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Heel pain in spondyloarthropathy

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  #1  
Old 1st June 2010, 02:35 AM
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Default Heel pain in spondyloarthropathy

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A randomised, multicentre, double-blind, placebo-controlled trial of etanercept in adults with refractory heel enthesitis in spondyloarthritis: the HEEL trial.
Dougados M, Combe B, Braun J, Landewé R, Sibilia J, Cantagrel A, Feydy A, van der Heijde D, Leblanc V, Logeart I.
Ann Rheum Dis. 2010 May 28. [Epub ahead of print]
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OBJECTIVE: Inflammation at the entheses is a distinguishing feature of spondyloarthritis (SpA). Enthesitis at the heel is the most common location and is often chronic, refractory to standard treatment and may have socioeconomic consequences. The objective of this study was to investigate the efficacy of etanercept in refractory heel enthesitis related to SpA.

METHODS: The present work was a 12-week, randomised, double-blind, placebo-controlled study compared etanercept with placebo in patients with SpA according to Amor's criteria, and heel enthesitis proven by MRI. The primary efficacy end point was the normalised net incremental area under the curve (AUC) between randomisation and week 12 for the patient's global assessment (PGA) of disease activity. Secondary end points included change from baseline in PGA, heel pain, the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) function subscale and improvement in enthesitis as measured by MRI.

RESULTS: A total of 24 patients were randomised. Mean normalised net incremental AUC for PGA of disease activity over 12 weeks was significantly greater in the etanercept versus placebo group: -28.5 versus -11.1, respectively (p=0.029). Significant improvements were also reported in the etanercept versus placebo group for PGA, -37.6 versus -11.6 (p=0.007); heel pain, -36.7 versus -13.1 (p=0.022); and WOMAC function, -23.2 versus -7.8 (p=0.024). No significant changes were observed in the MRI findings between groups. No unexpected adverse events or changes in laboratory values or vital signs.

CONCLUSIONS: This trial is the first randomised placebo-controlled study of an anti-tumour necrosis factor (TNF) agent in refractory heel enthesitis in patients with SpA. It demonstrates that etanercept has a statistically significant and clinically relevant benefit in such patients
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Old 1st June 2010, 02:40 AM
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Default Re: Heel pain in spondyloarthropathy

Related threads:
Heel raise for enthesitis?
Varied presentations of enthesopathy
'Inflammatory' vs 'mechanical' plantar fasciitis
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Old 28th May 2011, 03:37 PM
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Default Re: Heel pain in spondyloarthropathy

Enthesitis in an inception cohort of enthesitis-related arthritis.
Arthritis Care Res (Hoboken). 2011 May 25. doi: 10.1002/acr.20508. [Epub ahead of print]
Quote:
OBJECTIVE:
To describe an enthesitis-related arthritis (ERA) inception cohort and determine which entheses and joints are most commonly affected.

METHODS:
Retrospective inception cohort study of children with ERA diagnosed and treated at the Children's Hospital of Philadelphia between November 2007 and December 2009. RESULTS.: During the study period there were 32 newly diagnosed ERA patients. Fifty-nine percent were male, and the median age at the date of initial evaluation was 12.5 (IQR: 10.2, 14.3) years. The median number of tender entheses at presentation was 2 (IQR: 0, 5), and 21 subjects (66%) had at least 1 tender enthesis. The most prevalent tender entheses were the patellar ligament insertion at the inferior pole of the patella, the plantar fascial insertion at the calcaneus, the Achilles tendon insertion at the calcaneus, and the plantar fascial insertion at the metatarsal heads. Enthesitis was most often symmetric. The median number of active joints was 2 (IQR: 0, 4). The most commonly affected joints were the sacroiliacs, knees, and ankles. Sacroiliitis, which was defined clinically, was most often symmetric while peripheral arthritis was most frequently asymmetric. The odds of having active enthesitis at 6 months increased significantly with each additional tender enthesis at initial evaluation.

CONCLUSIONS:
Among pediatric patients with ERA, lower extremity enthesitis is prevalent at the time of diagnosis and is likely to persist 6-months later. Future studies should address standardization of the enthesitis exam, the pattern of enthesitis over time, enthesitis response to therapy, and the impact of enthesitis on quality of life.
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Old 31st August 2011, 09:39 PM
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Default Re: Heel pain in spondyloarthropathy

Clinical and ultrasonography assessment of peripheral enthesitis in ankylosing spondylitis.
Spadaro A, Iagnocco A, Perrotta FM, Modesti M, Scarno A, Valesini G.
Rheumatology (Oxford). 2011 Aug 28.
Quote:
Objective. The aim of this study was to compare clinical examination with power Doppler US (PDUS) in the detection of entheseal abnormalities in patients with AS.

Methods. Thirty-six AS patients underwent clinical and PDUS examination of the following bilateral entheseal sites: common extensor tendon at its insertion at the lateral humeral epicondyle; gluteus tendons at their insertion at the greater trochanter; quadriceps tendon at its insertion at the superior pole of the patella; patellar tendon at its proximal insertion at the inferior pole of the patella; patellar tendon at its distal insertion at the tibial tuberosity; Achilles tendon at its insertion at the calcaneus; and plantar aponeuroses at its insertion at the calcaneus.

Results. Clinical and PDUS examination revealed at least one abnormal enthesis in 23 (63.9%) and 35 (97.2%) AS patients, respectively. Furthermore, of 432 entheses examined in our 36 AS patients, 64 (14.8%) were considered abnormal by clinical examination and 192 (44.4%) by PDUS. US abnormalities most commonly found were enthesophytes (31.7%), calcifications (33.7%), thickening (29.8%) and hypoechogenicity (26.6%). We found erosions and PD signals in 9.7 and 6% of examined entheseal sites, respectively. The evidence of entheseal abnormalities by clinical examination has a poor likelihood ratio (LR) for the presence of US abnormalities with vascularization (LR = 1.61), without vascularization (LR = 1.24) or erosions (LR = 1.51) at all sites.

Conclusions. PDUS permits detection of structural and inflammatory abnormalities of the enthesis in AS and may complement the physical examination in order to better evaluate
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Old 13th September 2011, 01:23 PM
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Default Re: Heel pain in spondyloarthropathy

Efficacy and safety of ultrasound-guided local injections of etanercept into entheses of ankylosing spondylitis patients with refractory Achilles enthesitis.
Huang Z, Cao J, Li T, Zheng B, Wang M, Zheng R.
Clin Exp Rheumatol. 2011 Jul-Aug;29(4)

Quote:
OBJECTIVES:
Enthesitis is one of the most common and specific manifestations of ankylosing spondylitis (AS). However, the treatment of enthesitis is still a challenge for rheumatologist so far, especially to those AS patients with serious enthesitis. This study aimed to evaluate the efficacy and safety of ultrasound (US)-guided local injection of etanercept into entheses of AS patients with refractory Achilles enthesitis.

METHODS:
Twelve AS patients with severe unilateral refractory Achilles enthesitis were enrolled. Among them, 5 patients received US-guided local injection of etanercept and the other 7 received betamethasone. BASDAI, BASFI, VAS of the affected heel, the percentage of ASAS20 responders, CRP, ESR and any adverse events were recorded at baseline, 2, 4, 8 and 12 weeks after the treatment. US was also used to evaluate the corresponding entheses at baseline and every follow-up visit.

RESULTS:
The BASDAI, BASFI, VAS of the affected heel, CRP, ESR, the percentage of ASAS20 responders and the regional blood flow signals detected by colour Doppler were all improved in both the etanercept group and the betamethasone group, at each follow-up visit compared to the baseline data (p<0.05). There were no significant differences in the improvements of any of the above parameters between the two groups (p>0.05). In addition, there were no adverse events from the etaner- cept group, except for the mild acid bilges feeling during the injection procedure, while 1 patient from the betamethasone group developed mild local atrophoderma since the week 4 follow-up visit and the atrophoderma kept stable at the 2 subsequent visits.

CONCLUSIONS:
US-guided local injection of etanercept might be a highly effective, safe and well tolerated treatment for Achilles enthesitis in patients with AS.
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Old 29th September 2011, 01:26 PM
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Default Re: Heel pain in spondyloarthropathy

Comparative study of MRI and power Doppler ultrasonography of the heel in patients with spondyloarthritis with and without heel pain and in controls.
Feydy A, Lavie-Brion MC, Gossec L, Lavie F, Guerini H, Nguyen C, Rannou F, Drapé JL, Dougados M.
Ann Rheum Dis. 2011 Sep 26. [Epub ahead of print]
Quote:
Introduction
Imaging of heel enthesopathy in spondyloarthritis (SpA) could potentially be useful for diagnosis and monitoring. The aim of this study was to assess the diagnostic capacities of MRI and power Doppler ultrasonography (PDUS) of the heel to distinguish patients with SpA from controls and to distinguish between patients with SpA with and without enthesopathy.

METHODS:
A cross-sectional single-centre study was performed in 51 patients (102 heels) with definite SpA according to Amor's criteria. Patients with degenerative non-inflammatory low back pain (n=24, 48 heels) were included as controls. Bilateral heel MRI and PDUS were performed by two senior musculoskeletal radiologists blinded to the clinical and biological data on the same day as the clinical evaluation. The data were analysed by patient and by heel.

RESULTS:
Neither MRI nor PDUS could discriminate between patients with SpA and controls; bone oedema on MRI was the only abnormality specific to SpA (94%), but with a poor sensitivity (22%). However, among patients with SpA, painful heels had more inflammatory abnormalities (81% by MRI, 58% by PDUS) than heels with no pain (56% at MRI, 17% at PDUS).

CONCLUSION:
Heel MRI and PDUS frequently show inflammatory lesions in SpA, particularly in painful heels. However, they were also often abnormal in controls. These results suggest that heel MRI and PDUS cannot be used for the diagnosis of SpA. However, PDUS and MRI may be useful for the depiction and assessment of enthesis inflammatory lesions in patients with SpA with heel pain.
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Old 19th April 2012, 01:29 PM
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Default Re: Heel pain in spondyloarthropathy

Heel pain in spondyloarthritis: results of a cross-sectional study of 275 patients.
Koumakis E, Gossec L, Elhai M, Burki V, Durnez A, Fabreguet I, Meyer M, Payet J, Roure F, Paternotte S, Dougados M.
Clin Exp Rheumatol. 2012 Apr 17
Quote:
OBJECTIVES:
Heel pain is a common but poorly studied feature of spondyloarthritis (SpA). The aims of this study were to assess the prevalence and clinical features of heel pain in a cohort of patients with SpA.

METHODS:
This was a retrolective single centre observational study in 2010. Patients with SpA as defined by Amor's criteria were recruited. The data collected were: demographic and disease characteristics, history of heel pain, age at first heel pain, localisation, nature and intensity of pain and treatments. The analyses were descriptive.

RESULTS:
A total of 275 SpA patients (mean age 44.6±13.5 yrs, mean disease duration 16.7±11.8 yrs, 61.5% men) were assessed. A history of heel pain was reported in 130 patients (47.1%), and was the first symptom of SpA in 15.7% of all patients. Heel pain was frequent in both axial (89/201, 44.3%) and peripheral disease (27/56, 48.2%). Distribution was more frequently inferior (88, 69.3%) than posterior (61, 48.0%) (p<0.0001), and frequently bilateral: simultaneously (41.9%) rather than alternatively (29.1%) (p=0.03). Main clinical symptoms were: morning pain on weight bearing (83.6%), but also night pain (34.4%), and/or patient-described swelling (24.2%). Heel pain was frequently recurrent (74.2%), intense (70.3%), source of a limp (71.6%), and often resistant to non-steroidal anti-inflammatory drugs (NSAIDs) (54/108, 50%). Tumour necrosis factor blockers were efficacious on heel pain in 72/94 (76.6%) of cases.

CONCLUSIONS:
This study confirmed heel pain as a frequent symptom in both axial and peripheral SpA. It occurred early in the disease course and it was frequently recurrent and resistant to NSAIDs.
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Old 9th May 2012, 11:44 AM
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Default Re: Heel pain in spondyloarthropathy

Comparative study of MRI and power Doppler ultrasonography of the heel in patients with spondyloarthritis with and without heel pain and in controls.
Feydy A, Lavie-Brion MC, Gossec L, Lavie F, Guerini H, Nguyen C, Rannou F, Drapé JL, Dougados M.
Ann Rheum Dis. 2012 Apr;71(4):498-503.
Quote:
INTRODUCTION:
Imaging of heel enthesopathy in spondyloarthritis (SpA) could potentially be useful for diagnosis and monitoring. The aim of this study was to assess the diagnostic capacities of MRI and power Doppler ultrasonography (PDUS) of the heel to distinguish patients with SpA from controls and to distinguish between patients with SpA with and without enthesopathy.

METHODS:
A cross-sectional single-centre study was performed in 51 patients (102 heels) with definite SpA according to Amor's criteria. Patients with degenerative non-inflammatory low back pain (n=24, 48 heels) were included as controls. Bilateral heel MRI and PDUS were performed by two senior musculoskeletal radiologists blinded to the clinical and biological data on the same day as the clinical evaluation. The data were analysed by patient and by heel.

RESULTS:
Neither MRI nor PDUS could discriminate between patients with SpA and controls; bone oedema on MRI was the only abnormality specific to SpA (94%), but with a poor sensitivity (22%). However, among patients with SpA, painful heels had more inflammatory abnormalities (81% by MRI, 58% by PDUS) than heels with no pain (56% at MRI, 17% at PDUS).

CONCLUSION:
Heel MRI and PDUS frequently show inflammatory lesions in SpA, particularly in painful heels. However, they were also often abnormal in controls. These results suggest that heel MRI and PDUS cannot be used for the diagnosis of SpA. However, PDUS and MRI may be useful for the depiction and assessment of enthesis inflammatory lesions in patients with SpA with heel pain.
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Old 30th June 2012, 10:26 AM
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Default Re: Heel pain in spondyloarthropathy

Quantitative MRI measurements of the Achilles tendon in spondyloarthritis using ultrashort echo times.
Hodgson RJ, Menon N, Grainger AJ, O'Connor PJ, McGonagle D, Helliwell P, Emery P, Robson MD.
Br J Radiol. 2012 Jul;85(1015):e293-9.
Quote:
Objectives: Tendon involvement is common in spondyloarthritis. The MRI signal from the Achilles tendon has been used to quantify mechanical tendinopathy; however, conventional MRI is limited by the short T(2) of normal tendon. Short and ultrashort echo time (UTE) MRI have the potential to better measure signal intensity reflecting changes in T(2) or gadolinium enhancement. Furthermore, UTE images could be used for normalisation to reduce variability. The aim of this work was to investigate such techniques in patients with spondyloarthritis (SpA).

Methods: The Achilles tendons of 14 healthy volunteers and 24 patients with symptomatic spondyloarthritis were studied. Combined UTE (TE=0.07 ms) and gradient echo (TE=4.9 ms) images were acquired before and after intravenous gadolinium together with pre-contrast gradient echo images (TE=2 ms). The signal intensity from a region of interest in the Achilles tendon above the calcaneus was measured. The relative enhancement at echo times of 0.07 ms (RE(0.1)) and 4.9 ms (RE(5)) were calculated. The ratios of the signal intensities from both 4.9 ms and 2 ms gradient echo images to the signal intensity from the UTE image were calculated (RTE(5) and RTE(2) respectively).

Results: Interobserver intraclass correlation coefficients were excellent (≥0.97). The contrast-to-noise ratio was higher for enhancement on UTE images than on gradient echo images. RE(0.1), RTE(5) and RTE(2) were significantly higher in SpA patients than controls.

Conclusion: Signal intensity ratios using UTE images allow quantitative measurements to be made which are sensitive to tendon T(2) or contrast enhancement and which are increased in spondyloarthritis. They therefore have the potential for use as measures of tendon disease in spondyloarthritis.
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Old 12th November 2012, 04:44 PM
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Default Re: Heel pain in spondyloarthropathy

Ultrasonographic evaluation of lower limb enthesis in patients with early spondyloarthropathies
Yasser Ezzat, Wafaa Gaber, Sherif F. Abd EL-Rahman, Marwa Ezzat, Mohammad El Sayed
The Egyptian Rheumatologist; 7 November 2012
Quote:
Introduction

The enthesopathy of seronegative spondyloarthropathies (SpA) is the hallmark of these diseases, the ultrasound examination of these entheses confirms the frequency of their involvement.
Aim of the work

To detect entheseal abnormalities with ultrasound (US) in the lower limb of patients with early spondyloarthropathy (SpA) and to evaluate US as a valuable tool in detecting early enthesis.
Patients and methods

A total of 45 patients with early disease duration of 11.7 ± 8.5 months, including 10 patients with psoriatic arthritis (PsA), 10 patients with ankylosing spondylitis (AS), 10 patients with reactive arthritis (ReA), eight patients with ulcerative colitis (UC) and seven patients with Crohn’s disease and 20 healthy controls of matched age and sex underwent ultrasonographic evaluation of Achilles, quadriceps, patellar entheses and plantar aponeurosis. Ultrasonographic findings were scored according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS).
Results

On US examination a total of 290/450 (64.4%) of the entheseal sites were abnormal. Mean GUESS score was significantly higher in patients with SpA as compared with controls (p < 0.001), with a higher mean value in patients with PsA, ReA and AS. The mean thickness of all tendons examined was significantly higher in SpA patients than in controls (p < 0.0001) as well as the mean number of enthesophytes and bursitis in all sites examined (p = 0.002, p = 0.003), with a higher prevalence amongst patients with PsA and ReA. The GUESS score was correlated to duration of the disease and the anti-tumour necrosis factor alpha medications.

Conclusion
Enthesis involvement occurs early in spondyloarthritis, the enthesis US score appears to be reliable and useful for improving the diagnostic accuracy of early SpA, further studies are needed as US is an evolving technique.
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Old 8th March 2013, 04:10 PM
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Default Re: Heel pain in spondyloarthropathy

Achilles enthesis ultrasound: the importance of the bursa in spondyloarthritis.
Falcao S, de Miguel E, Castillo-Gallego C, Peiteado D, Branco J, Martín Mola E.
Clin Exp Rheumatol. 2013 Mar 7.
Quote:
OBJECTIVES:
This paper aims to assess the prevalence and relevance of the bursa-synovial lesion in spondyloarthritis (SpA).

METHODS:
A transversal blind and controlled two-dimensional (2D) and three-dimensional (3D) ultrasound (US) study of Achilles enthesis bursa in early SpA was undertaken. Clinical outcome measures were collected.

RESULTS:
Bilateral Achilles enthesis of 66 early SpA patients (34 women) and 46 control patients (23 asymptomatic healthy subjects and 23 rheumatoid arthritis [RA] patients) were analysed. Mean BASDAI, BASFI and BASRI-spine were 4.55±2.08, 2.16±1.95 and 0.65±0.77, respectively. Mean erythrocyte sedimentation rate (ESR) was 10.93±12.35 mm/h and C-reactive protein (CRP) was 6.46±10.09 mg/l. The κ-values for intra-reader agreement for 2D and 3D images and bursa measurement were 0.82 and 0.98, respectively. Bursas were visualised in 89/132 SpA enthesis (67.4%) vs. 27/46 enthesis (58.7%) of healthy controls (p<0.01), and 10/46 enthesis (21.7%) of RA controls (p<0.01). When the thicknesses of the bursas were analysed, the SpA group had a mean of 1.52±1.47 mm versus 0.76±0.76 mm in the healthy control group (p<0.0001), and 0.38±0.62 mm in the RA control group (p<0.0001). A positive likelihood ratio of 4.6 with a cut-off point of bursa >2 was found. No Doppler signal was detected in controls, but 6.6% of SpA Achilles enthesis had Doppler bursitis. Heel pain was more frequent when bursa was present (p<0.05). When Doppler was present, male predominance, HLA B27 positive, heel pain, and higher number of swollen joints, CRP levels, disease activity by the patient and BASDAI questions 2 and 3 achieved statistical significance (p<0.01).

CONCLUSIONS:
The presence of bursa and Doppler signal at retrocalcaneal bursa level could have a relevant contribution to differentiate SpA patients, and were correlated with clinical outcomes of SpA disease activity.
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