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Clin Exp Rheum 31/2/2013 161-326 Imaging Ultrasound imaging for the rheumatologist XLV. Ultrasound of the shoulder in psoriatic arthritis L. Riente1, A. Delle Sedie1, E. Filippucci2, A. Iagnocco3, G. Sakellariou4, 1 1 2 3 1 R. Talarico , L. Carli , L. Di Geso , F. Ceccarelli , S. Bombardieri 1Rheumatology Unit, University of Pisa, ABSTRACT psoriasis which can involve peripheral Pisa, Italy; 2Cattedra di Reumatologia, Objectives. The aims of this study were and axial joints. Classified as a spondy- Università Politecnica delle Marche, and to investigate the prevalence of ultra- loarthropathy, it shares many clinical Ospedale A. Murri, Ancona, Italy; sound (US) pathologic abnormalities and radiological features with other 3Rheumatology Unit, Dipartimento di Medicina Interna e Specialità Mediche, in the shoulders of psoriatic arthritis rheumatic disorders in the spectrum of Sapienza Università di Roma, Policlinico (PsA) patients and to compare them spondyloarthritis, such as ankylosing Umberto 1°, Rome, Italy; 4Division of with the main clinical findings. spondylitis (AS) or reactive arthritis. Rheumatology, IRCCS Policlinico San Methods. Ninety-seven PsA patients Enthesitis, dactylitis and arthritis with Matteo Foundation, Pavia, Italy. were enrolled in the study. The subacro- frequent involvement of sacroiliac Lucrezia Riente, MD mial/subdeltoid bursa, the sheath of the joints and spondylitis are observed in Andrea Delle Sedie, MD long biceps tendon, the glenohumeral PsA patients (1). It is known that shoul- Emilio Filippucci, MD joint and the acromion-clavicular joint der involvement occurs in up to 50% of Annamaria Iagnocco, MD were examined for the presence of syno- AS patients, but little is known on the Garifallia Sakellariou, MD Rosaria Talarico, MD vial effusions and synovial hypertrophy. prevalence and the outcome of shoul- Linda Carli, MD Rotator cuff tendons (supraspinatus, der joint involvement in PsA (2). Luca Di Geso, MD subscapularis, infraspinatus) were im- In the last decades, several radiographic Fulvia Ceccarellli, MD, PhD aged for tendinosis, calcifications and imaging modalities, including magnet- Stefano Bombardieri, MD, total or partial tears, while deltoid en- ic resonance imaging (MRI) and ultra- Professor of Rheumatology thesis were evaluated for local enthesi- sonography (US), have been explored Please address correspondence tis and the lesser and greater tuberos- for accurate and early diagnosis of ar- and reprint requests to: ity of the humerus for the presence of thritis, and particularly of rheumatoid Dr Lucrezia Riente, enthesophytes. U.O. Reumatologia, arthritis, and there is now growing in- Dipartimento di Medicina Clinica Results. Tendinosis represented the most terest for their use in spondyloarthritis e Sperimentale, frequent abnormal finding. Supraspina- (3-6). US is already established as an Università di Pisa, tus tendinosis was detected more often attractive imaging technique and has Via Roma 67, than subscapularis and infraspinatus been successfully used in the assess- Pisa 56126, Italy. tendinosis. When considering tendon ment of shoulder involvement in rheu- E-mail: [email protected] tear, supraspinatus was also the most matic disorders (7). However, to the Received on April 17, 2013; accepted frequently involved anatomical struc- best of our knowledge, so far, very few in revised form on April 19, 2013. ture. Clinical examination frequently studies have evaluated US examination Clin Exp Rheumatol 2013; 31: 329-333. failed to detect abnormalities in patients of shoulder joints in PsA patients (8). © Copyright CLINICAL AND in whom US examination showed patho- The aim of this multicentre study was to EXPERIMENTAL RHEUMATOLOGY 2013. logical findings. This is particularly true investigate the prevalence of US patho- for tendon involvement, i.e. effusion logic abnormalities in the shoulders of Key words: psoriatic arthritis, within the sheath of the biceps tendon PsA patients and to compare them with ultrasound, shoulder, synovitis, was imaged in 43 shoulders but clinical the main clinical findings. tendinosis, enthesitis assessment reported abnormalities only in 22 shoulders (p<0.0001). Patients and methods Conclusions. US examination appears The study included ninety-seven con- to be a useful and sensitive imaging secutive PsA patients (male/female ra- technique, specifically in identifying tio: 43/54; mean age 51±14 years, min: joint and tendon involvement of the 18, max: 83) attending the out-patient shoulder. and in-patient clinics of four Rheu- matology Units (University of Pisa, Introduction Università Politecnica delle Marche, Psoriatic arthritis (PsA) is a chronic in- University of Pavia and Sapienza Uni- Competing interests: none declared. flammatory arthropathy associated with versity of Rome, Italy), examined from 329 IMAGING Shoulder ultrasound in psoriatic arthritis / L. Riente et al. October 2012 to January 2013. The di- Table I. Demographic profile. agnosis of PsA was made according to Number of patients 97 the Classification Criteria for Psoriatic M/F 43/54 Arthritis (CASPAR) (9). The primary aim of the study was to assess the prev- Mean ± SD age (min-max) (years) 51±14 (18–83) alence of US pathologic abnormalities Mean ± SD disease duration (min-max) (months) 95±13 (2–576) in the shoulders of PsA patients and to Disease duration (months) Number of patients compare them with the clinical profile. <12 10 12–24 13 The secondary aim was to explore any 24–60 26 potential correlations between demo- >60 48 graphic features, clinical pattern and prevalence of US pathologic abnor- Table II. Shoulder clinical evaluation (provocative tests) in PsA patients. malities of the shoulders in the cohort examined. Therefore, data regarding Right Left Total joints sex, age, clinical features, US abnor- (n=97) (n=97) (n=194) malities, body mass index (BMI) (10) Hawkins’s test (n/%) 16/16.4 12/12.4 28/14.4 and quality of life (by means of vali- Patte’s test (n/%) 8/8.2 6/6.2 14/7.2 dated questionnaires) were collected Jobe’s test (n/%) 20/20.6 15/15.4 35/18 in an electronic database. Patients who Gerber’s test (n/%) 10/10.3 8/8.2 18/9.2 received corticosteroid injections in Speed test (n/%) 16/16.5 14/14.4 30/15.5 the shoulder within the 3 months prior to the study were excluded from the evaluation. Demographic and clinical Table III. US-detected features at the level of the rotator cuff tendons. characteristics of the cohort studied are Tendinosis Tears* summarised in Table I. Right Left Total Right Left Total n=97 n=97 n=194 n=97 n=97 n=194 Clinical assessment All the patients were assessed for his- Supraspinatus (n/%) 43/44 37/38 80/41 16/16 7/7 23/12 tory of shoulder pain and underwent Subscapularis (n/%) 23/24 20/21 43/22 1/1 2/2 3/1.5 a complete clinical assessment of the Infraspinatus (n/%) 16/16 13/13 29/15 0/- 0/- 0/- shoulder by an expert rheumatologist * for the presence/absence of pain and partial-thickness or complete tear. tenderness. The Hawkins test, Jobe test, Patte test, Gerber test and Speed by a single rheumatologist who was Rotator cuff tendons (supraspinatus, test were the provocative maneuvers well experienced in musculoskeletal subscapularis, infraspinatus) were im- performed to provide a more focused US. Before the start of the study, all the aged for the presence of tendinosis, evaluation for impingement syndrome, sonographers reached an agreement local calcifications and total or partial rotator cuff tendinopathies and biceps both on the scanning technique and the tears. brachi pathology, respectively (11). definition of the pathological findings The ACJ was examined for osteophytes All the patients underwent a comprehen- to detect. and erosions as well as fibrocartilage sive rheumatologic evaluation; DAS28 In all patients, US examination of both calcifications. The GHJ was also evalu- was used to evaluate the disease activ- shoulders was performed according to ated for the assessment of labrum cal- ity. The physicians conducting the clini- the EULAR guidelines (12). The su- cifications, intra-cartilagineous crystal cal and US examinations were blinded bacromial/subdeltoid bursa, the sub- material (double contour sign), topha- to the results of each other’s findings scapular bursa, the sheath of the long ceous deposits and erosions (with or biceps tendon, the axillary and poste- without local PD signal). Ultrasonographic assessment rior recesses of the gleno-humeral joint Finally, we imaged the deltoid en- In each of the 4 participating units in (GHJ) and the acromion-clavicular joint thesis at the acromion attachment for the study, US examinations (includ- (ACJ) were examined for the presence local enthesitis (defined according ing both grey-scale and power Doppler of synovial effusions (SE) and syno- to D’Agostino et al.), and lesser and examinations) were carried out using a vial hypertrophy (SH). When synovial greater tuberosity of the humerus for the MyLab TWICE XVG machine (Esa- hypertrophy was detected, power Dop- presence of local enthesophytes (8, 13). ote, Genoa, Italy) with a linear probe pler examination was performed and All abnormalities were studied ac- operating at 4-13 MHz and a Logiq 9 the following settings used: PRF 500 cording to the internationally accepted machine (General Electrics Medical Hz, Doppler frequency 7.1–7.5 MHz definitions and scored according to a Systems, Milwaukee, WI, USA) with and Doppler gain to avoid random dichotomous assessment (14, 15). In a linear probe operating at 9-14 MHz noise visualisation. addition, calcifications were assessed 330 Shoulder ultrasound in psoriatic arthritis / L. Riente et al. IMAGING for the presence of acoustic shadow- normalities of the rotator cuff tendons and 3/194 (1.5%) joints, respectively, ing and their maximal dimension was were frequently observed; in particu- while no infraspinatus tendon tear was measured. lar, tendinosis represented the most observed. Bilateral supraspinatus tear frequent abnormal finding (Table III). was detected in 4 patients. Statistical analysis Supraspinatus tendinosis was detect- Effusion within the sheath of the biceps All results are expressed in means ± ed more often than subscapularis and tendon was a frequent finding: it was standard deviation (SD).
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