves Diagnosis-Tender Entheses in the Heel Region Rarely Corresponds to Inflammatory Enthesitis in Patients with Peripheral Spondyloarthritis. J Clin Med 2022; 11:jcm11092325. [PMID: 35566451 PMCID: PMC9104274 DOI: 10.3390/jcm11092325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/04/2022] [Accepted: 04/20/2022] [Indexed: 12/10/2022] Open
Abstract
Enthesitis is a key pathology in spondyloarthritis (SpA), but diagnosis may be clinically challenging. The objective of this study was to investigate the prevalence of ultrasound enthesitis lesions in tender entheses in the heel region in patients with peripheral SpA. In 27 patients with tenderness upon palpation at the Achilles tendon or the plantar fascia insertion, ultrasound assessment of the affected enthesis was performed using greyscale and color Doppler mode. Images were evaluated using the Outcome Measures in Rheumatology (OMERACT) scoring system for enthesitis, scoring presence/absence of hypoechogenicity, thickening, calcifications/enthesophytes, and erosions, and color Doppler activity semi quantitatively from 0 to 3. A total enthesitis sum score was calculated. A second examiner scanned 10 patients for inter-reader reliability. Ultrasound signs of inflammatory enthesitis (thickening/hypoechogenicity and/or Doppler activity) were found in 48%, and 19% showed Doppler activity—all in the Achilles enthesis. Inflammatory pathologies other than enthesitis (e.g., tendinitis, arthritis, bursitis) were identified in 26% of tender heels. The ultrasound OMERACT scoring system for enthesitis lesions showed excellent intra- and inter-reader agreement in a clinical setting. In conclusion, less than 50% of clinically tender entheses are related to inflammatory enthesitis when assessed by ultrasound. Ultrasound is useful for diagnosing other pathologies that may explain tenderness in the area.
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