DOCSLIB.ORG

Detection of Enthesitis in Children with Enthesitisrelated Arthritis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Detection of Enthesitis in Children with Enthesitisrelated Arthritis ARTHRITIS & RHEUMATOLOGY Vol. 66, No. 1, January 2014, pp 218–227 DOI 10.1002/art.38197 © 2014, American College of Rheumatology Detection of Enthesitis in Children With Enthesitis-Related Arthritis Dolorimetry Compared to Ultrasonography Pamela F. Weiss,1 Nancy A. Chauvin,1 Andrew J. Klink,1 Russell Localio,2 Chris Feudtner,1 Diego Jaramillo,1 Robert A. Colbert,3 David D. Sherry,1 and Ron Keren1 Objective. To evaluate the distribution of enthesi- interval [95% CI] 0.63–0.93), and the interrater reliabil- tis and the accuracy of physical examination with a ity was 0.81 (95% CI 0.67–0.95). Tenderness as detected dolorimeter for the detection of enthesitis in children, by standardized dolorimeter examination had poor pos- using ultrasound (US) assessment as the reference itive predictive value for US-confirmed enthesitis. In standard. comparison to controls, patients with ERA reported Methods. We performed a prospective cross- more pain and had lower pain thresholds at every site, sectional study of 30 patients with enthesitis-related including control sites (P < 0.001 for all comparisons). arthritis (ERA) and 30 control subjects. The following The interrater reliability of dolorimeter examination CI %95] 0.49 ؍ tendon insertion sites were assessed by standardized for detection of enthesitis was low (␬ physical examination with a dolorimeter and US: com- 0.33–0.65]). mon extensor on the lateral humeral epicondyle, com- Conclusion. Compared to US, standardized dolo- mon flexor on the medial humeral epicondyle, quadri- rimeter examination for the detection of enthesitis in ceps at the superior patella, patellar ligament at the children has poor accuracy and reliability. The de- inferior patella, Achilles, and plantar fascia at the creased pain threshold of ERA patients likely contrib- calcaneus. uted to the limited accuracy of the physical examination Results. Abnormal findings on US were detected findings. Further research regarding the utility of US most commonly at the insertion of the quadriceps (30% for identifying enthesitis at diagnosis of juvenile idio- [18 of 60 sites]), common extensor (12% [7 of 60]), and pathic arthritis, accurately predicting disease progres- Achilles (10% [6 of 60]) tendons. The intrarater reli- sion, and guiding therapeutic decisions is warranted. ability of US (kappa statistic) was 0.78 (95% confidence Enthesitis refers to inflammation at the attach- Dr. Weiss’s work was supported by the NIH (National ments of the ligaments, tendons, and joint capsules to Institute of Arthritis and Musculoskeletal and Skin Diseases grant 1-K23-AR059749-01A1); she is also recipient of a Rheumatology the bone. It is a distinct clinical hallmark of the spondy- Research Foundation Bridge Funding award. Dr. Colbert’s work was loarthropathies (SpA) in both children and adults. In supported by the NIH (National Institute of Arthritis and Musculo- children, enthesitis is usually diagnosed by clinical find- skeletal and Skin Diseases Intramural Research Program grant Z01- AR-041184). ings, including localized pain, tenderness, and swelling. 1Pamela F. Weiss, MD, MSCE, Nancy A. Chauvin, MD, These features, however, are nonspecific and can also Andrew J. Klink, MPH, Chris Feudtner, MD, PhD, MPH, Diego be found in normal children (1) and in patients with Jaramillo, MD, David D. Sherry, MD, Ron Keren, MD, MPH: Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; overuse injuries, apophysitis, and fibromyalgia. In adult 2Russell Localio, MPH, MS, PhD: University of Pennsylvania, SpA, magnetic resonance imaging (MRI) and ultra- Perelman School of Medicine, Philadelphia, Pennsylvania; 3Robert A. sound (US) with power Doppler are used to distinguish Colbert, MD, PhD: National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland. inflammatory enthesitis from these other conditions Address correspondence to Pamela F. Weiss, MD, MSCE, (2–4). In studies that used these imaging modalities as Children’s Hospital of Philadelphia, 3535 Market Street, Room 1526, the reference standard in the evaluation of adult SpA, Philadelphia, PA 19104. E-mail: [email protected]. Submitted for publication June 20, 2013; accepted in revised physical examination had poor sensitivity for detecting form September 10, 2013. inflammatory enthesitis (2), and US was a useful tool 218 ULTRASOUND VERSUS PHYSICAL EXAMINATION FOR PEDIATRIC ENTHESITIS 219 Figure 1. Ultrasound examination of the common extensor tendon insertion at the lateral elbow using a Philips IU22 machine with a high-frequency linear-array 12-MHz transducer. Power Doppler imaging was performed in long and transverse planes. A, Images were acquired with the elbow in mild flexion and the forearm pronated. B, An image from the gray-scale evaluation shows the thickness of the tendon, as delineated by the arrowheads.LEϭ lateral epicondyle; R ϭ radial head. C, An image from the Doppler evaluation shows moderate vascularization. Red regions are increased power Doppler signals, which indicate increased vascularity. for following the response of enthesitis to treatment (5). during the examination and performed US as the refer- In those studies, the sensitivity of the physical examina- ence standard test at the same visit. tion findings was low, ranging from 0.16 to 0.22, and the specificity was moderate, ranging from 0.80 to 0.87 (2,6). PATIENTS AND METHODS The sensitivity, specificity, positive predictive Human subjects protections. The protocol for the value (PPV), and negative predictive value (NPV) of conduct of this study was approved by the Committee for the clinical examination for the detection of enthesitis have Protection of Human Subjects at the Children’s Hospital of been sparsely studied in juvenile idiopathic arthritis Philadelphia (CHOP). (JIA) (7,8). The accurate diagnosis of enthesitis is Study subjects. The study subjects were a convenience important because its presence has implications with sample drawn without regard to disease duration, severity, or current activity or therapy from a source population of chil- regard to the classification of JIA, which in turn, influ- dren with a diagnosis of ERA who were 5–18 years of age and ences treatment decisions and monitoring for extra- had been evaluated at the CHOP Rheumatology Clinic be- articular manifestations of the disease. Currently, physi- tween March 2011 and February 2013. All patients met the cians vary with regard to which entheses they evaluate, ILAR criteria for ERA (9), according to the treating physician. the amount of pressure they apply, and what criteria they The presence of at least 1 tender enthesis on physical exami- nation performed at the screening visit was required in order use to diagnose positive findings (e.g., verbal indication for an ERA patient to be eligible for study. Exclusion criteria of pain or withdrawal upon pain). The International were contraindications for performing US, including local League of Associations for Rheumatology (ILAR) cri- malignancy, metal implants below the area of examination, teria for JIA classifies many children with SpA as having localized tissue or bone infections, or vascular abnormalities. enthesitis-related arthritis (ERA) (9) based solely on the Healthy control subjects were recruited from a local primary care practice and were age- and sex-matched to the patients. presence of enthesitis. Clinical data. We collected self-reported information In the present study, we sought to evaluate the on sex, age, race, ethnicity, and family history of rheumatic distribution of enthesitis and the accuracy of physical disease. We abstracted information about medications (past examination for the detection of enthesitis in children. and current), disease duration, HLA–B27 status, and antinu- We examined 6 bilateral entheses in children with ERA, clear antibody (ANA) status from the electronic health record. Health status measures. The patients (if at least 13 the category of JIA with the highest prevalence of years of age) or their parents or legal guardians completed the enthesitis, as well as in healthy controls. We used a following 5 health status questionnaires: the Pediatric Rheu- dolorimeter to objectively measure the pressure applied matology Quality of Life (PRQL) (10), the Childhood Health 220 WEISS ET AL Table 1. Demographic and clinical features of the study subjects* ERA patients Control subjects (n ϭ 30) (n ϭ 30) Age at visit, median (IQR) years 13 (11–15) 12 (7–15) Disease duration, median (IQR) years 0.6 (0.1–2.6) – No. (%) male 18 (60) 16 (52) Criteria for ERA diagnosis, no. (%) Enthesitis 30 (100) – Arthritis 29 (97) – Inflammatory back pain 14 (47) – Acute symptomatic uveitis 2 (7) – Onset of arthritis in a male Ն6 years of age† 17 (94) – HLA–B27 positive 9 (30) – Family history of AS, ERA, IBD with associated sacroiliitis, 7 (23) – acute uveitis, or ReA in a first-degree relative No. of joints with active arthritis, median (IQR)‡ 2 (1–2) 0 (0) Erythrocyte sedimentation rate, median (IQR) mm/hour‡ 0 (0–12) – C-reactive protein, median (IQR) mg/dl 0 (0–0.5) – PRQL score, median (IQR) 6.5 (3–10) 0 (0–1) Patient’s/parent’s assessment of pain over the previous week, 4 (2–7) 0 (0–0) by VAS, median (IQR) score C-HAQ score, median (IQR) 0.31 (0.13–0.88) 0 (0–0) BASFI, median (IQR) 1.6 (0.7–4.9) 0 (0–0) BASDAI, median (IQR) 3.8 (2.6–6.4) 0 (0–0) Current medications, no. (%) Daily NSAIDs 19 (63) – DMARDs 7 (23) – Anti-TNF agents Etanercept 8 (27) – Infliximab 2 (7) – Adalimumab 1 (3) – * ERA ϭ enthesitis-related arthritis; IQR ϭ interquartile range; AS ϭ ankylosing spondylitis; IBD ϭ inflammatory bowel disease; ReA ϭ reactive arthritis; PRQL ϭ Pediatric Rheumatology Quality of Life; VAS ϭ visual analog scale; C-HAQ ϭ Childhood Health Assessment Questionnaire; BASFI ϭ Bath Ankylosing Spondylitis Functional Index; BASDAI ϭ Bath Ankylosing Spondylitis Disease Activity Index; NSAIDs ϭ nonsteroidal antiinflammatory drugs; DMARDs ϭ disease-modifying antirheumatic drugs; anti-TNF ϭ anti– tumor necrosis factor. † Results apply only to the 18 male patients.
Load more

Recommended publications
  • Juvenile Spondyloarthropathies: Inflammation in Disguise
    PP.qxd:06/15-2 Ped Perspectives 7/25/08 10:49 AM Page 2 APEDIATRIC Volume 17, Number 2 2008 Juvenile Spondyloarthropathieserspective Inflammation in DisguiseP by Evren Akin, M.D. The spondyloarthropathies are a group of inflammatory conditions that involve the spine (sacroiliitis and spondylitis), joints (asymmetric peripheral Case Study arthropathy) and tendons (enthesopathy). The clinical subsets of spondyloarthropathies constitute a wide spectrum, including: • Ankylosing spondylitis What does spondyloarthropathy • Psoriatic arthritis look like in a child? • Reactive arthritis • Inflammatory bowel disease associated with arthritis A 12-year-old boy is actively involved in sports. • Undifferentiated sacroiliitis When his right toe starts to hurt, overuse injury is Depending on the subtype, extra-articular manifestations might involve the eyes, thought to be the cause. The right toe eventually skin, lungs, gastrointestinal tract and heart. The most commonly accepted swells up, and he is referred to a rheumatologist to classification criteria for spondyloarthropathies are from the European evaluate for possible gout. Over the next few Spondyloarthropathy Study Group (ESSG). See Table 1. weeks, his right knee begins hurting as well. At the rheumatologist’s office, arthritis of the right second The juvenile spondyloarthropathies — which are the focus of this article — toe and the right knee is noted. Family history is might be defined as any spondyloarthropathy subtype that is diagnosed before remarkable for back stiffness in the father, which is age 17. It should be noted, however, that adult and juvenile spondyloar- reported as “due to sports participation.” thropathies exist on a continuum. In other words, many children diagnosed with a type of juvenile spondyloarthropathy will eventually fulfill criteria for Antinuclear antibody (ANA) and rheumatoid factor adult spondyloarthropathy.
    [Show full text]
  • Atraumatic Bilateral Achilles Tendon Rupture: an Association of Systemic
    378 Kotnis, Halstead, Hormbrey Acute compartment syndrome may be a of the body of gastrocnemius has been result of any trauma to the limb. The trauma is reported in athletes.7 8 This, however, is the J Accid Emerg Med: first published as 10.1136/emj.16.5.378 on 1 September 1999. Downloaded from usually a result of an open or closed fracture of first reported case of acute compartment the bones, or a crush injury to the limb. Other syndrome caused by a gastrocnemius muscle causes include haematoma, gun shot or stab rupture in a non-athlete. wounds, animal or insect bites, post-ischaemic swelling, vascular damage, electrical injuries, burns, prolonged tourniquet times, etc. Other Conclusion causes of compartment syndrome are genetic, Soft tissue injuries and muscle tears occur fre- iatrogenic, or acquired coagulopathies, infec- quently in athletes. Most injuries result from tion, nephrotic syndrome or any cause of direct trauma. Indirect trauma resulting in decreased tissue osmolarity and capillary per- muscle tears and ruptures can cause acute meability. compartment syndrome in athletes. It is also Chronic compartment syndrome is most important to keep in mind the possibility of typically an exercise induced condition charac- similar injuries in a non-athlete as well. More terised by a relative inadequacy of musculofas- research is needed to define optimal manage- cial compartment size producing chronic or ment patterns and potential strategies for recurring pain and/or disability. It is seen in injury prevention. athletes, who often have recurring leg pain that Conflict of interest: none. starts after they have been exercising for some Funding: none.
    [Show full text]
  • Juvenile Spondyloarthritis / Enthesitis Related Arthritis (Spa-ERA) Version of 2016
    https://www.printo.it/pediatric-rheumatology/GB/intro Juvenile Spondyloarthritis / Enthesitis Related Arthritis (SpA-ERA) Version of 2016 1. WHAT IS JUVENILE SPONDYLOARTHRITIS/ENTHESITIS- RELATED ARTHRITIS (SpA-ERA) 1.1 What is it? Juvenile SpA-ERA constitutes a group of chronic inflammatory diseases of the joints (arthritis), as well as tendon and ligament attachments to certain bones (enthesitis) and affects predominantly the lower limbs and in some cases the pelvic and spinal joints (sacroiliitis - buttock pain and spondylitis - back pain). Juvenile SpA-ERA is significantly more common in people that have a positive blood test for the genetic factor HLA-B27. HLA-B27 is a protein located on the surface of immune cells. Remarkably, only a fraction of people with HLA-B27 ever develops arthritis. Thus, the presence of HLA-B27 is not enough to explain the development of the disease. To date, the exact role of HLA-B27 in the origin of the disease remains unknown. However, it is known that in very few cases the onset of arthritis is preceded by gastrointestinal or urogenital infection (known as reactive arthritis). Juvenile SpA-ERA is closely related to the spondyloarthritis with onset in adulthood and most researchers believe these diseases share the same origin and characteristics. Most children and adolescents with juvenile spondyloarthritis would be diagnosed as affected by ERA and even psoriatic arthritis. It is important that the names "juvenile spondyloarthritis", "enthesitis-related arthritis" and in some cases "psoriatic arthritis" may be the same from a clinical and therapeutic point of view. 1 / 12 1.2 What diseases are called juvenile SpA-ERA? As mentioned above, juvenile spondyloarthritis is the name for a group of diseases; the clinical features may overlap with each other, including axial and peripheral spondyloarthritis, ankylosing spondylitis, undifferentiated spondyloarthritis, psoriatic arthritis, reactive arthritis and arthritis associated with Crohn’s disease and ulcerative colitis.
    [Show full text]
  • The Correlations Between Dimensions of the Normal Tendon And
    www.nature.com/scientificreports OPEN The correlations between dimensions of the normal tendon and tendinopathy changed Achilles tendon in routine magnetic resonance imaging Pawel Szaro 1,2,3* & Khaldun Ghali Gataa2 This comparative study aimed to investigate how tendinopathy-related lesions change correlations in the dimensions of the Achilles tendon. Our experimental group included 74 patients. The mean age was 52.9 ± 10.4 years. The control group included 81 patients with a mean age was 35.2 ± 13.6 years, p < .001. The most signifcant diference in correlation was the thickness of the tendon and the midportion’s width, which was more signifcant in the tendinopathy (r = .49 vs. r = .01, p < .001). The correlation was positive between width and length of the insertion but negative in normal tendons (r = .21 vs. r = − .23, p < .001). The correlation was between the midportions width in tendinopathy and the tendon’s length but negative in the normal tendon (r = .16 vs. r = − .23, p < .001). The average thickness of the midportion in tendinopathy was 11.2 ± 3.3 mm, and 4.9 ± 0.5 mm in the control group, p < .001. The average width of the midportion and insertion was more extensive in the experimental group, 17.2 ± 3.1 mm vs. 14.7 ± 1.8 mm for the midportion and 31.0 ± 3.9 mm vs. 25.7 ± 3.0 mm for insertion, respectively, p < .001. The tendon’s average length was longer in tendinopathy (83.5 ± 19.3 mm vs. 61.5 ± 14.4 mm, p < .001). The dimensions correlations in normal Achilles tendon and tendinopathic tendon difer signifcantly.
    [Show full text]
  • Heel Enthesopathy of Diffuse Idiopathic Skeletal Hyperostosis
    Images in Rheumatology Heel Enthesopathy of Diffuse Idiopathic Skeletal Hyperostosis Resembling Enthesitis of Spondyloarthritis IGNAZIO OLIVIERI, MD, SALVATORE D’ANGELO, MD, Rheumatology Department of Lucania, San Carlo Hospital, Contrada Macchia Romana, 85100 Potenza, Italy; and Madonna delle Grazie Hospital; FRANCESCO BORRACCIA, Researcher, Radiology Department, San Carlo Hospital; ANGELA PADULA, MD, Senior Researcher, Rheumatology Department of Lucania, San Carlo Hospital, and Madonna delle Grazie Hospital, Matera, Italy. Address correspondence to Dr. Olivieri; E-mail: [email protected]. J Rheumatol 2010;37:192–3; doi.10.3899/jrheum.090514 Diffuse idiopathic skeletal hyperostosis (DISH) and anky- tendons, resembling the typical fusiform soft tissue swelling losing spondylitis (AS) are 2 clearly different disease enti- of Achilles enthesitis of spondyloarthritis5 (Figure 1). ties having in common the involvement of the axial skeleton However, palpation of the region did not reveal any inflam- and the peripheral entheses1,2. Both diseases produce bone matory findings of enthesitis but did reveal bone prolifera- proliferation in the spine and at the extraspinal entheseal tion due to large spurs, a condition confirmed by radio- sites in the later phases of their course. Although the aspects graphs (Figure 2). A sacroiliac joint computed tomography of the bone proliferations of the 2 diseases are dissimilar, (CT) scan showed the normal aspect of joint space and bony confusion of radiographic differential diagnosis between the margins together with the presence of capsular ossifications 2 diseases exists, partly as a consequence of a lack of aware- (Figure 3). ness of their respective characteristic features2,3. It has been pointed out that the differential diagnosis between DISH and REFERENCES longstanding advanced AS is not limited to the radiologic 1.
    [Show full text]
  • Clinical and Imaging Assessment of Peripheral Enthesitis in Ankylosing Spondylitis
    Special RepoRt Clinical and imaging assessment of peripheral enthesitis in ankylosing spondylitis Enthesitis, defined as inflammation of the origin and insertion of ligaments, tendons, aponeuroses, annulus fibrosis and joint capsules, is a hallmark of ankylosing spondylitis. The concept of entheseal organ prone to pathological changes in ankylosing spondylitis and other spondyloarthritis is well recognized. The relevant role of peripheral enthesitis is supported by the evidence that this feature, on clinical examination, has been included in the classification criteria of Amor (heel pain or other well-defined enthesopathic pain), European Spondiloarthropathy Study Group and Assessment in SpondyloArthritis International Society for axial and peripheral spondyloarthritis. Nevertheless, the assessment of enthesitis has been improved by imaging techniques to carefully detect morphological abnormalities and to monitor disease activity. 1 Keywords: ankylosing spondylitis n clinical assessment n enthesitis n MrI Antonio Spadaro* , n spondyloarthritis n ultrasound Fabio Massimo Perrotta1, In primary ankylosing spondylitis (AS) the fre- has proven to be a highly sensitive and nonin- Alessia Carboni1 quency of peripheral enthesitis has been found vasive tool to assess the presence of enthesitis, & Antongiulio Scarno1 to be between 25 and 58% [1], however, the real characterized by hypoechogenicity with loss 1Dipartimento di Medicina Interna e prevalence of this feature depends on the type of tendon fibrillar pattern, tendon thickening, Specialità
    [Show full text]
  • Foot Pain & Psoriatic Arthritis
    WHEATON • ROCKVILLE • CHEVY CHASE • WASHINGTON, DC Foot Pain & Psoriatic Arthritis Daniel El-Bogdadi, MD, FACR Arthritis and Rheumatism Associates, P.C. Do you feel heel pain in the Plantar fasciitis ARTHRITIS morning or after a period of can be caused by inactivity? This might be an a number AND indication of plantar fasciitis that of factors, RHEUMATISM could be part of an underlying including aerobic ASSOCIATES, P.C. psoriatic arthritis condition. dance exercise, running, and Board Certified Rheumatologists Psoriatic arthritis is an inflammatory ballet. arthritis that typically causes pain, Herbert S.B. Baraf MD FACP MACR swelling and stiffness in the Robert L. Rosenberg peripheral joints or spine. However, MD FACR CCD if you have psoriatic arthritis, you Evan L. Siegel may notice that not only are the MD FACR joints and spine involved, but Emma DiIorio symptoms may also occur in the soft MD FACR tissue such as tendons or ligaments. David G. Borenstein MD MACP MACR This usually happens in a place Alan K. Matsumoto where tendons and ligaments attach There are several treatment options MD FACP FACR to bone, known as the enthesis. for plantar fasciitis: David P. Wolfe When this attachment gets inflamed MD FACR it is called enthesitis. • The first immediate intervention is Paul J. DeMarco MD FACP FACR to decrease or stop any Shari B. Diamond One of the more common areas to repetitive activities, such as MD FACP FACR get enthesitis is in the Achilles running or dancing, which may Ashley D. Beall tendon. Another common area for aggravate the condition. MD FACR inflammation is in thick band of (over) Angus B.
    [Show full text]
  • Spondylitis Diseases Psoriasis
    CD8 T-cell Spondylitis leads to the development of syndesmophytes and ankylosis Spondyloarthritis Diseases Cognitive ASp Recognition TCR •A group of autoimmune Unknown Self Antigenic Peptide diseases that in common Presented by class I MHC appear mediated by activation Target Cell of autoreactive CD8 T cells •Physical stress, inflammation and infection with specific microorganisms trigger the immune response •Primarily affect joints, skin, eyes and mucous membranes T cells invade the junction Annulus fibers are eroded, Progressive of annulus fibrosis and then replaced by fibrocartilage cartilaginous and vertebral body forming that ossifies to form a periosteal ossification •Autoantibodies such as ANA or RF are absent granulation tissue syndesmophyte. Subperiosteal forms a “bamboo spine”, (activated macrophages, T new bone formation ensues osteoporosis develops cells and fibroblasts) Spondylitis Diseases Sacroiliitis DAnkylosing spondylitis (ASp) DReiter’s syndrome (RS) / reactive arthritis (ReA) DPsoriatic arthritis (PsA) Undifferentiated spondyloarthritis (USpA) Enteropathic arthritis (ulcerative colitis, regional enteritis) The subchondral regions of the The cartilage on the iliac side is eroded synarthrotic SI joints are first, causing bone plate blurring, joint invaded by T cells leading to space “widening” and reactive sclerosis. Psoriasis the formulation of granulation Ultimately the resultant fibrous ankylosis tissue is replaced by bone, obliterating the SI joint Spondyloarthritis Diseases-features common to all Enthesitis (enthesopathy) the central inflammatory unit of spondyloarthritis Entheses are the specialized fibrocartilagenous region of bone 1. Clinical:- Affect joints, skin, eyes and mucous membranes in where ligaments, tendons, fascia or joint capsules insert varying proportions with characteristic joint involvement: Spondylitis (inflammation of vertebral discs), sacroiliitis (sacroiliac joints) and enthesitis (tendon insertions).
    [Show full text]
  • Assessment of Enthesitis in Psoriatic Arthritis
    Editorial Assessment of Enthesitis in Psoriatic Arthritis There has been an increasing focus on enthesitis in psoriatic They found a higher prevalence of entheseal tenderness in arthritis (PsA). Enthesitis, defined as inflammation at the FM but more enthesitis using US in PsA and psoriasis. insertion of tendons and ligaments into bone, has been Overall, B-mode US changes were common, particularly proposed as the primary pathological lesion of PsA, and this around the knee, with power Doppler abnormalities being hypothesis has received support from animal models that less frequent across the 3 groups of patients. Therefore, is have focused on the enthesis in spondyloarthropathy-like my advice to clinicians to rely only on the Achilles tendon 1,2 disease . Enthesitis is part of the entry “stem” for the justified by this report? No, because clinically an equal ClASsification for Psoriatic ARthritis criteria (CASPAR) proportion of patients with PsA and FM had tenderness at criteria, although it must be emphasized that only a few cases the Achilles entheseal insertion; and yes, because power 3 of PsA had isolated entheseal involvement in that study . Doppler abnormalities at the Achilles (at cortical bone Yet the clinical evaluation of enthesitis remains a vexing insertion, pre-insertional area, and body of tendon) were problem. When delivering educational symposia, I am often found much more frequently in PsA. asked by dermatology and rheumatology colleagues how to What are the strengths and weaknesses of this study? The assess and treat enthesitis. To the dermatologists I say look authors correctly state that because none of the patients with only at the Achilles insertion because (1) it is readily identi- PsA were taking disease-modifying drugs or steroids, it is fiable, (2) it is the major enthesis of the body, and (3) likely that they represent a milder spectrum of disease, and involvement is quite specific for spondyloarthropathy (SpA).
    [Show full text]
  • Therapies for Psoriatic Enthesopathy. a Systematic Review CHRISTOPHER T
    Therapies for Psoriatic Enthesopathy. A Systematic Review CHRISTOPHER T. RITCHLIN ABSTRACT. Enthesitis is defined as inflammation at sites of tendon, ligament, joint capsule, or fascia insertion sites to bone, and is a hallmark feature of psoriatic arthritis. Several outcome measures have been developed to assess enthesitis, but none have been validated in psoriatic arthritis. In this evidence-based review, we assess the limited data on treatments for enthesitis and make recommendations for further studies in psoriatic enthesitis. (First Release May 15 2006; J Rheumatol 2006;33:1435–8) Key Indexing Terms: ENTHESITIS ENTHESOPATHY PSORIATIC ARTHRITIS ANKYLOSING SPONDYLITIS SPONDYLOARTHROPATHY TREATMENT INTRODUCTION Several outcome measures have been developed to assess Enthesitis (or inflammation at tendon, ligament, joint capsule enthesitis (Table 1). The Mander Enthesitis Index (MEI) sites, or fascia insertion sites to bone), although rare in grades severity of tenderness (0–4) at 66 sites7. This index is rheumatoid arthritis (RA), is a hallmark feature of psoriatic generally thought to be too cumbersome for routine use2. The arthritis (PsA)1. The most common clinical syndromes in PsA modified MEI is an assessment of tenderness (0–4) at 17 axial include plantar fasciitis, epicondylitis, and Achilles ten- and peripheral sites8. donitis2. The Maastricht Ankylosing Spondylitis (AS) Enthesitis Biopsies of bone underlying entheses revealed edema and Score (MASES), like the modified MEI, was designed as a 3 predominance of CD8+ T lymphocytes , while monocytes less cumbersome instrument than the MEI. Tenderness and/or were the major cell type isolated from the tendon or liga- swelling are measured at 13 sites without grading pain inten- 4 ment .
    [Show full text]
  • Achilles Tendon Disorders
    BMJ 2013;346:f1262 doi: 10.1136/bmj.f1262 (Published 12 March 2013) Page 1 of 7 Clinical Review CLINICAL REVIEW Achilles tendon disorders 1 Chad A Asplund director of military sports medicine , Thomas M Best professor and pomerene chair 2 1Department of Family Medicine, Eisenhower Army Medical Center, Fort Gordon, GA 30905, USA; 2Division of Sports Medicine, Department of Family Medicine, Ohio State University, Columbus, OH 43221, USA Disorders of the Achilles tendon are common in active fasciculi from cutaneous nerves, especially the sural nerve.4 The people—competitive and recreational athletes alike—but they paratenon is a highly vascular structure, and along with the can occur in less active people. As the largest tendon in the surrounding muscle complex supplies blood to the Achilles body, the Achilles experiences repetitive strain from running, tendon.5 jumping, and sudden acceleration or deceleration, so is Cadaveric studies suggest that there is an area 2-6 cm above the susceptible to rupture and degenerative changes. This review calcaneal insertion with a relatively poor blood supply, and that aims to describe the anatomy and diagnostic evaluation of the this predisposes the region to chronic inflammation and Achilles tendon, and to discuss the best available evidence to rupture.5 6 However, in vivo studies have failed to demonstrate help in the management of Achilles tendon disorders. this “watershed” area. Direct measurement of forces reveal What are Achilles tendon disorders? loading in the Achilles tendon to be as high as 9 kilonewtons 1 (up to 12.5 times body weight) during running, which probably The Achilles tendon is the strongest tendon in the body, serving contributes to its high rate of injury.7 both the gastrocnemius and soleus muscles.
    [Show full text]
  • Postural Stability and the Relationship with Enthesitis in Ankylosing Spondylitis: a Cross-Sectional Study
    Available online at www.medicinescience.org Medicine Science ORIGINAL RESEARCH International Medical Journal Medicine Science 2019;8(3):613-9 Postural stability and the relationship with enthesitis in ankylosing spondylitis: A cross-sectional study Sena Tolu1, Aylin Rezvani1, Nurbanu Hindioglu1, Ibrahim Ethem Kirez1, Merve Calkin Korkmaz2 1Medipol University Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Istanbul, Turkey 2Alsancak Nevvar Salih Isgoren State Hospital, Department of Physical Medicine and Rehabilitation, Izmir, Turkey Received 19 January 2019; Accepted 10 March 2019 Available online 04.04.2019 with doi:10.5455/medscience.2019.08.9030 Copyright © 2019 by authors and Medicine Science Publishing Inc. Abstract This study aims to investigate the static and dynamic postural stability in ankylosing spondylitis (AS), and to evaluate their relationships with clinical parameters, postural measurements, and enthesitis. Sixty-four patients with AS (37 males, 27 females; mean age 41.06±8.89 years) and 42 healthy individuals (23 males, 19 females; mean age 38.45±8.46 years) were involved in the study. The static and dynamic postural stability of all participants were assessed using the Biodex Balance System. Patients’ posture was evaluated using chest expansion, tragus-wall distance, and the modified Schober’s test. The disease activity (Bath Ankylosing Spondylitis Disease Activity Index: BASDAI), functional status (Bath Ankylosing Spondylitis Functional Index: BASFI), spinal mobility (Bath Ankylosing Spondylitis Metrology Index: BASMI), enthesitis score (Maastricht Ankylosing Spondylitis Enthesitis Score: MASES), pain (Visual Analogue Scale: VAS), quality of life (Ankylosing Spondylitis Quality of Life: ASQoL) and depression (Beck Depression Inventory: BDI) of all patients were evaluated. Similar demographic data were found in both groups.
    [Show full text]