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Clinical and ultrasonographic enthesopathy in inflammatory rheumatic diseases

Is MASEI or only calcaneal enthesitis sufficient?

Klinische und sonographische Enthesiopathie bei entzündlichen rheumatischen Erkrankungen

MASEI oder Sonographie auf Enthesitis im Kalkaneusbereich?

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Abstract

Aim

We aimed at investigating the ultrasonographic (US) and clinical prevalence of enthesopathy in patients with rheumatoid arthritis (RA), and axial spondyloarthropathy (SpA), as well as the correlation between this condition and disease activity, along with the quality of life.

Methods

Included in the study were 30 axial SpA, 21 patients with RA, and 25 healthy cases. Bath Anklylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Quality of Life (ASQoL), Disease activity index  28 (DAS28), and Health Assessment Questionnaire (HAQ) were used for clinical evaluation, and enthesal pain was evaluated by VAS, whereas enthesitis US evaluation was performed by using the MAdrid Sonographic Enthesitis Index (MASEI). A total of 152 knees, ankles, and elbow regions of all patients and controls were examined by US.

Results

Total scores of physical examination of enthesitis were 1.97 ± 2.68 in axial SpA, 2.43 ± 1.80 in RA, and 0.23 ± 0.12 in the control groups. No statistically significant difference was identified in the enthesitis examination between axial SpA and RA groups (p = 0.123). According to the MASEI, no significant difference was observed in quadriceps tendon enthesitis or in distal patellar ligament enthesitis between axial SpA and RA groups (MASEI 3, 4, 5: p = 0.993, p = 0.124, p = 0.652). Aside from those points, axial SpA patients had statistically higher enthesitis scores at all MASEI enthesitis points (p < 0.05). In the axial SpA group, a significant and positive correlation was identified between BASDAI scores and total scores of enthesitis physical examination and MASEI total scores (r = 0.739, p = 0.0001, r = 0.516, p = 0.002). A moderately significant correlation was identified between ASQoL total scores and MASEI total scores (r = 0.466, p = 0.006), but not between the HAQ total scores and MASEI total scores (r = 0.213, p = 0.065).

Conclusions

Compared to RA, US and clinical examination of enthesitis in patients with axial SpA should focus on the calcaneal enthesitis region. In axial SpA, ultrasonographic enthesitis is associated with impaired quality of life.

Zusammenfassung

Zielsetzung

Ermittelt werden sollten die sonographische (US) wie die klinische Prävalenz der Enthesopathie bei Patienten mit rheumatoider Arthritis (RA) und Patienten mit axialer Spondyloarthropathie (SpA) sowie die Korrelationen mit der Krankheitsaktivität und der Lebensqualität.

Methoden

In die Studie aufgenommen waren 30 Patienten mit axialer SpA, 21 mit RA und 25 gesunde Kontrollpersonen. Zur klinischen Evaluation dienten „Bath Anklylosing Spondylitis Disease Activity Index“ (BASDAI), „Ankylosing Spondylitis Quality of Life“ (ASQoL), „Disease activity index 28“ (DAS28) und „Health Assessment Questionnaire“ (HAQ), Schmerzen im Bereich von Sehnen wurde mittels einer VAS (visuelle Analogskala) dokumentiert, die sonographische Evaluation dagegen erfolgte unter Verwendung des MASEI (MAdrid Sonographic Enthesitis Index). Insgesamt 152 Knie‑, Sprunggelenk- und Ellenbogenregionen aller Patienten und Kontrollen wurden sonographiert.

Ergebnisse

Die Summenscores der körperlichen Untersuchung betrugen bei axialer SpA 1,97 ± 2,68 in axial SpA, bei RA 2,43 ± 1,80 und bei den Kontrollpersonen 0,23 ± 0,12. Kein statistisch signifikanter Unterschied ließ sich bei der Untersuchung auf Enthesitis zwischen den beiden Patientengruppen ausmachen (p = 0,123). Gemäß dem MASEI wurde zwischen diesen Gruppen ebenfalls kein signifikanter Unterschied beobachtet hinsichtlich einer Enthesitis der Quadrizeps- oder der distalen Patellarsehne (MASEI 3, 4, 5: p = 0,993, p = 0,124, p = 0,652). Neben diesen Aspekten hatten die SpA-Patienten statistisch signifikant höhere Scores an allen MASEI-Enthesitispunkten (p < 0,05). In der Patientengruppe mit axialer SpA zeigte sich eine signifikante, positive Korrelation zwischen BASDAI-Scores und Summenscores der körperlichen Untersuchung auf Enthesitiden und den MASEI-Summenscores (r = 0,739, p = 0,0001, r = 0,516, p = 0,002). Eine mäßig signifikante Korrelation bestand zwischen den ASQoL- und den MASEI-Summenscores (r = 0,466, p = 0,006), keine statistisch signifikante Korrelation dagegen zwischen den HAQ- und den MASEI-Summenscores (r = 0,213, p = 0,065).

Schlussfolgerungen

Anders als bei RA sollten bei axialer SpA die sonographische und die klinische Untersuchung auf Enthesitis auf mögliche entsprechende Befunde in der kalkanearen Region fokussiert sein. Bei Patienten mit axialer SpA ist eine sonographisch dargestellte Enthesitis mit einer beeinträchtigten Lebensqualität verbunden.

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Authors and Affiliations

  1. Faculty of Medicine, Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Sakarya University, 54100, Sakarya, Turkey

    Ekrem Süleyman M.D.,  Kemal Nas, Halil Harman M.D. & Nedim Kaban M.D.

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  1. Ekrem Süleyman M.D.
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  2. Kemal Nas
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  3. Halil Harman M.D.
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Correspondence to Halil Harman M.D..

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E. Süleyman, K. Nas, H. Harman and N. Kaban declare that they have no competing interests.

The study has been performed in accordance with the Declaration of Helsinki and was approved by the independent ethics committee of Sakarya University of Faculty of Medicine. All patients signed informed consent to participate in the study for the collection and publication of the data.

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U. Müller-Ladner, Bad Nauheim

U. Lange, Bad Nauheim

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Süleyman, E., Nas, K., Harman, H. et al. Clinical and ultrasonographic enthesopathy in inflammatory rheumatic diseases. Z Rheumatol 77, 719–726 (2018). https://doi.org/10.1007/s00393-017-0405-2

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  • DOI: https://doi.org/10.1007/s00393-017-0405-2

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