Achilles Enthesitis Research Articles

Disabling foot pain and its impact on daily living among people with psoriatic arthritis in Singapore: a cross-sectional observational investigation

BackgroundPsoriatic Arthritis (PsA)-related foot involvement has been shown to have a profound impact on daily functioning, with most studies having focused on predominantly Caucasian populations. The aim was to describe disabling foot pain (DFP) and its impact on daily living in PsA in Singapore.MethodsA cross-sectional, retrospective study was conducted using clinical data collected during a single-visit to a rheumatology clinic in Singapore. Records for adults with physician-diagnosed PsA were reviewed for sociodemographic information, disease characteristics, global disease activity and burden. Foot-specific measures included clinical assessment and the Manchester Foot Pain and Disability Index used to define DFP and evaluate between-group differences.ResultsForty-two participants with PsA (83% female, 57% Chinese, 31% Malay, 9.5% Indian, mean (SD) age 54-years (16)) attended the rheumatology clinic over the study-period. The median (IQR) disease duration was 2-years (11) and all were taking current DMARDs. Global disease measures demonstrated mild-to-moderate global disease activity and mild functional impairment, and were significantly higher in those with DFP. Despite 90% reporting to be coping well with their condition, self-care and having emotional support (n = 38), this study sample demonstrated high levels of anxiety/depression (29%), sleep disturbance (34%) and fatigue (24%), and a lack of disease- and drug-specific knowledge (64%). Further management was indicated for medication adherence counselling (48%), occupational therapy (43%), physiotherapy (36%) and podiatry (30%). Nearly half had current foot pain with 40% reporting DFP (n = 17), which caused significantly greater difficulty walking 3 km than those without DFP (p < 0.05). Rearfoot enthesitis (plantar fasciitis, Achilles enthesitis) was the most common cause of DFP (67%) with pain lasting longer than 1-year. 72% were overweight or obese, with a high proportion not engaging in any cardiovascular exercise (70%). Three of 42 participants had previously seen a podiatrist.ConclusionsPeople with DFP in PsA experience more severe global disease activity, reduced mobility and higher levels of negative impact on their daily lives in Singapore. In the absence of working in a multidisciplinary-team, there is value in comprehensive assessments that have potential to capture a holistic view of personal impact and improve person-centred care in PsA.

Ultrasound assessment of Achilles enthesitis: a dedicated training program.

To describe an intensive and multimodal ultrasound (US) training program focused on Achilles enthesitis and to illustrate the learning curve of trainees without experience. Three medical students (trainees) and two rheumatologists experienced in musculoskeletal US (trainers) were involved in the training program, which encompassed one preliminary theoretical-practical meeting and five scanning sessions (two patients per session). The students and one expert performed the US examination of the Achilles enthesis bilaterally. The trainees acquired representative images and assessed the presence of Outcome Measures in Rheumatology (OMERACT) US abnormalities of enthesitis. The experts provided feedback addressing trainees' misinterpretations, and the quality of the acquired images was evaluated. A dedicated questionnaire was used to evaluate the students' confidence. After each session, five sets of static images (total=100 images of most commonly scanned entheses) were provided and scored by the students according to OMERACT US definitions. Total agreement and prevalence and bias adjusted kappa (PABAK) were used to evaluate the concordance between the trainees and the expert sonographer. The total agreement and PABAK significantly improved between the first and fifth scanning sessions (76.2% versus 92.9%, p<0.01, and 0.5 versus 0.79, p<0.01) and between the first and fifth static image sets (64.5% versus 81.9%, p<0.01, and 0.29 versus 0.74, p<0.01). Image quality did not significantly improve (p=0.34). A significant increase in trainees' confidence was registered (p<0.01). The described training program rapidly improved the students' performance in the US assessment of Achilles enthesitis, appearing to be an effective starting model for the future development of pathology-oriented teaching programs for the US in rheumatology.

Enthesitis in a European registry-based cohort of patients with psoriatic arthritis treated with tumour necrosis factor inhibitors: clinical burden, patient-reported outcomes, and treatment response

Objective To explore the registration of enthesitis among biologic-naïve patients with psoriatic arthritis (PsA) initiating tumour necrosis factor inhibitor (TNFi) treatment across 12 European registries, compare the disease burden and patient-reported outcomes (PROs) between patients with and without enthesitis, and assess the enthesitis treatment response. Method Demographics, clinical characteristics, and PROs at first TNFi (TNFi-1) initiation (baseline) were assessed in patients with PsA, diagnosed by a rheumatologist, with versus without assessment of entheses and between those with versus without enthesitis. Enthesitis scores and resolution frequency were identified at follow-up. Results Of 10 547 patients in the European Spondyloarthritis (EuroSpA) Research Collaboration Network initiating TNFi, 1357 underwent evaluation for enthesitis. Eight registries included a validated scoring system for enthesitis. At baseline, 874 patients underwent entheses assessment [Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) 485 patients, Spondyloarthritis Research Consortium of Canada (SPARCC) 389 patients]. Enthesitis was detected by MASES in 170/485 (35%, mean score ± sd 3.1 ± 2.4) and by SPARCC in 236/389 (61%, 4 ± 3.4). Achilles enthesitis was most frequent, by both MASES (unilateral/bilateral 28%/9%) and SPARCC (48%/18%). MASES/SPARCC baseline and follow-up scores for TNFi-1 were available for 100/105 patients. Of these, 63 patients (63%) (MASES) and 46 (43.8%) (SPARCC) achieved resolution of enthesitis. The site-specific enthesitis resolution was overall lower at SPARCC sites (peripheral; 63–80%) than at MASES sites (mainly axial; 82–100%) following TNFi-1. Disease activity and PROs were worse in patients with versus without enthesitis. Conclusion Entheseal assessments are only registered in a minority of patients with PsA in routine care. When assessed, enthesitis was common, and a substantial proportion demonstrated resolution following treatment with TNFi-1.

Impact of ankylosing spondylitis on foot health and quality of life: an observational case-control study.

Ankylosing spondylitis (AS) is a chronic, inflammatory, and autoimmune disease. This condition primarily affects the axial skeleton and presents direct foot involvement, such as Achilles enthesitis or plantar fascia involvement. This study aimed to investigate the impact of foot health on the quality of life of individuals with AS compared to a control group without AS. A sample of 112 subjects was recruited, with a mean age of 46.80 ± 10.49 years, divided into two groups: 56 individuals with AS (cases) and 56 individuals without AS (controls). Demographic data were collected, and the scores obtained in the Foot Health Status Questionnaire domains were recorded. Of the participants, 27.79% (N = 30) were men and 73.21% (N = 82) were women. The mean age in the group was 46.80 ± 10.49. Significant differences (p < 0.05) were found in the domains of foot function, foot pain, footwear, overall foot health, general health-related physical activity, and social capacity between the AS group and the control group. Individuals with AS exhibited a decreased quality of life, as indicated by their Foot Health Status Questionnaire scores.

P401 The diagnostic efficacy of the DETAIL questionnaire as a screening tool for spondyloarthritis in Korean patients with Inflammatory Bowel Disease

Abstract Background The DETection of Arthritis in Inflammatory boweL diseases (DETAIL) is a very simple questionnaire consisting of six items. Developed in Italy as a screening tool for spondyloarthritis (SpA) in patients with inflammatory bowel diseases (IBD), it has not been validated in Asian patients with IBD. This study aims to assess whether the DETAIL questionnaire demonstrates appropriate screening properties in Korean patients with IBD. Methods Adult patients with IBD experiencing musculoskeletal symptoms were prospectively enrolled. An IBD specialist assessed them using a Korean-translated version of the DETAIL questionnaire, and referred them to a rheumatologist. The diagnosis of SpA was made based on the Assessment of SpondyloArthritis international Society classification criteria. The performance of the DETAIL questionnaire was evaluated using a Bayesian analysis model, with results graphically represented using Fagan’s nomogram. Results Eighty-seven patients with IBD (58 with ulcerative colitis and 29 with Crohn’s disease) completed the DETAIL questionnaire. Male was 50.1%, and the mean age of the patients was 39.1±12.1 years. Among these patients, 30 (34.5%) were diagnosed with SpA (20 peripheral, 10 axial). In the DETAIL questionnaire, items 1 (exploring peripheral synovitis), 2 (exploring dactylitis), and 3 (exploring Achilles enthesitis), which assess peripheral SpA, demonstrated good performance, especially with the highest positive likelihood ratio (LR+) found in item 2 (LR+ 3.26). Meanwhile, questions about inflammatory low back pain (items 4, 5, and 6), exhibited poorer performance, with LR+ values near or below 1. In subgroup analysis, the DETAIL questionnaire exhibited superior performance in younger IBD patients (&amp;lt; 40 years old) across three items for peripheral SpA, compared to older IBD patients (≥ 40 years old). An affirmative response to at least two questions about peripheral arthritis yielded a posttest probability of SpA of 85% or more. Conclusion The DETAIL questionnaire demonstrates effective screening properties for detecting SpA in young Korean IBD patients.

Achilles tendinopathy following severe acute respiratory syndrome coronavirus 2 infection and COVID-19 vaccination

Abstract: Musculoskeletal symptoms are commonly reported following SARS-CoV-2 infection, with fatigue, arthralgia, and myalgia being the most common manifestations. Severe cases may include conditions like arthritis and rhabdomyolysis. Similarly, post-vaccination musculoskeletal symptoms have been documented. However, tendinopathy, particularly Achilles tendinopathy, remains underreported in both contexts. We present two cases of Achilles tendinopathy, one following SARS-CoV-2 infection and the other post-vaccination, to highlight potential musculoskeletal complications associated with COVID-19 and vaccination. In the first case, a 48-year-old male developed bilateral ankle pain eight weeks after a confirmed COVID-19 infection. The second case involves a 27-year-old male who experienced sudden, intense left Achilles tendon pain following SARS-CoV-2 vaccination. Case 1: The 48-year-old patient exhibited bilateral ankle pain and swelling, with MRI confirming Achilles enthesitis. Laboratory tests showed elevated ESR and CRP, with other parameters within normal ranges. Treatment with sulfasalazine led to significant improvement. Case 2: The 27-year-old patient demonstrates Achilles tendon rupture post-vaccination. Detailed findings and treatment outcomes were discussed to emphasize the rarity and significance of this condition. These two cases underscore the need for awareness and further research on the relatively serious musculoskeletal complications like Achilles tendinopathy following COVID-19 infection and vaccination. Enhanced medical understanding is crucial for optimizing patient care and addressing potential side effects effectively.

P072 Significant functional impairment and disability in individuals with psoriatic arthritis and Achilles tendon pain

Abstract Background/Aims Enthesitis is a hallmark clinical feature of psoriatic arthritis (PsA) with the most commonly affected site being the Achilles tendon (AT) insertion into the posterior calcaneum. There is overlap in the clinical and ultrasound (US) pathological presentation of Achilles enthesitis and Achilles tendinopathy, however their treatment guidelines differ significantly. AT pain in PsA is complex, with the potential interplay of mechanobiology and inflammation. The aim of this study was to assess the structure and function of the AT in individuals with PsA to inform the future development of a non-pharmacological intervention. Methods A single-centre, cross-sectional observational study was conducted. People with PsA with (PsA+AT) and without (PsA-AT) AT pain were age and sex-matched with healthy controls (n = 11 per group). AT structure and function were assessed by clinical examination (Leeds Enthesitis Index and AT tendinopathy tests), B-mode and Power Doppler (PD) US, the Victorian Institute of Sports Assessment - Achilles (VISA-A) questionnaire, the bilateral heel raise test and 10-metre walk test (10MWT). Patient-reported outcome measures were used to evaluate local and global disease activity, impact, and quality of life. Group membership associations and between-group differences for domains of interest were evaluated using Pearson’s Chi-squared, one-way ANOVA, Mann-Whitney or Kruskal-Wallis tests. Results All groups were comparable in terms of sex, age and BMI. PsA disease duration was longer in the PsA-AT group (mean [SD], 20.1 years [13.1]) compared to the PsA+AT group (7.4 [6.3]). Structural changes at the enthesis on US were detected in all groups; however inflammatory features were significantly more prevalent in the PsA+AT group (p&amp;lt;0.001). PD signal was only detected in the PsA+AT group. Mid-portion and myotendinous AT pathology, including diffuse thickening, altered echogenicity and partial tears were also present, irrespective of the presence of enthesitis. PsAID-12 and HAQ-DI scores were significantly worse in the PsA+AT compared to the PsA-AT group (p=0.018 and p=0.001, respectively). The PsA+AT group walked slower (mean=17.89 seconds for 10MWT) compared to the PsA-AT group (12.23) and controls (11.55), could perform significantly less heel raises until the point of fatigue (PsA+AT mean=19.45, PsA-AT=39.18, controls=51.55, p=0.007) and had significantly worse VISA-A scores (PsA+AT mean=33, PsA-AT=71, controls=92, p&amp;lt;0.001), indicative of impaired AT function. In the PsA+AT group, AT pain was persistent and disabling despite pharmacological management in line with current guidelines and &amp;lt;30% had received treatment from podiatry or physiotherapy services. Conclusion People with PsA and AT pain exhibit severe functional limitations as demonstrated by the bilateral heel raise test, 10MWT and VISA-A scores. The diversity of US imaging features detected, and the inconsistencies in treatment provided, highlights an opportunity to develop individualised non-pharmacological management strategies stratified by US features and performance-based testing. Disclosure A. Patience: None. M.P. Steultjens: None. S. Siebert: None. G.J. Hendry: None.

Achilles enthesitis on physical examination leads to worse outcomes after 2 years of follow up in patients with ankylosing spondylitis from REGISPONSER-AS registry

BackgroundEnthesitis represents one of the most important peripheral musculoskeletal manifestations in patients with axial spondyloarthritis (axSpA). However, studies specifically evaluating Achilles tendon enthesitis and its impact over time are scarce. The objectives of this study were to evaluate the impact of Achilles’ tendon enthesitis found at baseline during physical examination on the outcome measures after 2 years of follow-up in patients with ankylosing spondylitis (AS).MethodsThis was an observational and prospective study conducted during 2 years of follow-up in the REGISPONSER-AS registry. Linear regression models adjusted for age, body mass index (BMI), and anti-TNF intake were conducted to evaluate the association between the presence of Achilles enthesitis at baseline and the patient-reported outcome (PRO) scores at baseline. The impact of this feature on PROs over 2 years of follow-up was evaluated using mixed models for repeated measures adjusted for age, BMI, and anti-TNF intake.ResultsAmong the 749 patients included, 46 patients (6.1%) showed Achilles’ tendon enthesitis during physical examination at the baseline study visit. Patients with Achilles enthesitis had an increase in the global VAS score, BASDAI, mBASDAI, ASDAS-CRP, and BASFI scores in comparison with patients without this feature. In addition, the mean global VAS, BASDAI, and ASDAS-CRP scores were significantly higher among patients with Achilles enthesitis over the 2 years of follow-up after adjusting for age, BMI, and current anti-TNF intake. The percentage of patients achieving ASDAS low disease activity (ASDAS < 2.1) after 2 years of follow-up was 15.9% and 31.5% for patients with and without Achilles enthesitis, respectively (p = 0.030).ConclusionsIn patients with AS, the presence of Achilles’ tendon enthesitis was associated with worse scores on the outcome measures after 2 years of follow-up, leading to a lower probability of achieving low disease activity.

38 Spectacular improvement of refractory calcaneal enthesitis with anti TNF alpha

BackgroundSpondyloarthritis is a heterogeneous group of chronic inflammatory rheumatism, of which enthesitis is the most common. Achilles involvement is frequent and can be disabling, resisting various treatments (non-steroidal anti-inflammatory drugs and local treatment). Only anti TNF alpha drugs are effective.We report the case of a patient with extremely painful achilles enthesitis causing functional disability who responded dramatically to anti TNF alpha.ObservationChild A.N, 13 years old, followed for juvenile idiopathic arthritis in the form of psoriatic arthritis evolving since the age of 4 years, treated with methotrexate at a rate of 7.5 mg/week, well balanced for 7 years.Three years later, the patient consulted us for disabling right inflammatory heel pain with the impossibility of putting his shoes on.The clinical examination revealed a painless position with the inability to put the heel on the ground; difficulty in walking requiring the use of crutches; pain on palpation of the Achilles tendon up to its insertion on the calcaneus, with painful limitation of dorsiflexion. Skin and mucous membrane examination revealed psoriasis lesions on the dorsum of the foot and on the nails.Laboratory tests: CBC without abnormality, ESR= 25mmH1 CRP =12mg/lX-ray of the rear feet: no abnormalities.Ultrasound of the right ankle: enthesitis taking colour doppler at the insertion of the Achilles tendon with erosion within the calcaneus.Magnetic resonance imaging of the right ankle: medullary oedema in the calcaneus with hyper signal on the DP sequence associated with retro calcaneal bursitis.The patient was put on NSAIDs without improvement, two ultrasound-guided cortisone injections were performed, followed by total failure. Treatment with an anti TNF alpha (Etanercept 0.8 mg/kg/week 25 mg) was started, the improvement was spectacular after 8 weeks with disappearance of the pain, including when standing, walking and putting shoes on. On the ultrasound (disappearance of the retro calcaneal bursitis and negativation of the doppler signal) no recurrence was noticed.ConclusionEnthesitis is an essential lesion in spondyloarthritis. Generally resistant to conventional DMARDs, anti TNF alpha is a treatment of choice.

Ankle and foot pathologies in early rheumatoid arthritis, what can ultrasound tell us?

Rheumatoid arthritis (RA) is a systemic autoimmune polyarticular disease. Despite being commonly affected in RA, the ankle and foot do not receive much attention, particularly in early disease. The precise diagnosis of their involvement and its impact on health is a clinical challenge that requires accurate assessment. To determine the role of ultrasound in evaluation of ankle and foot pathologies and assess its impact on functional activity in newly diagnosed RA patients. The study was conducted on 152 RA patients and 52 healthy controls. Patients were subjected to history taking, clinical examination, and ultrasound scan. Impact on health was measured by health assessment questionnaire, as well as foot function index. In a cohort of patients with early RA with median duration of 1 month, tibialis posterior (TP) tenosynovitis (45.4%) was the most common pathology, followed by tibiotalar (TTJ) synovitis (39.8%), and peroneal tenosynovitis (39.1%). In terms of disease duration, TTJ (P=.001) foot pathologies were less common in early RA and tended to worsen over time, whereas TP (P=.048) and peroneal tenosynovitis (P=.011) were more common in early RA. In multivariate analysis TTJ, subtalar synovitis, forefoot pathologies, TP tenosynovitis, and Achilles enthesitis were found to be significant predictors of functional disability. The most important predictors of ankle pain were TTJ synovitis, TP tenosynovitis, peroneal tenosynovitis, and plantar fasciitis. Ankle and foot involvement is a common issue of early RA, and it has a significant impact on quality of life. Ultrasound is a reliable tool for evaluating various abnormalities in this complex area, allowing for better management.

O001. Juvenile-onset spondyloarthritis: a study of 54 cases in Senegal

Abstract Background Juvenile onset spondyloarthritis (JoSpA), also known as enthesitis-related arthritis (ERA), accounts for approximately 10-20% of all juvenile idiopathic arthritis (JIA) and affects four times more boys than girls. It’s characterized by frequent arthritis of the lower limbs and strongly associated with presence of HLA-B27. In sub-Saharan Africa, SpA is considered as a rare disease where the frequency of HLA-B27 is &amp;lt; 1% in the population. However, an interesting exception is found in the Fula ethnic group of Gambia, where the prevalence of HLA-B27 was estimated at 6% to 7.8%. This ethnic group is also present in Senegal Aims: To determine the epidemiological, clinical, Para clinical, therapeutic and disease course aspects of JoSpA in Senegal. Methods A retrospective observational study, was conducted in rheumatology department of Aristide Le Dantec Hospital, between January 2012 and December 2020. Two hundred and fifteen JIA cases were collated, 54 were JoSpA fulfilling the ILAR classification criteria of ERA, with age of onset of symptoms ≤ 16 years. Exclusion criteria were: psoriasis or history of psoriasis, presence of rheumatoid factor and presence of systemic arthritis. Disease activity was assessed by activity indexes (BASDAI and ASDAS), functional impact by BASFI, and Quality of Life by Nottingham Health Profile (NHP). Results A total of 54 patients (29 males and 25 females with a sex ratio M/F of 1.16) were included in the study. The mean age at onset of symptoms was 12.4 years, mean age at diagnosis was 23.2 years. 34 (63%) patients were of Fula ethnicity. The inaugural symptomatology was exclusively peripheral in 33 cases (61.1%), axial and peripheral in 23 cases (42.6%). At the time of diagnosis, arthritis was located in the lower limbs in 92.1% of cases, where knee involvement was predominant in 30 (55.6%) cases, followed by hip involvement in 17 (31.5%) cases. Axial involvement was present in 46 cases (85.2%), dominated by sacroiliac pain/ buttock pain in 73.9%, followed by low back pain in 52.1%. Entheseal involvement was present in 30 cases, dominated by Achilles enthesitis and plantar fasciitis in 83.3%. Involvement of the anterior chest wall was found in 12 patients. Uveitis was present in 3 patients. Biological inflammatory syndrome was found in 55.5% of cases, with a mean CRP level of 17.1mg/l. Search for HLA-B27 was carried out in 34 patients, 25 were HLA-B27 positive (73.5%). Among HLA-B27 positive patients, 21 (84%) were of Fula ethnicity. On radiography, sacroiliitis was present in 29 patients, and 8 had coxitis. On admission, the mean BASDAI and ASDAS-CRP were 4.66/10 and 2.98 respectively, mean BASFI was 4.36/10. NHP showed impairment of all items, especially the concepts of energy, pain, sleep and physical mobility. Treatment was based on: NSAIDs (42 patients, 79.6%), methotrexate (30 patients, 55.5%), sulfasalazine (8 patients, 14.8%), oral steroids (15 patients, 27.7%), intra-articular joint steroid injections (6 patients), hip replacement surgery (2 patients), and functional rehabilitation (5 patients). The evolution was favorable, after 6 months of treatment, mean BASDAI and BASFI were 2.47/10 and 2.19/10 respectively. Conclusion In our study, JoSpA affects both girls and boys. The prevalence of HLA-B27 was 73.5% of cases, especially in the Fula ethnic group. The disease is considered as a source of significant functional impact and impairment of quality of life. The treatment was based mainly on conventional treatment. Evolution was globally favorable after treatment. Further epidemiological studies are needed to obtain reliable prevalence rates and to better understand our findings.

Ultrasound features of Achilles enthesitis in psoriatic arthritis: a systematic review.

ObjectivesThe objectives were to evaluate the methodological and reporting quality of ultrasound (US) studies of Achilles enthesitis in people with psoriatic arthritis (PsA), to identify the definitions and scoring systems adopted and to estimate the prevalence of ultrasound features of Achilles enthesitis in this population.MethodsA systematic literature review was conducted using the AMED, CINAHL, MEDLINE, ProQuest and Web of Science databases. Eligible studies had to measure US features of Achilles enthesitis in people with PsA. Methodological quality was assessed using a modified Downs and Black Quality Index tool. US protocol reporting was assessed using a checklist informed by the European League Against Rheumatism (EULAR) recommendations for the reporting of US studies in rheumatic and musculoskeletal diseases.ResultsFifteen studies were included. One study was scored as high methodological quality, 9 as moderate and 5 as low. Significant heterogeneity was observed in the prevalence, descriptions, scoring of features and quality of US protocol reporting. Prevalence estimates (% of entheses) reported included hypoechogenicity [mean 5.9% (s.d. 0.9)], increased thickness [mean 22.1% (s.d. 12.2)], erosions [mean 3.3% (s.d. 2.5)], calcifications [mean 42.6% (s.d. 15.6)], enthesophytes [mean 41.3% (s.d. 15.6)] and Doppler signal [mean 11.8% (s.d. 10.1)].ConclusionsThe review highlighted significant variations in prevalence figures that could potentially be explained by the range of definitions and scoring criteria available, but also due to the inconsistent reporting of US protocols. Uptake of the EULAR recommendations and using the latest definitions and validated scoring criteria would allow for a better understanding of the frequency and severity of individual features of pathology.

AB0692 REACTIVE ARTHRITIS ASSOCIATED WITH COVID-19 INFECTION: A REVIEW

Background:The incidence of COVID-19 infection is increasing globally with high mortality rate. Cytokine release syndrome might contribute to extra-pulmonary manifestations such as acute kidney injury, venous thrombosis, neurological complications, hepatic and myocardial injury. Reactive arthritis is an emerging musculoskeletal (MSK) manifestation post COVID-19 infection. Reactive arthritis manifests as asymmetrical, oligoarthritis mainly involving peripheral or axial joints of lower extremities and associated with extra-articular manifestations.Objectives:review the clinical presentation and management outcomes of COVID-19 associated reactive arthritis.Methods:A literature research was conducted using PubMed and Google scholar for published abstracts, case reports, and studies from January 2020 to January 2021. We used search keywords” reactive arthritis”, “COVID-19 pneumonia”, “ SARS CoV2 infection”, and “Musculoskeletal”. Descriptive analysis was used due to small sample size.Results:COVID-19 associated reactive arthritis is rarely reported. In review of literature, 10 cases were identified and we included our case of hip arthritis and avascular necrosis post COVID-19 infection. The mean age of cases (n=11) was of 42.8 years and 54.5 % of patients were males. (Table 1) The median duration of reactive arthritis diagnosis from COVID-19 infection ranged from 1 to 8 weeks. The severity of COVID-19 infection varied from mild (n= 6) to severe disease (n=2) per description in each reported case. Majority of the patients had oligoarticular involvement (2 to 4 joints) 45.5%, followed by monoarticular 36.4%, and polyarticular (&gt; 4 joints) in 18%. Extra-articular manifestations were identified in 54.5% of patients including skin rash (erythematous itchy rash), urticarial rash, wrist tendinitis, Achilles enthesitis /tendonitis and balanitis. HLA-B27 testing was done in five patients and only one patient had a positive result. Plain radiographs were normal. Therapy provided of such cases were NSAIDS (n=4), steroids (oral, intra-articular) (n=1) or combination of steroids and NSAIDS (n=3) with favorable outcomes. The median reported follow up period ranged from 1.5 to 8 weeks.Table 1.Characteristics of the reported reactive arthritis cases post COVID-19 infectionClinical data of patients (n=11)Results (n=11)Age (mean) 42.8 Years oldSex %Female (n= 5 [45.5%])Male (n= 6 [54.5%])Severity of COVID-19 infectionMild (n=6 [54.5%])Moderate (n=3 [27.3%])Severe (n= 2 [18%])Prior history of rheumatologic disease(n=0)Time to onset of reactive arthritis (median)1 to 8 weeksNumber of joints involved at time of diagnosisMonoarticular (n= 4[36.4%])Oligoarticular (n= 5[45.5%])Polyarticular (n= 2[18%])Location of involved joints (upper vs. lower limbs)Upper joints (18%)Lower joints (54.5%)Both (27.3%)Enthesitis(n= 1[9%]) AchillesTendonitis(n= 2[18%]) (wrist / Achilles tendonitis)Extra-articular involvement (eyes, skin, GI, GU, others)- Skin rash (n=2 [18%]) (erythematous itchy rash, urticarial rash)- GU: balanitis (n=1 [9%])Inflammatory back pain(n=0)Avascular necrosis of bone(n= 1[9%])HLA-B27(n= 1[9%]), (n = 5 tested)Autoimmune workupNegativeTreatment of reactive arthritis:DMARDs (n=0)NSAIDs (n=4 [36.4%])Steroids (n=1 [9%])NSAIDs and steroids (n= 3[27.3%])Not provided (n=2), others (n=1)Outcomes of MSK symptomsImprovement (n=11 [100%])Follow up period (Median, weeks)1.5 to 8 weeksGastrointestinal (GI), genitourinary (GU), NSAIDs: non-steroidal anti-inflammatory drugConclusion:Reactive arthritis is a rare MSK manifestations post COVID-19 infection. HLA-B27 positive testing might indicate severe and delayed form of arthritis with risk of recurrence. Larger studies are required to delineate the potential risk factors and long-term management outcomes for reactive arthritis associated with COVID-19 infection.

Imaging of enthesitis by an LED-based photoacoustic system

.Significance: One key pathological characteristic of seronegative spondyloarthropathy (SpA) is inflammation at the insertion of tendons and ligaments into the bone (enthesitis).Aim: We explore the potential of the emerging photoacoustic (PA) imaging in diagnosis of SpA and review its feasibility in detecting SpA-associated Achilles tendon enthesitis.Approach: A light-emitting diode (LED)-based PA and ultrasound combined system was employed. The PA images, both along the long and the short axes of each Achilles tendon insertion region, were acquired at 850-nm wavelength, which is sensitive in depicting increased blood volume (i.e., hyperemia). To assess the hyperemia indicating enthesis inflammation, two parameters were quantified in the imaged tendons, including the average intensity and the density of the color pixels in the pseudo-color PA images. Ten SpA patients, all of which met Assessment of SpA International Society (ASAS) criteria for SpA and were found to have Achilles enthesitis by clinical exam according to a board-certified rheumatologist, were included in the study.Results: The PA and Doppler ultrasound imaging of Achilles enthesitis resulting from these 10 SpA patients were compared to those from 10 healthy volunteers, leading to statistically significant differences () in the applied -tests.Conclusions: This preliminary clinical study suggests that the LED-based PA imaging holds a promise for sensitive and objective assessment of SpA enthesitis in an outpatient setting of the rheumatology clinic.

Multicenter Validation of the DETAIL Questionnaire for the Screening of Spondyloarthritis in Patients With Inflammatory Bowel Diseases.

Spondyloarthritis (SpA) is among the most frequent extraintestinal manifestations of inflammatory bowel diseases (IBD). In this study, we aimed to validate the DETection of Arthritis in Inflammatory boweL diseases (DETAIL) questionnaire in a multicenter cohort of patients with IBD enrolled at 11 gastroenterology units. From October 2018 to March 2019, consecutive adult patients with IBD, either Crohn disease or ulcerative colitis, independently filled out the DETAIL questionnaire in the outpatient waiting room. Within 2 weeks a blinded rheumatologist assessed all the patients, irrespective of the DETAIL results, and classified them to be affected or not by SpA. The performance of the questions was evaluated through Bayesian analysis. Overall, 418 patients with IBD filled out the DETAIL questionnaire. Upon rheumatological evaluation, 102 (24.4%) patients received a diagnosis of SpA. Of the 6 questions, the best performances were found in question 6 [positive likelihood ratio (LR)+ 3.77], reporting inflammatory back pain at night, and in question 3 (LR+ 3.31), exploring Achilles enthesitis. The presence of back pain lasting > 3 months (LR+ 2.91), back pain with inflammatory features (LR+ 2.55), and a history of dactylitis (LR+ 2.55), also showed a fairly good performance, whereas a history of peripheral synovitis was slightly worse (LR+ 2.16). The combination of at least 3 questions answered affirmatively yielded a posttest probability of SpA of 80% or more. The presence of alternative diagnoses, such as osteoarthritis or fibromyalgia, represented a minor confounder. The DETAIL questionnaire is a useful tool for the early detection of SpA in IBD.

FRI0320 MULTICENTER VALIDATION OF THE DETECTION OF ARTHRITIS IN INFLAMMATORY BOWEL DISEASES (DETAIL) QUESTIONNAIRE FOR THE SCREENING OF SPONDYLOARTHRITIS IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES

Background:Spondyloarthritis (SpA) is the most frequent extra-intestinal manifestation in inflammatory bowel diseases (IBD), since it may occur in up to 25% of patients. The early referral to a Rheumatology Unit may lead to proper treatment and better outcomes for patients with suspect SpA. Recently, we have developed and preliminarily validated a self-administered screening questionnaire, called DETection of Arthritis in Inflammatory boweL diseases (DETAIL)1.Objectives:To validate the DETAIL questionnaire in a multicenter cohort of IBD patients enrolled at ten Gastroenterology and Rheumatology Units in Italy.Methods:The DETAIL instrument is a 6-item questionnaire developed through a Delphi method1. From October 2018 to March 2019, consecutive adult patients with IBD, Crohn’s disease (CD) or ulcerative colitis (UC), filled out independently the DETAIL in the outpatient waiting room. Thereafter, within 2 weeks a blinded rheumatologist assessed all the patients, irrespectively of the DETAIL results, and classified them to be affected or not by SpA according to ASAS criteria. The performance of the DETAIL was evaluated trough Bayesian analysis, defining for each item of the questionnaire the sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios.Results:Overall, 418 IBD patients filled out the DETAIL questionnaire. Upon rheumatological evaluation, 102 (24.4%) patients received a diagnosis of SpA. Of the six questions, the best performances were found in item 6 (LR+ 3.77), reporting inflammatory back pain at night, and in item 3 (LR+ 3.31), exploring Achilles enthesitis. The presence of back pain lasting more than three months (LR+ 2.91), of back pain with inflammatory features (LR+ 2.55) and a history of dactylitis (LR+ 2.55), showed also a fairly good performance, whereas a history of peripheral synovitis was slightly worse (LR+ 2.16). The combination of at least three items answered affirmatively yielded a post-test probability of SpA of 75% or more. The presence of alternative diagnoses, such as osteoarthritis and fibromyalgia, represented a minor confounder.Conclusion:The DETAIL questionnaire is the first screening tool for the early detection of SpA/IBD that has been validated by a multicenter study group.

The evaluation of the tendon and muscle changes of lower extremity in patients with acromegaly.

Although it is well known that acromegaly causes enlargement in the extremities, studies investigating the effects of acromegaly on tendons, muscles and soft tissue are limited. The aims of our study were to investigate tendons, the presence of enthesitis, soft tissue, muscle groups in terms of thickness and pennation angle (PA) which is an indicator of microstructure and strength of the muscle, of the lower extremities. Thirty-nine patients with acromegaly and thirty-nine healthy control subjects similar for age, sex and body mass index were enrolled. Lower extremity tendons, skin, muscle groups were evaluated by ultrasound. The thicknesses of heel skin, heel pad, plantar fascia and Achilles tendon were higher in acromegaly than the control group (p < 0.05). The incidence of Achilles enthesitis were increased in the acromegaly group (p < 0.05). The thicknesses of the gastrocnemius medial head, vastus medialis, lateralis muscles for both sides and the left rectus femoris muscle were found to be lower in the acromegaly patients than controls (p < 0.05). However, thicknesses of vastus intermedius, gastrocnemius lateral head and soleus were similar between the acromegaly and control groups (p > 0.05). PA values of the right and left vastus medialis and the right vastus lateralis were found to be decreased in the acromegaly group (p < 0.05). Myostatin levels were lower in acromegaly group (p < 0.05). Acromegaly may cause to an increase in tendon and soft tissue thickness, enthesitis formation, decrease in the thickness of some muscles, and deterioration in microstructures in lower extremity.

The Relationship Between Physical Examination and Ultrasonography of Large Entheses of the Achilles Tendon and Patellar Tendon Origin.

To investigate the relationship between physical examination (PE) and sonographic features of enthesitis, based on anatomical sites. The analysis was done using merged raw data of 3 studies on 2298 entheses. Patients with clinical Achilles enthesitis had more abnormalities on ultrasound (US): hypoechogenicity, p < 0.001; thickening, p = 0.001; Doppler signals, p = 0.002; and erosions, p = 0.02. The patellar tendon origin also correlated with PE but distal patellar tendon insertion and plantar aponeurosis were uncoupled from the US. The relationship between clinical and sonographic findings for large entheses is dependent on the anatomical site. For the patellar tendon origin and Achilles entheses, PE is significantly linked to US findings.

MRI of Cuboid Pulley Lesion.

The aim of this study was to describe cuboid pulley lesions and associated abnormalities on the basis of clinical findings and the results of MRI examinations of the ankle. A retrospective search was performed to identify patients who had a cuboid pulley lesion during a 10-year period. A cuboid pulley lesion was defined as bone marrow edema in the lateroplantar ridge of the cuboid that was shown to be wrapped by the peroneus longus tendon on MRI of the ankle. A total of 19 patients (11 men and eight women; mean age, 45.4 years) were included in the group of patients with a cuboid pulley lesion, and 38 age-and sex-matched patients without a cuboid pulley lesion were randomly selected as the control group. We reviewed medical records and assessed MRI findings that could be associated with a cuboid pulley lesion. The mean (± SD) diameter of the cuboid pulley lesion was 8.9 ± 4.7 mm. Cuboid pulley lesions were associated with peroneal tenosynovitis (p < 0.001), Achilles enthesitis (p = 0.004), and a clinical diagnosis of inflammatory arthritis (p < 0.001). Eleven of the 19 patients in the group with cuboid pulley lesions had inflammatory arthritis (either rheumatoid arthritis [n = 7] or spondyloarthritis [n = 4]). The cuboid pulley lesions did not cause localized lateral foot pain and tenderness, except in one patient who had an accompanying stress fracture of the cuboid. MRI of the ankle rarely but clearly shows cuboid pulley lesions, which themselves are not likely to cause localized pain, and cuboid pulley lesions show significant associations with peroneal tenosynovitis, Achilles enthesitis, and clinically diagnosed inflammatory arthritis.

Achilles enthesitis defined by ultrasound is not associated with clinical enthesitis in patients with psoriatic arthritis

ObjectiveTo compare clinical and ultrasonographic (US) evaluation of Achilles enthesitis in patients with psoriatic arthritis (PsA).MethodsThe Achilles insertion of outpatients with PsA was examined by clinical assessment of tenderness and...