Semiquantitative scoring for subacromial bursa (SAB), subdeltoid bursa (SDB), and subcoracoid bursa by both gray-scale (GS) and power Doppler (PD) ultrasonography was performed in 15 patients with polymyalgia rheumatica (PMR) (72.6 ± 7.7 years old) and 15 patients with elderly onset rheumatoid arthritis with PMR-like onset (pm-EORA) (70.7 ± 7.0 years old) before starting treatment. The GS grades of SAB were significantly higher in the shoulders with pm-EORA than in the shoulders with PMR. The GS and PD scores of SAB and the PD scores of SDB were significantly higher in pm-EORA than in PMR cases. The sums of GS and/or PD scores for the three bursae were significantly higher in pm-EORA than in patients with PMR. The sums of GS and PD scores for SAB were significantly higher in pm-EORA than in PMR cases. Moderate to severe proliferative synovitis of the shoulder bursae, especially in SAB, is a key feature for discriminating pm-EORA from PMR.
The consecutive reports and stored images of ultrasound examinations for 100 symptomatic ankles of 74 patients with rheumatoid arthritis (RA) were reviewed for the presence or absence of retrocalcaneal bursitis (RCB) and Achilles tendon enthesitis (ATE). The ankles were classified into 4 categories based on the presence or absence of RCB or ATE. The number of RCB(−)/ATE(−), RCB(+)/ATE(−), RCB(+)/ATE(+), and RCB(−)/ATE(+) ankles was 62, 16, 12, and 10, respectively. When classifying patients into early RA and established RA, the percentage of RCB(−)/ATE(+) ankles with early RA was significantly lower than that with established RA (P = .00595). The disease duration was significantly longer in the RCB(−)/ATE(+) ankles than in the RCB(+)/ATE(−) ankles (median [interquartile range]: 15.29 [8.69] months vs 3.6 [3.06] months, P = .0247). It was speculated that RCB precedes or accompanies ATE in the early phase of RA, which suggests that entheseal inflammation in RA arises from synovial tissues.
BackgroundWe had reported the frequencies of various pathologies detected by ultrasound (US) in symptomatic ankles and heels in rheumatoid arthritis (RA) patients 1. Through that study, we recognised that Achilles tendon (AT) involvement is not rare in RA, because retrocalcaneal bursitis (RCB), AT enthesitis, AT tendonitis and AT paratendonitis was detected in 27%, 22%, 13%, and 6% of the symptomatic ankles examined, respectively. Recently, it has been reported that RA and SpA patients did not differ in entheseal abnormalities seen on US 2. However, we think that there is fundamental difference between the inflammation of synovio-entheseal complexes in RA and that in SpA.ObjectivesThis study aims to investigate characteristics of entheseal abnormalities in RA by evaluating the association between US-detected RCB or AT enthesitis and clinical data.MethodsWe reviewed consecutive records of 100 ankles in 74 RA patients (fulfilling the 2010 criteria) who underwent US examination of symptomatic ankles because of clinical need. The patients consist of 52 women and 22 men (median age 63.3 years, range 26–83 years) with median disease duration of 4.2 months (range 0.23 months to 19.4 years), as described previously. 55/74 (74%) of them were positive for RF and/or ACPA. The association between presence of RCB or AT enthesitis in a narrow definition (i.e., insertional tendinitis) and clinical data were analysed using Fisher’s exact test or Mann-Whitney U test.ResultsAmong the overall 100 ankles, the frequency of RCB-positive/AT enthesitis-negative ankles, that of RCB-positive/AT enthesitis-positive ankles and that of RCB-negative/AT enthesitis-positive ankles were all more than 10%. Interestingly, the frequency of RCB-negative/AT enthesitis-positive ankles among the 62 ankles with early RA (disease duration <6 months) was significantly lower as compared to that among the 38 ankles with established RA (p=0.00595). Similarly, the frequency of RCB-negative/AT enthesitis-positive ankles among the 58 ankles of untreated patients was lower as compared to that among the 42 ankles of already-treated patients. The disease duration was significantly longer in the RCB-negative/AT enthesitis-positive ankles than in the rest of the ankles (43.8±74.6 months vs. 16.7±35.3 months, p=0.0179).ConclusionsMcGonagle et al. advocated the concept of synovio-entheseal complex and suggested that the inflammation occurs primarily at the enthesis and spreads to adjacent synovial tissues such as bursae in SpA patients. Our cross-sectional data indirectly indicated that RCB precedes or accompanies AT enthesitis in a narrow definition in the early phase of the RA, suggesting that the inflammation around the enthesis of RA patients occurs primarily at the synovial tissues and spreads to the enthesis in an opposite way. In addition, the isolated AT enthesitis without RCB in the established and/or treated RA patients may suggest several possibilities as follow: 1. Enthesitis is more refractory to RA treatment than bursitis; 2. Enthesitis is partially due t...
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