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Assessment of enthesitis in ankylosing spondylitis by power Doppler ultrasonography

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To evaluate the relationship between power Doppler ultrasonography (PDUS) assessment and clinical variables including enthesitis index, pain threshold and disease activity parameters, and to document grey-scale US findings of the 13 entheses examined.

Design and patients

A total of 390 entheses were examined in thirty patients with AS, and clinical variables of the Maastricht Ankylosing Spondylitis Enthesitis Index (MASES), anthropometric measurements, disease activity and functional parameters were documented. A total MASES score by palpation (t-PS) and algometric pressure pain threshold (t-PPT) was obtained. Grey scale and PDUS examination of 13 entheses were performed. Grey-scale changes such as altered tendon echogenity, calcification, cortical reactive changes and bursitis were noted, and flow on PDUS was graded semi-quantitatively.


Cumulative power Doppler (t-PDS) score significantly correlated with t-PS and t-PPT. Ultimate correlations were found between power Doppler scores and pain, disease activity and disability parameters. Changes in grey scale combined with PDUS were more prevalent in lower-extremity entheses. The intraobserver agreement of flow signal grading was excellent (kappa=0.82). Clinical and sonographic results were concordant for three regions, but were discordant for four regions where tenderness was accepted as the sole clinical manifestation of enthesis.


Pain or tenderness is associated with increased vascularity of entheses. Power Doppler US examination of the entheses may be useful and complementary to the clinical evaluation, and further research is needed to assess its role in diagnosis and follow-up of disease course.

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  1. McGonagle D, Khan MA, Marzo-Ortega H, O’Connor P, Gibbon W, Emery P Enthesitis in spondyloarthropathy. Curr Opin Rheumatol 1999;11:244–250

    Article  PubMed  CAS  Google Scholar 

  2. Khan MA Enthesitis: a broader definition. Ann Rheum Dis 2000;59:998

    Google Scholar 

  3. Francois RJ, Braun J, Khan MA Entheses and enthesitis : a histopathologic review and relevance to spondyloarthritides. Curr Opin Rheumatol 2001;13:255–264

    Article  PubMed  CAS  Google Scholar 

  4. Mander M, Simpson JM, McLellan A, Walker D, Goodacre JA, Dick CW Studies on an enthesis index as a method of clinical assessment in ankylosing spondylitis. Ann Rheum Dis 1987;46:197–202

    Article  PubMed  CAS  Google Scholar 

  5. Heuft-Dorenbosch L, Spoorenberg A, van Tubergen A, Landewe R, van der Tempel H, Mielants H, Daugados M, van der Heijde D Assessment of enthesitis in ankylosing spondylitis. Ann Rheum Dis 2003;62:127–132

    Article  PubMed  CAS  Google Scholar 

  6. McGonagle D, Gibbon W, O’Connor P, Green M, Pease C, Emery P Characteristic magnetic resonance imaging entheseal changes of knee synovitis in spondylarthropathy. Arthritis Rheum 1998;41:694–700

    Article  PubMed  CAS  Google Scholar 

  7. Balint PV, Kane D, Wilson H, McInnes IB, Sturrock RD Ultrasonography of entheseal insertions in lower limp in spondylarthropathy. Ann Rheum Dis 2002;61:905–910

    Article  PubMed  CAS  Google Scholar 

  8. D’Agostino MA, Said-Nahal R, Hacquard-Bounder C, Brasseur JL, Daugados M, Breban M Assessment of peripheral enthesitis in spondyloarthropathies by ultrasonography combined with power Doppler. A cross-sectional study. Arthritis Rheum 2003;48:523–533

    Article  PubMed  Google Scholar 

  9. Grassi W, Cervini C Ultrasonography in rheumatology: an evolving technique. Ann Rheum Dis 1998;57:268–271

    Article  PubMed  CAS  Google Scholar 

  10. Balint P, Sturrock RD Musculoskeletal ultrasound imaging: a new diagnostic tool for the rheumatologist? Br J Rheumatol 1997;36:1141–1142

    Article  PubMed  CAS  Google Scholar 

  11. Grassi W, Flippucci E, Busilacchi P Musculoskeletal ultrasound. Best Pract Res Clin Rheumatol 2004;18:813–826

    Article  PubMed  Google Scholar 

  12. Newman JS, Adler RS, Bude RO, Rubin JM Detection of soft tissue hyperemia: value of power Doppler sonography. AJR Am J Roentgenol 1994;163:385–389

    PubMed  CAS  Google Scholar 

  13. Szkudlarek M, Court-Payen M, Strandberg C, Klarlund M, Klausen T, Ostergaard M Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis. A comparison with dynamic magnetic resonance imaging. Arthritis Rheum 2001;44:2018–2023

    Article  PubMed  CAS  Google Scholar 

  14. Ozgocmen S, Kiris A, Kocakoc E, Ardicoglu O, Kamanli A Evaluation of metacarpophalangeal joint synovitis in rheumatoid arthritis by power Doppler technique: relationship between synovial vascularization and periarticular bone mineral density. Joint Bone Spine 2004;71:384–388

    Article  PubMed  Google Scholar 

  15. Schmidt WA Doppler sonography in rheumatology. Best Pract Res Clin Rheumatol 2004;18:827–846

    Article  PubMed  Google Scholar 

  16. Van der Linden S, Valkenburg HA, Cats A Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 1984;27:361–368

    Article  PubMed  Google Scholar 

  17. Garett SL, Jenkinson TR, Whitelock HC, Kennedy LG, Gaisford P, Calin A A new approach to defining disease status in ankylosing spondylitis: The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). J Rheumatol 1994;21:2286–2291

    PubMed  Google Scholar 

  18. Daltroy LH, Larson MG, Roberts WN, Liang MH A modification of the health assessment questionnaire for spondyloarthropathies. J Rheumatol 1990;17:946–950

    PubMed  CAS  Google Scholar 

  19. Dougados M, GueguenA, Nakache JP, Nguyen M, Mery C, Amor B Evaluation of a functional index and an articular index in ankylosing spondylitis. J Rheumatol 1988;15:302–307

    PubMed  CAS  Google Scholar 

  20. Calin A, Garrett S, Whitelock H et al A new approach to defining functionalability in ankylosing spondylitis: The developmentof the Bath Ankylosing Spondylitis Functional Index. J Rheumatol 1994;21:2281–2285

    PubMed  CAS  Google Scholar 

  21. D’Agostino MA, Breban M, Said-Nahal R, Daugados M Refractory inflammatory heel pain in spondylarthropathy: a significant response to infliximab documented by ultrasound. Arthritis Rheum 2002;46:840–841

    Article  PubMed  Google Scholar 

  22. Ozgocmen S, Kiris A, Ardicoglu O, Kocakoc E, Kaya A Glucocorticoid iontophoresis for Achilles tendon enthesitis in ankylosing spondylitis: significant response documented by power Doppler ultrasound. Rheumatol Int 2005;25:158–160

    Article  PubMed  Google Scholar 

  23. Gibbon W, Long G Ultrasound of the plantar aponeurosis (fascia). Skelet Radiol 1999;28:21–26

    Article  CAS  Google Scholar 

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Correspondence to Adem Kiris.

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Kiris, A., Kaya, A., Ozgocmen, S. et al. Assessment of enthesitis in ankylosing spondylitis by power Doppler ultrasonography. Skeletal Radiol 35, 522–528 (2006).

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