Enthesopathies and enthesitis. Part 2: Imaging studies


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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 61 (June 2015) > List of articles

Enthesopathies and enthesitis. Part 2: Imaging studies

Iwona Sudoł-Szopińska * / Brygida Kwiatkowska / Monika Prochorec-Sobieszek / Grzegorz Pracoń / Marta Walentowska-Janowicz / Włodzimierz Maśliński

Keywords : enthesopathy, enthesitis, spondyloarthritis, rheumatic diseases, imaging

Citation Information : Journal of Ultrasonography. Volume 15, Issue 61, Pages 196-207, DOI: https://doi.org/10.15557/JoU.2015.0017

License : (CC BY-SA 4.0)

Received Date : 05-May-2014 / Accepted: 14-July-2015 / Published Online: 13-September-2016



The pathologies of tendon and ligament attachments are called enthesopathies. Enthesitis is one of enthesopathies and it is considered a characteristic sign of rheumatic diseases from the spondyloarthritis group, including peripheral spondyloarthritis. Therefore, enthesitis has been included in a number of clinical classifi cations for diagnosing these diseases. Clinical diagnosis of enthesitis is based on rather non-specifi c clinical signs and results of laboratory tests. It is believed that imaging examinations might improve diagnosis, particularly because numerous papers prove that differentiating enthesitis from other enthesopathic processes is possible. On the other hand, a number of authors report the lack of specifi c signs in imaging as well as typical histological and immunological features that would enable confi rmation of clinical diagnosis of enthesitis. The first part of the publication presented theories on the etiopathogenesis of enthesitis (infl ammatory, mechanical, autoimmune and associated with the synovio-entheseal complex) as well as on the formation of enthesophytes (infl ammatory, molecular and mechanical). This paper – the second part of the article, is a review of the state-of-the-art on the ability of imaging examinations to diagnose enthesitis. It turns out that none of the enthesitis criteria used in imaging examinations is specifi c for infl ammation. As enthesitis may be the only symptom of early spondyloarthritis (particularly in patients with absent HLA-B27 antigen), the lack of its unambiguous picture in ultrasound and magnetic resonance imaging prompts the search for other signs characteristic of spondyloarthritis and more specific features in imaging in order to make a diagnosis as early as possible.

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1. Sudoł-Szopińska I, Kwiatkowska B, Prochorec-Sobieszek M, Maśliński W: Enthesopathies and enthesitis. Part 1. Etiopathogenesis. J Ultrason 2015; 15: 72–84.
2. Balint PV, Kane D, Wilson H, McInnes IB, Sturrock RD: Ultrasonography of entheseal insertions in the Lower limb in spondyloartropathy.Ann Rheum Dis 2002; 61: 905–910.
3. Goldring SR: Osteoimmunology and Bone Homeostasis: Relevance to  Spondyloarthritis. Curr Rheumatol Rep 2013; 15: 342.
4. Czyrny Z: Sonographic and histological appearance of heel enthesopathy, what the „heel spurs” really are and what are their consequences.
J Orthop Trauma Surg Rel Res 2010; 2: 23–36.
5. Benjamin M, Toumi H, Ralphs JR, Bydder G, Best TM, Milz S: Where tendons and ligaments meet bone: attachment sites („entheses”) in relation
to exercise and/or mechanical load. J Anat 2006; 208: 471–490.
6. Benjamin M, McGonagle D: The anatomical basis for disease localization in seronegative spondyloarthropathy at entheses and related sites.
J Anat 2001; 199: 503–526.
7. Benjamin M, Ralphs JR: Fibrocartilage in tendons and ligaments – an adaptation to compressive load. J Anat 1998; 193: 481–494.
8. Francois RJ, Braun J, Khan MA: Entheses and enthesitis: a histopathologic review and relevance to spondyloarthritides. Curr Opin Rheumatol
2001; 13: 255–264.
9. Spadaro 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.
10. Maffulli N, Kader D: Tendinopathy of tendo Achillis. Tendinopathy of tendo Achillis. J Bone Joint Surg 2002; 84: 1–8.
11. Czyrny Z: Diagnostic anatomy and diagnostics of enthesal pathologies of the rotator cuff. J Ultrason 2012; 12: 178–187.
12. Dębek A, Nowicki P, Czyrny Z: Ultrasonographic diagnostics of pain in the lateran cubital compartment and proximal forearm. J Ultrason
2012;12: 188–201.
13. D’Agostino MA: Enthesitis. Best Pract Res Clin Rheumatol 2006; 20:473–486.
14. D’Agostino MA, Aegerter P, Bechara K, Salliot C, Judet O, Chimenti MS et al.: How to diagnose spondyloarthritis early? Accuracy of peripheral
enthesitis detection by power doppler ultrasonography. Ann Rheum Dis 2011; 70: 1433–1440.
15. Balint PV, Kane D, Wilson H, McInnes IB, Sturrock RD: Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy.
Ann Rheum Dis 2002; 61: 905–910.
16. D’Agostino MA, Said-Nahal R, Hacquard-Bouder C, Brasseur JL, Dougados M, Breban M: Assessment of peripheral enthesitis in the spondyloarthropathies by ultrasonogfraphy combined with power Doppler: a cross-sectional study. Arthritis Rheum 2003; 48: 523–533.
17. 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; 79: 402–408.
18. D’Agostino MA, Palazzi C, Olivieri I: Entheseal involvement. Clin Exp Rheumatol 2009; 27 (Suppl. 55): S50–S55.
19. Genc H, Cakit BD, Tuncbilek I, Erdem HR: Ultrasonographic evaluation of tendons and enthesal sites in rheumatoid arthritis: comparison
with ankylosing spondylitis and healthy subjects. Clin Rheumatol 2005; 24: 272–277.

20. Feydy A, Lavie-Brion MC, Gossec L, Lavie F, Guerini H, Nguyen C et al.: Comparative study of MRI and power Doppler ultrasonography of the
heel in patients with spondyloarthritis with and without heel pain and in controls. Ann Rheum Dis 2012; 71: 498–503.
21. Hermann KG, Baraliakos X, van der Heijde DM, Jurik AG, Landewé R, Marzo-Ortega H et al.: Descriptions of spinal MRI lesions and defi nition
of a positive MRI of the spine in axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI study group. Ann Rheum Dis
2012; 71: 1278–1288.
22. Bollow M, Fischer T, Reisshauer H, Backhaus M, Sieper J, Hamm B et al.: Quantitative analyses of sacroiliac biopsies in spondyloarthropathies:
T cells and macrophages predominate in early and active sacroiliitiscellularity correlates with the degree of enhancement detected by magnetic
resonance imaging. Ann Rheum Dis 2000; 59: 135–140.
23. Appel H, Loddenkemper C, Grozdanovic Z, Ebhardt H, Dreimann  M, Hempfi ng A et al.: Correlation of histopathological fi ndings and magnetic resonance imaging in the spine of patients with ankylosing spondylitis. Arthritis Res Ther 2006; 8: R143.
24. Eshed I, Bollow M, McGonagle D, Tan AL, Althoff CE, Asbach P et al.: MRI of enthesitis of the appendicular skeleton in spondyloarthritis. Ann
Rheum Dis 2007; 66: 1553–1559.
25. McGonagle D, Gibbon W, O’Connor P, Green M, Pease C, Emery P: Characteristic magnetic resonance imaging entheseal changes of knee
synovitis in spondyloarthropathy. Arthritis Rheum 1998; 41: 694–700.
26. Benjamin M, McGonagle D: Entheses, enthesitis and enthesopathy. ARC, Topical Reviews 2009; 4: 1–6.
27. Pierre-Jerome C, Moncayo V, Terk M: MRI of the Achilles tendon:a comprehensive review of the anatomy, biomechanics, and imaging of
overuse tendinopathies. Acta Radiol 2010; 51: 438–454.
28. Olivieri I, Barozzi L, Padula A, De Matteis M, Pierro A, Cantini F et al.:Retrocalcaneal bursitis in spondyloarthropathy: assessment with ultrasonography
and magnetic resonance imaging. J Rheumatol 1998; 25:1352–1357.
29. Benjamin M, McGonagle D: The enthesis organ concept and its relevance to the spondyloarthropathies. In: Lopez-Larrea C, Diaz-Pena R (eds.):
Molecular mechanisms of spondyloarthropathies. Springer-Science + Business Media LLC, New York 2009: 57–70. 

30. Benjamin M, McGonagle D: Histopathologic changes at „synovio-entheseal complexes” suggesting a novel mechanizm for synovitis in osteoarthritis
and spondylarthritis. Arthritis Rheum 2007; 56: 3601–3609. 

31. 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.
32. 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 (54): 319–328.
33. Benjamin M, Redman S, Buttner A, Amin A, Moriggl B, Brenner E 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.
34. Gandjbakhch F, Terslev L, Joshua F, Wakefi eld RJ, Naredo E, D’Agostino MA: Ultrasound in the evaluation of enthesis: status and perspectives. Arthritis
       Res Ther 2011; 13: R188.