Enthesopathies and enthesitis. Part 1. Etiopathogenesis


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Journal of Ultrasonography

Polish Ultrasound Society (Polskie Towarzystwo Ultrasonograficzne)

Subject: Medicine


ISSN: 2084-8404
eISSN: 2451-070X





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VOLUME 15 , ISSUE 60 (March 2015) > List of articles

Enthesopathies and enthesitis. Part 1. Etiopathogenesis

Iwona Sudoł-Szopińska * / Brygida Kwiatkowska / Monika Prochorec-Sobieszek / Włodzimierz Maśliński

Keywords : enthesopathy, enthesitis, etiopathogenesis, spondyloarthropathies, rheumatic diseases

Citation Information : Journal of Ultrasonography. Volume 15, Issue 60, Pages 72-84, DOI: https://doi.org/10.15557/JoU.2015.0006

License : (CC BY-NC-ND 4.0)

Received Date : 16-April-2014 / Accepted: 07-May-2014 / Published Online: 13-September-2016



The pathologies of tendon and ligament attachments are called enthesopathies. One of its types is enthesitis which is a characteristic sign of peripheral spondyloarthropathy.
Clinical diagnosis of enthesitis is based on rather non-specifi c clinical signs and results of laboratory tests. Imaging examinations are highly promising. Numerous  publications prove that enthesitis can be differentiated from other enthesopathic processes in an ultrasound examination or magnetic resonance imaging. However, some reports indicate the lack of histological criteria, specifi c immunological changes and features in imaging examinations that would allow the clinical diagnosis of enthesitis to be confi rmed. The fi rst part of the publication presents theories on the etiopathogenesis of enthesopathies: infl ammatory, mechanical, autoimmune, genetic and associated with the synovio-entheseal complex, as well as theories on the formation of enthesophytes: infl ammatory, molecular and mechanical. The second part of the paper is a review of the state-of-the-art on the ability of imaging examinations to diagnose enthesitis. It indicates that none of the criteria of infl ammation used in imaging medicine is specifi c for this pathology. As enthesitis may be the only symptom of early spondyloarthropathy (particularly in patients with absent HLA-B27 receptor), the lack of its unambiguous picture in ultrasound and magnetic resonance scans prompts the search for other signs characteristic of this disease and more specifi c markers in imaging in order to establish diagnosis as early as possible. 

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1. Eshed I, Bollow M, McGonagle DG, Tan AL, Althoff CE, Asbach P et al.:MRI of enthesitis of the appendicular skeleton in spondyloarthritis. Ann Rheum Dis 2007; 66: 1553–1559.
2. D’Agostino MA: Role of ultrasound in the diagnostics work-up of spondyloarthritis.Curr Opin Rheumatol 2012; 24: 375–379.
3. Benjamin M, McGonagle D: The enthesis organ concept and its relevance to the spondyloarthropathies. Adv Exp Med Biol 2009; 649: 57–70.
4. Filipucci E, Aydin SZ, Karadag O, Salaffi F, Gutierrez M, Direskeneli H et al.: Reliability of high-resolution ultrasonography in the assessment of Achilles tendon enthesopathy in seronegative spondyloarthropathies. Ann Rheum Dis 2009; 68: 1850–1855.
5. de Miguel E, Muñoz-Fernández S, Castillo C, Cobo-Ibáñez T, Martín- Mola E: Diagnostic accuracy of enthesis ultrasound in the diagnosis of early spondyloarthritis. Ann Rheum Dis 2011; 70: 434–439.
6. D’Agostino MA, Aegerter P, Jousse-Joulin S, Chary-Valckenaere I, Lecoq B, Gaudin P et al.: How to evaluate and improve the reliability of power Doppler ultrasonography for assessing enthesitis in spondyloarthritis. Arthritis Rheum 2009; 61: 61–69.
7. Sudoł-Szopińska I, Zaniewicz-Kaniewska K, Kwiatkowska B: Spectrum of ultrasound pathologies of Achilles tendon, plantar aponeurosis and fl exor digiti brevis entheses in patients with clinically suspected enthesitis. Pol J Radiol 2014 [w druku].
8. Benjamin M, McGonagle D: The enthesis organ concept and its relevance to the spondyloarthropathies. In: López-Larrea C, Diaz-Peña R (eds.): Molecular mechanisms of spondyloarthropathies. Landes Bioscience and Springer Science + Business Media, New York 2009: 57–70.
9. Sudoł-Szopińska I, Kontny E, Zaniewicz-Kaniewska K, Prohorec-Sobieszek M, Saied F, Maśliński W: Role of infl ammatory factors and adipose tissue in pathogenesis of rheumatoid arthritis and osteoarthritis. Part I: Rheumatoid adipose tissue. J Ultrason 2013; 13: 192–201. 
10. Sudoł-Szopińska I, Hrycaj P, Prohorec-Sobieszek M: Role of infl ammatory factors and adipose tissue in pathogenesis of rheumatoid arthritis and osteoarthritis. Part II: Infl ammatory background of osteoarthritis. J Ultrason 2013; 13: 319–328.
11. McGonagle D, Wakefi eld RJ, Tan AL, D’Agostino MA, Toumi H, Hayashi K et al.: Distinct topography of erosion and new bone formation in achilles tendon enthesitis: implications for understanding the link between infl ammation and bone formation in spondylarthritis. Arthritis Rheum 2008; 58: 2694–2649.
12. Emad Y, Ragab Y, Gheita T, Anbar A, Kamal H, Saad A et al.; Knee Enthesitis Working Group: Knee enthesitis and synovitis on magnetic resonance imaging in patients with psoriasis without arthritic symptoms.J Rheumatol 2012; 39: 1979–1986. 
13. Benjamin M, Toumi H, Ralphs JR, Bydder G, Best TM, Milz S: Where tendons and ligaments meet bone: attachment sites (“enthuses”) in relation to exercise and/or mechanical load. J Anat 2006; 208: 471–490.
14. François RJ, Braun J, Khan MA: Entheses and enthesitis: a histopathologic review and relevance to spondyloarthritides. Curr Opin Rheumatol 2001; 13: 255–264.
15. Tei MM, Farraro KF, Woo SLY: Ligament and Tendon Enthesis: Anatomy and Mechanics. In: Structural Interfaces and Attachements in Biology. Springer, New York 2013: 69–89.

16. Shaw HM, Santer RM, Watson AHD, Banjamin M: Adipose tissue at entheses: the innervations and cell composition of the retromalleolar fat pad associated with the rat Achilles tendon. J Anat 2007; 211: 436–443.
17. Feydy A, Lavie-Brion MC, Gossec L, Lavie F, Guerini H, Nguyen C et al.: Comparative study of MRI and power Doppler ultrasonography of heel in patients with spondyloarthritis with and without heel pain and in controls. Ann Rheum Dis 2012; 71: 498–503.
18. Healy P, Helliwell PS: Measuring clinical enthesitis in psoriatic arthritis: assessment of existing measures and development of an instrument
specifi c to psoriatic arthritis. Arthritis Rheum 2008; 59: 686–691.
19. Wong PC, Leung YY, Li EK, Tam LS: Measuring disease activity in psoriatic arthritis. Int J Rheumatol 2012; 2012: 839425.
20. Sparado A, Iagnocco A, Perrotta FM, Modesti M, Scarno A, Valesini G: Clinical and ultrasonography assessment of peripheral enthesitis in ankylosing spondylitis. Rheumatology 2011; 50: 2080–2086.
21. McMichael A, Bowness P: HLA-B27: natural function and pathogenic role in spondyloarthritis. Arthritis Res 2002; 4 (Suppl. 3): S153–S158. 

22. Braem K, Deroose CM, Luyten FP, Lories RJ: Inhibition of infl ammation but not ankylosis by glucocorticoids in mice: further evidence for the entheseal stress hypothesis. Arthirits Res Ther 2012; 14: R59.
23. Joyce-Shaikh B, Turner SP, Chao CC, Sathe M, Grein J, Gorman DM et al.: IL-23 induces spondyloarthropathy by acting on ROR-γt(+) CD3(+) CD4(−)CD8(−) entheseal resident T cells. Nat Med 2012; 18: 1069–1076.
24. Benham H, Rehaume LM, Hasnain SZ, Velasco J, Baillet AC, Ruutu M et al.: IL-23-mediates the intestinal response to microbial beta-glucan and the development of spondyloarthritis pathology in SKG mice. Arthritis Rheumatol 2014; Mar 24. DOI: 10.1002/art.38638.
25. Benjamin M, McGonagle D: The anatomical basis for disease localisation in seronegative spondyloarthropathy at entheses and related sites. J Anat 2001; 199: 503–526.
26. D’Agostino MA, Palazzi C, Olivieri I: Entheseal involvement. Clin Exp Rheumatol 2009; 27 (Suppl. 55): S50–S55.
27. Fredberg U, Ostgaard R: Effect of ultrasound-guided, peritendinuous injections of adalimubab and anakinra in chronic Achilles tendinopathy: a pilot study. Scand J Med Sci Sports 2009; 19: 338–344.
28. Prochorec-Sobieszek M, Małdyk P: Obraz mikroskopowy ścięgien i pochewek ścięgnistych w przypadkach reumatoidalnego zapalenia stawów. Reumatologia 1993; 31: 22–28.
29. Benjamin M, Redman S, Milz S, Büttner A, Amin A, Moriggl B et al.: Adipose tissue at entheses: the rheumatological implications of its distribution. A potential site of pain and stress dissipation? Ann Rheum Dis 2004; 63: 1549–1555.
30. O’Rielly DD, Rahman P: Advances in the genetics of spondyloarthritis and clinical implications. Curr Rheumatol Rep 2013; 15: 347.
31. Hébert HL, Ali FR, Bowes J, Griffi ths CE, Barton A, Warren RB: Genetic susceptibility to psoriasis and psoriatic arthritis: implications for therapy. Br J Dermatol 2012; 166: 474–482.
32. Goldring SR: Osteoimmunology and bone homeostasis: relevance to spondyloarthritis. Curr Rheumatol Rep 2013; 15: 342.
33. Schett G, Rudwaleit M: Can we stop progression of ankylosing spondylitis? Best Pract Res Clin Rheumatol 2010; 24: 363–371.