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Ultrasound for enthesitis: handle with care!

Enthesitis, the inflammation involving the insertion of tendons, ligaments and joint capsule is a characteristic sign and hallmark of several rheumatic diseases in both adult and paediatric patients. The change in the perception of enthesitis (ie, its growing significance as a clinicopathological entity) is best reflected in the new European League Against Rheumatism (EULAR) recommendations for psoriatic arthritis, which recommend antitumour necrosis factor therapy for patients with active enthesitis and/or dactylitis and insufficient response to non-steroidal anti-inflammatory drugs or local steroid injections.1 It is also one of three entry criteria (the other two being arthritis and dactylitis) for the new Assessment of SpondyloArthritis Society classification criteria for peripheral spondylarthritis.2 Broadly, enthesitis can be evaluated either clinically or by one of several imaging modalities that have been validated to various extents for the assessment thereof.

A recent systematic literature review that examined the US definition of enthesitis found large variability in the definitions utilised to outline enthesitis.3 Indeed, the appropriate definition of enthesitis and of its components remains an issue that is crucial for the evaluation of enthesitis with any given imaging modality. As of yet, we have no single examining modality that is capable of evaluating all of these components.

Clinical examination may aid in the detection of enthesitis when palpation is used to trigger pain or tenderness. However, it only allows the detection of soft tissue swelling, including tendon thickening and accompanying bursitis, two key features of enthesitis, while failing to provide information on typical bony changes, ie, bone erosions, enthesophytes and calcifications. Clinical evaluation has been shown to underestimate enthesitis involvement compared with imaging modalities.3,–,6 Contrary to clinical evaluation, conventional radiography is useful for assessing bony changes, as described …