Abstract:
Enthesitis is one of the key manifestations of spondyloarthritides (SpA) including ankylosing spondylitis (AS) and psoriatic arthritis. Enthesitis can occur alone or in combination with peripheral arthritis, sacroiliitis, or spondylitis. The inflammatory process is typically located at the insertion of the enthesis or ligament to bone, often resulting in osteitis as well. Because of its anatomical and functional complexity the term 'enthesis organ' has been coined. Biomechanical stress applied to the enthesis seems to play an important role for the occurrence of enthesitis in genetically predisposed individuals. Ultrasound imaging of peripheral entheses reveals enthesis abnormalities including entheseal calcification, bony erosion, or bony proliferation. Power Doppler signals demonstrating increased vascularization of inflamed entheses at the insertional site appear to be the most characteristic finding for enthesitis, yet study results are conflicting. Enthesitis-related osteitis and enthesitis at the spine is best visualized by MRI. Enthesitis may resolve spontaneously or may run a chronic course. Standard treatment includes local steroid injections, non-steroidal anti-inflammatory drugs (NSAIDs), and physical therapy. There is little evidence for the efficacy of disease-modifying anti-rheumatic drugs (DMARDs) in enthesitis. In contrast, anti-TNF agents have proven efficacy, and their use in treatment-resistant enthesitis is recommended in the Assessment of SpondyloArthritis international Society (ASAS)/European League Against Rheumatism (EULAR) recommendations for the management of AS and axial SpA and in the EULAR recommendations for psoriatic arthritis.Keywords:
Enthesis
Enthesopathy
Spondyloarthropathy
Rheumatism
Bursitis
Spondylitis
Objective The aims were to assess prevalence of enthesitis among different subtypes of early spondyloarthropathy (SpA) and to evaluate specificity of entheseal involvement in such patients using ultrasonography and power Doppler. Background Enthesitis is one of the characteristic etiopathogenic manifestations of spondyloarthritis; however, in clinical practice, its presence often goes unnoticed. Ultrasound (US) can visualize most of the relevant enthesitis-associated pathologies such as bone erosions, calcification, bursitis, tendon structure, and thickness. Patients and methods A total of 80 patients with SpA with early disease duration and 20 controls (10 with mechanical low back pain and 10 with rheumatoid arthritis) of matched age and sex underwent ultrasonographic evaluation of entheses and were scored according to Madrid Sonographic Enthesitis Index. Patients were distributed as 36 patients with ankylosing spondylitis, 18 patients with reactive arthritis, and 26 patients with psoriatic arthritis. Results On clinical examination of entheses, 22.5% of the examined sites were abnormal as compared with US, which achieved higher sensitivity of 62.5%. Mean US score was significantly higher in patients with SpAs (22.6 ± 6.34) as compared with controls (P Conclusion The entheses US score may be useful for improving the diagnostic accuracy of early SpA, which is difficult to diagnose.
Spondyloarthropathy
Enthesis
Enthesopathy
Bursitis
Power doppler
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The 2 major categories of idiopathic inflammatory arthritis are rheumatoid arthritis and the seronegative spondyloarthropathies. Whilst the synovium is the primary site of joint disease in the former, the primary site in the latter is less well defined. However, it has recently been proposed that enthesitis‐associated changes in the spondyloarthropathies are primary and that all other joint manifestations are secondary. Nevertheless, some of the sites of disease localisation have not been adequately explained in terms of enthesitis. This article summarises current knowledge of the structure, function, blood supply, innervation, molecular composition and histopathology of the classic enthesis (i.e. the bony attachment of a tendon or ligament) and introduces the concept of ‘functional’ and articular ‘fibrocartilaginous’ entheses. The former are regions where tendons or ligaments wrap‐around bony pulleys, but are not attached to them, and the latter are synovial joints that are lined by fibrocartilage rather than hyaline cartilage. We describe how these 3 types of entheses relate to other, and how all are prone to pathological changes in spondyloarthropathy. We propose that the inflammatory responses characteristic of spondyloarthropathies are triggered at these seemingly diverse sites, in genetically susceptible individuals, by a combination of anatomical factors which lead to higher levels of tissue microtrauma, and the deposition of microbes.
Enthesis
Spondyloarthropathy
Fibrocartilage
Microtrauma
Hyaline cartilage
Enthesopathy
Synovial joint
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Inflammation at the insertions of ligaments, tendons, or joint capsules to bone, which is termed enthesitis, is a characteristic feature of spondyloarthropathy. Because of the relative inaccessibility of the enthesis, the inflammatory, microbiologic, and immunologic events at that site have been poorly defined. Recent magnetic resonance imaging studies have drawn attention to the ubiquitous nature of enthesitis in spondyloarthropathies, especially adjacent to synovial joints. This may have implications for the mechanisms of synovitis in spondyloarthropathies. Magnetic resonance imaging studies also suggest that enthesitis lesions may be extensive, which could explain the diffuse nature of bone changes seen in some patients with spondyloarthropathies. The importance of enthesitis as a skeletal phenomenon in spondyloarthropathies has gained further support from transgenic models in which either tumor necrosis factor-alpha or bone morphogenetic protein-6 overexpression result in entheseal-associated polyarthropathy.
Spondyloarthropathy
Enthesis
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Background
Psoriasis is a chronic immune-mediated inflammatory skin disease characterized by reddish, thick patches covered with marked silvery scaling [1]. In about 70% of the patients, psoriasis is present many years before the onset of psoriatic arthritis [2]. The early recognition and therapeutic intervention especially with the new biologic treatments is critical to prevent the destructive and debilitating changes of psoriatic arthritis [3]. Enthesitis is inflammation at the attachment of tendons and ligaments to the bones, has been suggested as being the unifying feature of psoriatic arthritis, and the disease can be considered an enthesis associated disorder rather than primary synovitic arthropathy [4].Objectives
We aimed to correlate the subclinical enthestitis in patients with psoriasis detected by means of power Doppler (PD) ultrasonography (US) with other disease parameters.Methods
50 persons with a definite diagnosis of psoriasis with no clinical evidence of arthritis or enthesitis were selected. All patients underwent complete clinical assessment included Psoriasis severity (PASI) score, body mass index (BMI), PDUS evaluation of Achilles, quadriceps, patellar entheses and plantar aponeurosis. US findings were scored according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS).Results
In 18 of 50 of patients (36%) PDUS found signs indicative of enthesopathy. The Achilles enthesis had the highest number of PDUS signs of enthesopathy (33.3%), followed by distal patellar enthesis (22.2%), proximal patellar enthesis (16.7%), quadriceps enthesis (16.7%), and plantar aponeurosis enthesis (11.1%) with variable enthesial morphostructural abnormalities. The GUESS score was directly correlated with age (p=0.012), disease duration (p=0.044), PASI (p=0.035), BMI (p=0.011), hyperuricemia (p=0.011).Conclusions
In addition to the importance of PDUS as a complimentery tool in examination of entheses in psoriatic patients, the presence of high PASI score together with the increased BMI and hyperuricemia in addition to long disease duration could be considered as predictive parameters for the presence of psoriatic enthesitis.References
Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis, section 1. Overview of psoriasis and guide lines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008; 58(5):826–50. Dimitrios TB, Ioannis OT. Psoriatic arthritis. In: Klippel JH, ed.Primer on the Rheumatic Diseases. Atlanta, GA: Arthritis Foundation, 1997: 175–179. Rozenblit M, Lebwohl M. New biologics for psoriasis and psoriatic arthritis. Dermatol Ther. 2009; 22(1):56–60. McGonagle D, Conaghan PG, Emery P. Psoriatic arthritis: a unified concept twenty years on. Arthritis Rheum. 1999; 42:1080–7.Disclosure of Interest
None declaredEnthesopathy
Enthesis
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Background
Enthesitis is one of the most common and specific manifestations of spondyloarthropathy (SpA). Ultrasonography has demonstrated to be a highly sensitive tool in the evaluation of entheses in patients with spondyloarthropathy (SpA).Objectives
The objectives of the study were to determine the prevalence of subclinical entheseal involvement in spondyloarthropathy patients in lower limbs.Methods
The study was included 25 patients with spondylarthritis – 15 with ankylosing spondylitis and 10 with psoriatic arthritis, without known history of entheseal involvement. Besides, 20 healthy sex- and age-matched controls were included. All patients with no clinical evidence of arthritis or enthesitis underwent an US examination. All US findings were identified according to GUESS. Clinical examination and ultrasound were consecutively performed at each of the entheses to detect signs indicative of enthesopathy.Results
A total of 246 enthesis in patients with ankylosing spondylitis and psoriatic arthritis (due to the psoriatic lesions on the knee) were evaluated by US. In 88 of 246 (35.77%) entheses, grayscale US found signs indicative of enthesopathy and in 17/246 (6.9%) entheses PD signal was detected. In the healthy population, US found signs of enthesopathy in 12 of 200 (6.0%) entheses and no PD signal was detected. The GUESS score was higher in patients with ankylosing spondylitis than in the psoriasis group, and both scores were significantly higher than in healthy controls (P<0.0001).Conclusions
Our results indicate that both grayscale US and PD findings demonstrate a higher sensitivity for enthesopathy of ultrasonography, with respect to physical examination indicative. Due to the US ability to detect signs of subclinical enthesopathy, further study is needed about the prognostic value of the ultrasound findings for predicting clinical onset of entheseal involvement.Disclosure of Interest
None DeclaredEnthesopathy
Enthesis
Spondyloarthropathy
Bursitis
Spondylitis
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Entheses are sites where tendons, ligaments, joint capsules or fascia attach to bone. Inflammation of the entheses (enthesitis) is a well-known hallmark of spondyloarthritis (SpA). As entheses are associated with adjacent, functionally related structures, the concepts of an enthesis organ and functional entheses have been proposed. This is important in interpreting imaging findings in entheseal-related diseases. Conventional radiographs and CT are able to depict the chronic changes associated with enthesitis but are of very limited use in early disease. In contrast, MRI is sensitive for detecting early signs of enthesitis and can evaluate both soft-tissue changes and intraosseous abnormalities of active enthesitis. It is therefore useful for the early diagnosis of enthesitis-related arthropathies and monitoring therapy. Current knowledge and typical MRI features of the most commonly involved entheses of the appendicular skeleton in patients with SpA are reviewed. The MRI appearances of inflammatory and degenerative enthesopathy are described. New options for imaging enthesitis, including whole-body MRI and high-resolution microscopy MRI, are briefly discussed.
Enthesis
Enthesopathy
Appendicular skeleton
Spondyloarthropathy
Axial skeleton
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Higher subclinical enthesitis on US has been reported in IBD and celiac disease, separately. The objective of this study was to compare IBD and celiac disease for enthesitis on US. Higher enthesitis scores in IBD compared with celiac disease would support a shared pathogenic mechanism between IBD and spondyloarthritis, whereas similar scores may suggest a general impact of gut inflammation on the enthesis.Patients with IBD, celiac disease and healthy controls (HCs) were recruited and 12 entheses were scanned by US, blind to the diagnosis and clinical assessment. Elementary lesions for enthesitis were scored on a scale between 0 and 3, for inflammation, damage and total US scores.A total of 1260 entheses were scanned in 44 patients with celiac disease, 43 patients with IBD and 18 HCs. The three groups were matched for age and BMI. Patients with celiac disease and IBD had higher inflammation scores than HCs [10.4 (6.5), 9.6 (5.4) and 5.6 (5.2), respectively, P = 0.007) whereas damage scores were similar. Both age and BMI had significant effects on the entheseal scores, mostly for inflammation scores but when controlling for these the US enthesopathy scores were still higher in celiac disease and IBD.The magnitude of subclinical enthesopathy scores is similar between celiac disease and IBD in comparison with HCs. These findings suggest that the common factor between both diseases and enthesopathy is abnormal gut permeability, which may be modified by the genetic architecture of IBD leading to clinical arthropathy.
Enthesopathy
Enthesis
Spondyloarthropathy
Subclinical infection
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Aim: to assess enthesis lesions in patients with inflammatory bowel disease/IBD (ulcerative colitis/UC and Crohn’s disease/CD) and associations between the clinical pattern of the underlying disease and enthesopathy verified by ultrasound. Patients and Methods: this study included 95 patients with IBD aged 26–37 (the mean age was 37 years). Each patient underwent clinical examination and ultrasound of the entheses of the upper and lower extremities with calculating enthesial indices. The pattern of enthesopathy in patients with UC and CD was compared. Correlations between clinical characteristics of IBD and enthesopathy were evaluated. The analysis of individual anatomical sites of tendon and ligament insertions in patients with IBD was performed for the first time. Results: pain elicited on local pressure of entheseal points was seen in 52%. Enthesitis was diagnosed through ultrasound in 76% of patients (enthesitis with vascularization in 76%, erosions at insertions in 80%, and enthesophytes in 39%). When assessing anatomical sites, the most common impairment was a medial collateral ligament lesion, while the most common localization of enthesophytes was the insertion point of the quadriceps femoris muscle. Disease duration directly correlated to the number of painful entheses on palpation (SR=0.24, р=0.017) and the number of enthesophytes (SR=0.20, р=0.044). We failed to identify any significant associations between the severity of the attack and enthesis lesions in UC and CD. Direct correlations between the number of extraintestinal manifestations and the number of painful entheses on palpation (SR=0.35, р=0.0004) and LEI (SR=0.2, р=0.04) and GUESS scores (SR=0.28, р=0.004); the number of erosions with vascularization and ESR (SR=0.26, р=0.01) and CRP (SR=0.25, р=0.01); the number of painful entheses on palpation and the number of enthesitis (SR=0.71, р=0.00) including those with vascularization (SR=0.27, р=0.00) were revealed. Conclusion: enthesopathy is a common extraintestinal manifestation of IBD independent of a nosology of the severity of the attack of the underlying disease. Greater disease duration, pain at entheses on palpation, and increased inflammatory markers (ESR, CRP) are associated with enthesis lesions. Therefore, current enthesopathy indices can be applied to assess and monitor entheses. KEYWORDS: inflammatory bowel disease, ultrasound, enthesitis, vascularization, Power Doppler imaging, enthesopathy scores. FOR CITATION: Gainullina G.R., Kirillova E.R., Odintsova A.Kh., Abdulganieva D.I. Clinical and sonographic characteristics of enthesis lesions in inflammatory bowel disease. Russian Medical Inquiry. 2021;5(6):385–390 (in Russ.). DOI: 10.32364/2587-6821-2021-5-6-385-390.
Enthesis
Enthesopathy
Palpation
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There has been an increasing focus on enthesitis in psoriatic arthritis (PsA). Enthesitis, defined as inflammation at the insertion of tendons and ligaments into bone, has been proposed as the primary pathological lesion of PsA, and this hypothesis has received support from animal models that have focused on the enthesis in spondyloarthropathy-like disease1,2. Enthesitis is part of the entry "stem" for the ClASsification for Psoriatic ARthritis criteria (CASPAR) criteria, although it must be emphasized that only a few cases of PsA had isolated entheseal involvement in that study3. Yet the clinical evaluation of enthesitis remains a vexing problem. When delivering educational symposia, I am often asked by dermatology and rheumatology colleagues how to assess and treat enthesitis. To the dermatologists I say look only at the Achilles insertion because (1) it is readily identifiable, (2) it is the major enthesis of the body, and (3) involvement is quite specific for spondyloarthropathy (SpA). I caution against misinterpreting a fusiform swelling of the Achilles tendon 5–10 cm proximal to the insertion as insertional tendinitis — Achilles paratendinitis is quite common and mostly unrelated to SpA. To the rheumatologist I give the same advice, but also advise using a simple enthesitis index for assessment, such as the Leeds enthesitis index, in which the patient is queried about pain when pressure is applied at each lateral epicondyle, medial femoral condyle, and Achilles tendon insertion. I warn about overinterpreting pure entheseal disease without arthritis for 2 reasons. First, there is a consistently … Address correspondence to Dr. P.S. Helliwell, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Harehills Lane, Leeds LS7 4SA, UK. E-mail: P.Helliwell{at}leeds.ac.uk
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Enthesopathy
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A report from a symposium held at Klinikum Benjamin Franklin, Free University, Berlin, Germany, 25–26 February 2000 This symposium was organised by J Braun and J Sieper (Free University, Berlin) to review the current knowledge of the anatomical, inflammatory, microbiological, and immunological events in enthesitis. The term "enthesopathy" is relatively new and its medical history short, but some important contributions can be listed (boxFB1). Figure FB1 History of "enthesopathy" • 1966 Enthesopathy first used by Niepel • 1970 Entheses centrally affected in ankylosing spondylitis, in contrast with rheumatoid arthritis (RA; Heberden oration lecture by Ball) • 1975 Some enthesitis in sacroiliitis (François) • 1983 Syndrome of seronegative enthesopathy and arthropathy in children (Rosenberg) • 1982 Sacroiliitis starts in the subchondral bone (Shichikawa) • 1991 Enthesopathy discriminative feature of spondyloarthropathy (SpA; European Spondyloarthropathy Study Group criteria, Dougados) • 1998 Entheses more commonly affected in arthritis in SpA compared with RA (McGonagle) The spondyloarthropathies are among the most common inflammatory rheumatic diseases.1 In addition to the strong genetic predisposition, partly due to HLA-B27,2 there are characteristic clinical features of SpA3: inflammatory back pain often due to sacroiliitis4 and enthesitis occurring mostly at various well defined locations, predominantly of the legs, such as the Achilles tendon, the plantar aponeurosis, the knee, the trochanter regions of the femur, and several pelvic sites.5 Thus entheses are ubiquitous, resulting in a diversity of associated pathological manifestations. Sacroiliitis is the most common early sign of SpA.6Whether or not ligamentous and entheseal structures are affected in sacroiliac inflammation has not yet been entirely clarified. To answer some of the most critical questions an expert symposium on enthesitis was organised:
Enthesopathy
Enthesis
Spondyloarthropathy
Bursitis
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Citations (96)