Enthesitis and its relationship with disease activity, functional status, and quality of life in psoriatic arthritis: a multi-center study

  • Ismihan SunarEmail author
  • Sebnem Ataman
  • Kemal Nas
  • Erkan Kilic
  • Betul Sargin
  • Sevtap Acer Kasman
  • Hakan Alkan
  • Nilay Sahin
  • Gizem Cengiz
  • Nihan Cuzdan
  • Ilknur Albayrak Gezer
  • Dilek Keskin
  • Cevriye Mülkoğlu
  • Hatice Resorlu
  • Ajda Bal
  • Mehmet Tuncay Duruöz
  • Okan Küçükakkaş
  • Ozan Volkan Yurdakul
  • Meltem Alkan Melikoglu
  • Yıldıray Aydın
  • F. Figen Ayhan
  • Hatice Bodur
  • Mustafa Calis
  • Erhan Capkın
  • Gul Devrimsel
  • Kevser Gok
  • Sami Hizmetli
  • Ayhan Kamanlı
  • Yaşar Keskin
  • Hilal Kocabas
  • Oznur Kutluk
  • Nesrin Şen
  • Omer Faruk Şendur
  • Ibrahim Tekeoğlu
  • Sena Tolu
  • Murat Toprak
  • Tiraje Tuncer
Observational Research


Psoriatic arthritis (PsA) is an inflammatory arthritis with distinct phenotypic subtypes. Enthesitis is assigned as a hallmark of the disease, given its significant relations to disease activity and quality of life. Our objective is to evaluate the prevalence of enthesitis and its association with some clinical parameters, particularly quality of life, using data from a national registry. Patients with PsA meeting ClASsification criteria for Psoriatic Arthritis (CASPAR) were enrolled by means of a multi-centre Turkish League Against Rheumatism (TLAR) Network Project. The following information was recorded in web-based case report forms: demographic, clinical and radiographic data; physical examination findings, including tender and swollen joint counts (TJC and SJC); nail and skin involvement; Disease Activity Score-28 for Rheumatoid Arthritis with Erythrocyte Sedimentation Rate (DAS 28-ESR); Bath Ankylosing Spondylitis Disease Activity Index (BASDAI); Maastricht Ankylosing Spondylitis Enthesitis Score (MASES); Psoriasis Area Severity Index (PASI); Bath Ankylosing Spondylitis Radiology Index for the spine (BASRI-s); Health Assessment Questionnaire (HAQ); Bath Ankylosing Spondylitis Functional Index (BASFI); Health Assessment Questionnaire for the spondyloarthropathies (HAQ-s); Psoriatic arthritis quality of Life scale (PsAQoL); Short Form 36 (SF-36); Hospital Anxiety Depression Scale (HADS); Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F); and Fibromyalgia Rapid Screening Tool (FiRST) scores. The patients were divided into two groups, namely with and without enthesitis, based on the triple Likert-type physician-reported statement of ‘active enthesitis’, ‘history of enthesitis’ or ‘none’ in the case report forms. Patients with active enthesitis were compared to others in terms of these clinical parameters. A total of 1130 patients were enrolled in this observational study. Of these patients, 251 (22.2%) had active enthesitis according to the clinical assessment. TJC, HAQ-s, BASDAI, FiRST and PsAQoL were significantly higher whereas the SF-36 scores were lower in patients with enthesitis (p < 0.05). Chronic back pain, dactylitis, and tenosynovitis were more frequent in the enthesopathy group (59.4%/39%, 13.1%/6.5% and 24.7%/3.4%, respectively). Significant positive correlations between the MASES score and the TJC, HAQ, DAS 28-ESR, BASDAI, FiRST and PsAQoL scores, and a negative correlation with the SF-36 score were found. When linear regression analysis was performed, the SF-36 MCS and PCS scores decreased by − 9.740 and − 11.795 units, and the FiRST scores increased by 1.223 units in patients with enthesitis. Enthesitis is an important involvement of PsA with significant relations to quality of life determined with PsAQoL and SF-36 scores. Our study found higher frequency of dactylitis and chronic back pain, and worse quality of life determined with SF-36 and PsAQoL scores in patients with enthesitis.


Enthesitis Psoriatic arthritis Enthesopathy Registry Disease activity Quality of life 



We acknowledge dr Nazmiye Kurşun for statistical consulting and Scribendi Editing Services for external editing.

Author contributions

All authors have substantial contributions to the conception or design of the work, drafting or revising it critically for important intellectual content, have approved the final version to be published, and in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All co-authors are fully responsible for all aspects of the study and the final manuscript in line with the IJME 4 criteria.

Compliance with ethical standards

Conflict of interest

Authors declare no conflicts of interest or financial support.

Ethical approval

Ethics committee approval was obtained from the Sakarya University Ethics Committee on 25.01.2018 and with the number of 42 and conducted in accordance with the Helsinki Declaration.


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© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Rheumatology, Department of Physical Medicine and RehabilitationAnkara University School of MedicineAnkaraTurkey
  2. 2.Division of Rheumatology and Immunology, Department of Physical Medicine and RehabilitationSakarya University School of MedicineSakaryaTurkey
  3. 3.Rheumatology ClinicAfyonkarahisar State HospitalAfyonkarahisarTurkey
  4. 4.Division of Rheumatology, Department of Physical Medicine and RehabilitationAdnan Menderes University School of MedicineAydınTurkey
  5. 5.Division of Rheumatology, Department of Physical Medicine and RehabilitationMarmara University School of MedicineIstanbulTurkey
  6. 6.Department of Physical Medicine and RehabilitationPamukkale University School of MedicineDenizliTurkey
  7. 7.Department of Physical Medicine and RehabilitationBalıkesir University School of MedicineBalıkesirTurkey
  8. 8.Division of Rheumatology, Department of Physical Medicine and RehabilitationErciyes University School of MedicineKayseriTurkey
  9. 9.Rheumatology ClinicVan Training and Research HospitalVanTurkey
  10. 10.Rheumatology ClinicŞanlıurfa Training and Research HospitalŞanlıurfaTurkey
  11. 11.Department of Physical Medicine and RehabilitationSelçuk University School of MedicineKonyaTurkey
  12. 12.Department of Physical Medicine and RehabilitationKırıkkale University School of MedicineKirikkaleTurkey
  13. 13.Department of Physical Medicine and RehabilitationAnkara Training and Research HospitalAnkaraTurkey
  14. 14.Department of Physical Medicine and RehabilitationÇanakkale Onsekiz Mart University School of MedicineÇanakkaleTurkey
  15. 15.Department of Physical Medicine and RehabilitationDışkapı Yıldırım Beyazıt Training and Research HospitalAnkaraTurkey
  16. 16.Department of Physical Medicine and RehabilitationBezmiâlem Foundation UniversityIstanbulTurkey
  17. 17.Division of Rheumatology, Department of Physical Medicine and RehabilitationAtatürk University School of MedicineErzurumTurkey
  18. 18.Department of Physical Theraphy and RehabilitationUşak University, High School of Health SciencesUşakTurkey
  19. 19.Department of Physical Medicine and RehabilitationYıldırım Beyazıt University School of MedicineAnkaraTurkey
  20. 20.Department of Physical Medicine and RehabilitationKaradeniz Technical University School of MedicineTrabzonTurkey
  21. 21.Department of Physical Medicine and RehabilitationRecep Tayyip Erdoğan University School of MedicineRizeTurkey
  22. 22.Rheumatology ClinicAnkara Numune Training and Research HospitalAnkaraTurkey
  23. 23.Division of Rheumatology, Department of Physical Medicine and RehabilitationCumhuriyet University School of MedicineSivasTurkey
  24. 24.Division of Rheumatology, Department of Physical Medicine and RehabilitationNecmettin Erbakan University Meram School of MedicineKonyaTurkey
  25. 25.Division of Rheumatology, Department of Physical Medicine and RehabilitationAkdeniz University School of MedicineAntalyaTurkey
  26. 26.Rheumatology ClinicKartal Dr. Lutfi Kirdar Training and Research HospitalIstanbulTurkey
  27. 27.Department of Physical Medicine and RehabilitationAdnan Menderes University School of MedicineAydınTurkey
  28. 28.Department of Physical Medicine and RehabilitationYuzuncu Yıl University School of MedicineVanTurkey
  29. 29.Department of Physical Medicine and RehabilitationMedipol University School of MedicineIstanbulTurkey

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