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Psoriatic Arthritis
Published in Jason Liebowitz, Philip Seo, David Hellmann, Michael Zeide, Clinical Innovation in Rheumatology, 2023
Elena Ciofoaia, Ana-Maria Orbai, Jason Liebowitz
Enthesitis is defined as inflammation at the site of tendon and ligament insertion into bone. It is a feature of all the spondyloarthropathies and may be a presenting feature in PsA. Enthesitis can be seen in up to 50% of patients with PsA and is hypothesized to be the site of disease initiation (Dubash et al., 2020). The clinical examination of the entheses records entheseal point tenderness and may be overestimating entheseal tenderness in patients with concomitant fibromyalgia or pain sensitization. Agreement between ultrasound-diagnosed enthesitis and clinical enthesitis is very low (Yamada et al., 2021; Michelsen et al., 2017). Interrater reliability of clinical enthesitis indices was low even when standardized examination techniques were used; thus, determining the true prevalence of enthesitis in PsA is challenging (Ogdie, 2015). The most common entheseal sites involved are the Achilles tendon and plantar fascia insertions. Other sites of involvement include the insertions of the quadriceps and patellar tendons, the iliac crest, the rotator cuff, and the epicondyles at the elbow. There is overlap between the anatomical enthesitis lesion and dactylitis such that enthesitis is a component of dactylitis. Indeed, ultrasound-proven enthesitis has also been associated with disease severity and radiographic progression (Eder & Aydin, 2018).
The locomotor system
Published in C. Simon Herrington, Muir's Textbook of Pathology, 2020
Ankylosing spondylitis is characterized by inflammation at the sites of insertion of ligaments into bone, the joint capsule and fibres of the annulus fibrosus of the intervertebral discs. The site of ligamentous insertion is the enthesis, and the resultant disease is known as enthesopathy. Inflammation is followed by fibrosis and ossification, particularly around intervertebral discs, with the formation of bridging spurs of bone (syndesmophytes). The synovitis histologically resembles that seen in rheumatoid arthritis. Bony ankylosis is more common than in rheumatoid arthritis, and may affect large joints, particularly the hips.
Clinical Spectrum of Spondyloarthritis
Published in Siba P. Raychaudhuri, Smriti K. Raychaudhuri, Debasis Bagchi, Psoriasis and Psoriatic Arthritis, 2017
Entheses are attachment sites of tendons and ligaments to bone. Enthesitis is commonly seen in SpA, and it has been argued that enthesitis (in contrast to the synovitis in rheumatoid arthritis) is the pathological substrate underlying joint inflammation in SpA [29]. Enthesitis manifests as pain and tenderness ± swelling on physical examination. The Achilles tendon and plantar fascia insertions at the calcaneus and the attachment sites of the quadriceps and patellar tendons at the patella and tibia are frequently affected. However, entheses are ubiquitous and enthesitis anywhere may cause local symptoms. In fact, inflammation at vertebral edges may be considered to represent enthesitis.
Effects of TNF-α inhibition on pre-clinical enthesitis: observational study on 49 psoriatic patients
Published in Journal of Dermatological Treatment, 2022
Alessandra Narcisi, Mario Valenti, Clara De Simone, Maria Esposito, Antonio Richetta, Miriam Teoli, Giuseppe Argento, Antonio Costanzo
PsA is a seronegative and inflammatory spondilo-arthropathy that affects up to 30% of psoriatic patients [1]. In two-thirds of patients with PsA, skin manifestations precede articular involvement. [2]. Actually, the inflammation of tendons, ligaments or joint capsule insertions (enthesitis) is widely considered as a common characteristic of the different subtypes of PsA [5]. Furthermore, enthesitis has been suggested as the primum movens of the inflammatory process that leads to synovitic arthritis. In this context, imaging plays a major role in order to detect PsA at early stages and to assess the disease activity [11]. In particular, US permits to show preclinical abnormalities of tendons and ligaments that are typical of psoriatic enthesitis and that could predict a progression to an advanced form of PsA [8]. The correlation between disease severity and enthesitis development is still debated. Aydin et al. found higher disease activity to be among risk factors for developing enthesitis while Bandinelli et al. suggest that occult entheseal involvement is not related to the clinical subtype and the severity of the disease [12,13]. US has the potential of detecting early enthesitis permetting to prevent permanent damages and contrasting the natural degenerative course of the disease [14].
Role of the IL-23 pathway in the pathogenesis and treatment of enthesitis in psoriatic arthritis
Published in Expert Opinion on Biological Therapy, 2020
Maurizio Rossini, Oscar Massimiliano Epis, Ilaria Tinazzi, Rosa Daniela Grembiale, Annamaria Iagnocco
Instrumental evaluation of entheses provides more specificity in detecting inflammation and in identifying their early involvement. Available imaging techniques for the diagnosis and assessment of enthesitis include conventional radiography, MRI, and ultrasound imaging [32]. Unlike conventional radiography, whose use is limited by its inability to visualize inflammation or soft tissue changes [32], MRI and ultrasound imaging can detect both inflammatory and bone changes in enthesitis at early and late stages [33]. Ultrasound imaging remains the preferred technique for enthesitis detection and monitoring in clinical practice, as well as in research [12,34,35]. It enables accurate assessment of entheses and monitoring of the various changes associated with enthesitis. In 2018, Kaeley and colleagues reviewed studies demonstrating the usefulness of ultrasound imaging to assess enthesitis in PsA [1]. They concluded that, in general, there is poor correlation between clinical and ultrasound assessment of enthesitis, with the higher sensitivity of ultrasound, particularly color Doppler or power Doppler, able to detect pathological blood flow in synovial tissue, a measure of enthesitis activity in the joint. One study in patients with new-onset PsA found that clinical assessment overestimated enthesitis activity in 13% of entheses studied [36]. Ultrasound may also improve the assessment for certain sites by the reducing the false positives and negatives associated with physical examination [37].
Ultrasound Doppler enthesitis shows sensitivity to change after biological therapy in spondyloarthritis and psoriatic arthritis patients
Published in Scandinavian Journal of Rheumatology, 2022
J Molina Collada, C Macía-Villa, C Plasencia-Rodríguez, JM Álvaro-Gracia, E de Miguel
Inflammation of the entheses (enthesitis) is considered a pathological hallmark of spondyloarthritis (SpA) and psoriatic arthritis (PsA) (1). Clinical assessment of enthesitis has been based traditionally on the recognition of tenderness elicited by palpation of the entheseal site, and several clinical scores grading this disease have been published (2–4). However, tenderness over an entheseal site may reflect conditions that mimic enthesitis, such as tendinitis, mechanical injury, or fibromyalgia, leading to false-positive results (2). Overall, clinical enthesitis has shown low sensitivity, specificity, and reliability (5), indicating an important need for improvement in the evaluation of this outcome.