Ultrasound assessment of Achilles enthesitis: a dedicated training program
Gianluca SmerilliEdoardo CipollettaGiulia Maria Destro CastanitiGiovanni PieroniGianmarco SartiniAlessandra CenciAndrea Di MatteoMarco Di CarloGiuliana GugginoWalter GrassiEmilio Filippucci
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Abstract:
Objective. To describe an intensive and multimodal ultrasound (US) training program focused on Achilles enthesitis and to illustrate the learning curve of trainees without experience. Methods. Three medical students (trainees) and two rheumatologists experienced in musculoskeletal US (trainers) were involved in the training program, which encompassed one preliminary theoretical-practical meeting and five scanning sessions (two patients per session). The students and one expert performed the US examination of the Achilles enthesis bilaterally. The trainees acquired representative images and assessed the presence of Outcome Measures in Rheumatology (OMERACT) US abnormalities of enthesitis. The experts provided feedback addressing trainees’ misinterpretations, and the quality of the acquired images was evaluated. A dedicated questionnaire was used to evaluate the students’ confidence. After each session, five sets of static images (total=100 images of most commonly scanned entheses) were provided and scored by the students according to OMERACT US definitions. Total agreement and prevalence and bias adjusted kappa (PABAK) were used to evaluate the concordance between the trainees and the expert sonographer. Results. The total agreement and PABAK significantly improved between the first and fifth scanning sessions (76.2% versus 92.9%, p<0.01, and 0.5 versus 0.79, p<0.01) and between the first and fifth static image sets (64.5% versus 81.9%, p<0.01, and 0.29 versus 0.74, p<0.01). Image quality did not significantly improve (p=0.34). A significant increase in trainees’ confidence was registered (p<0.01). Conclusions. The described training program rapidly improved the students’ performance in the US assessment of Achilles enthesitis, appearing to be an effective starting model for the future development of pathology-oriented teaching programs for the US in rheumatology.Keywords:
Sonographer
Concordance
Enthesis
Entheses are sites of attachment of tendons, ligaments, fascia, or capsule into bone, providing a mechanism for reducing stress at the bony interface. Entheses dissipate biomechanical stress and, in doing so, are thought to be subjected to repeated micro traumas. Inflammation of the entheses, enthesitis, is a well-known hallmark of spondyloarthritis (SpA), playing a central role in disease pathogenesis. It can also be associated with degenerative, endocrinologic, metabolic and traumatic conditions. Magnetic resonance imaging (MRI) is a sensitive tool for the detection of early signs of enthesitis in patients with SpA. The MRI features of enthesitis are well described, and include thickened enthesis with altered signal intensity and perientheseal soft tissue edema. Bone marrow edema and erosions at the adjacent bone appear mainly in SpA-associated enthesitis. Contrast material administration improves the reliability, sensitivity and specificity of detecting enthesitis on an MRI. Whole-body (WB) MRI allows assessment of all peripheral and axial joints and entheses from “head-to-toe” in one examination. The promising role of WBMRI in the evaluation of enthesitis in SpA and other rheumatic diseases was evaluated in several cross sectional and prospective studies. Indeed WB MRI was shown to be sensitive in the detection of inflammatory lesions, including enthesitis, on multiple sites, potentially serving as a one stop shop for the estimate of active disease load. In the current presentation, the typical imaging properties of enthesitis on conventional and WB-MRI will be presented along with several challenging quiz cases.
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None declaredEnthesis
Spondyloarthropathy
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Purpose: Ultrasonographical assessment of pathological changes in Achilles tendon and plantar aponeurosis entheses in patients with suspected enthesitis.
Enthesis
Aponeurosis
Enthesopathy
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Enthesitis is one of the key manifestations of spondyloarthritis (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 antirheumatic 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.
Enthesis
Enthesopathy
Spondyloarthropathy
Rheumatism
Bursitis
Spondylitis
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Enthesitis is one of the key manifestations of spondyloarthritis (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 antirheumatic drugs (DMARDs) in enthesitis. In contrast, anti-TNF agents and other biologics 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.
Enthesis
Enthesopathy
Rheumatism
Spondyloarthropathy
Bursitis
Spondylitis
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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.
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Enthesopathy
Spondyloarthropathy
Rheumatism
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Spondylitis
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The enthesis is a site crucial for mobility of the musculoskeletal system yet it is also commonly a target of inflammation, especially in spondyloarthritis. Because the enthesis is prone to high biomechanical forces, it has been hypothesized that biomechanical forces may be implicated in the onset of the enthesitis and spondyloarthritis in general. However, treatment recommendations involve exercise therapy which at first glance appears to pose a paradox. Using a case, we will discuss the current knowledge on enthesitis, the link with mechanical stress and the implications thereof in diagnosis and management of spondyloarthritis.
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Axial spondyloarthritis
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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.
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Enthesopathy
Appendicular skeleton
Spondyloarthropathy
Axial skeleton
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Abstract Background/Aims Enthesitis, which is the inflammation of the entheses area where the tendon or ligaments are attached into the bone, is considered a hallmark and pathological feature for spondyloarthropathies (SpA). The lower limb entheses are more prone to being affected than the upper extremity enthesis, the most common one is Achilles tendon where heel enthesitis is considered the most frequent finding in SpA patients. Ultrasound is widely used by rheumatologists because it has higher sensitivity and specificity in detecting enthesitis compared with clinical assessment. The abnormal characteristics of enthesitis in greyscale ultrasound includes the hypoechoic area at the insertion or body of the tendon due to the loss of the normal fibrillar pattern, increase in the tendon thickness, bone erosion, calcification and increase in Dopplar signals. Although ultrasound has many advantages compared with other imaging modalities, it is operator-dependent and the diagnosis is exposed to the subjectivity of the observer, which leads to the variability in defining the abnormal features of enthesitis. Using static ultrasound images of Achilles tendon entheses of patients with SpA, we first determined the intra- and inter-observer reliability of grading ‘hypoechogenicity’ using a panel of readers and second, compared a computerised pixel counting method against an expert consensus score to determine the level of agreement between approaches. Methods Six participants (rheumatologists and sonographer) with experience in ultrasound scored the presence of hypoechogenicity in 100 static images of Achilles tendon entheses of patients with SpA. Two scoring systems were used- an OMERACT derived SQ system (0-3) of the whole enthesis and binary score system of the distal 2mm (0-1). The intra-class correlation coefficient (ICC) and Cohen's kappa was used to assess inter-observer reliability. The ImageJ software was used to measure the mean grey values (MGV) of the pixels within the enthesis. Results The inter-observer reliability was good for using the SQ score (ICC 0.780 (95% CI 0.691-0.849) and moderate for the binary score (ICC 0.632 (95% CI 0.490-0.745)). There was no match between the results from the quantitative score of the pixels MGV and the expert semi-quantitative score. Conclusion This study is novel as in that it has specifically evaluated the scoring of hypoechogenicity within the entheses of patients with SpA. It has demonstrated variation in scoring between observers and highlighted the challenges of image interpretation. A lack of correlation of expert scoring with the manual pixel MGV was limited by the image artefacts and different machine settings which may have implications as we work towards future AI systems. Disclosure A.S. Aldahes: None. R. Wakefield: None. K. Smith: None.
Enthesis
Enthesopathy
Spondyloarthropathy
Quadriceps tendon
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Enthesitis is the inflammatory process marked by the insertion of tendons, ligaments and joint capsules on the bone and it is a cardinal feature (and diagnostic criteria) of spondyloarthropathies (SpA). Although it is usually revealed by clinical examination, recent studies using magnetic resonance imaging (MRI) and ultrasonography (US) have confirmed that enthesitis (as well as synovitis) can often be asymptomatic, both in the axial and peripheral skeleta. Therefore, a systematic US study of peripheral entheses could be useful in the diagnostic process of patients suspected with SpA, and peripheral enthesitis scoring systems have been proposed. Recently, power Doppler US (PDUS) has been proved to be useful for differentiating mechanical and inflammatory enthesitis and for monitoring the efficacy of therapy. This article reviews the main anatomical and histopathological aspects of enthesitis and describes the general US features of enthesis and the basic US features of enthesitis, in its various stages. The usefulness of US and PDUS in the diagnosis and assessment of SpA is discussed on the basis of the available literature and our experience. Keywords: ultrasonography, power doppler, enthesis, enthesitis, enthesopathy, spondyloarthropathy
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Enthesopathy
Spondyloarthropathy
Bursitis
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Enthesitis is one of the key manifestations of spondyloarthritis (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 antirheumatic drugs (DMARDs) in enthesitis. In contrast, anti-TNF agents and other biologics 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.
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Enthesopathy
Rheumatism
Spondyloarthropathy
Bursitis
Spondylitis
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