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    Clinical Examination, Ultrasound and MRI Imagingof The Painful Elbow in Psoriatic Arthritisand Rheumatoid Arthritis: Which is Better, Ultrasoundor MR, for Imaging Enthesitis?

    Clare Groves . Muthusamy Chandramohan . Ne Siang Chew .

    Tariq Aslam . Philip S. Helliwell

    Received: October 14, 2016 / Published online: February 8, 2017 The Author(s) 2017. This article is published with open access at


    Introduction: The purpose of the current studywas to examine the painful elbow, and in par-ticular enthesitis, in psoriatic arthritis (PsA) andrheumatoid arthritis (RA) using clinical exami-nation, ultrasonography (US) and magneticresonance imaging (MRI).Methods: Patients with elbow pain (11 with PsAand 9 with RA) were recruited. Clinical exami-nation, US and MRI studies were performed onthe same day. For enthesitis, the commonextensor and flexor insertions and the tricepsinsertionwere imaged (20 patients, giving a totalof 60 sites with comparative data). Imaging wasperformed with the radiologists blinded to thediagnosis and clinical findings. US was used toassess inflammatory activity (Power Dopplersignal, oedema, tendon thickening and bursalswelling) and damage (erosions, corticalroughening and enthesophytes). MRI was used

    to assess inflammation (fluid in paratenon,peri-entheseal soft-tissue oedema, enthesealenhancement with gadolinium, enthesealoedema and bone oedema) and damage (ero-sion, cortical roughening and enthesophyte).Results: Complete scan data were not availablefor all patients as one patient could not toleratethe MRI examination. No significant differencesin imaging scores were found between PsA andRA. Analysis of damage scores revealed com-plete agreement between US and MRI data in43/55 (78%) comparisons; in 10/55 (18%) casesthe US data were abnormal but the MRI datanormal; in 2/55 (4%) cases, the MRI data wereabnormal and the US data normal. Analysis ofthe inflammation scores revealed completeagreement between US and MRI data in 33/55(60%) comparisons; in 3/55 (5%) cases US datawere abnormal but MRI data normal; in 19/55(35%) cases the MRI data were abnormal andthe US data normal. There was a poor relation-ship between assessments based on clinicalexamination and imaging studies. Readerscould not accurately identify the disease fromimaging findings.Conclusion: Based on our results, at the elbow,US and MR have different roles in assessingenthesitis, with US apparently the better diag-nostic tool for assessing damage and MR thebetter tool for assessing inflammation. In thisstudy enthesitis and synovitis in the painfulelbow were found equally in cases of establishedRA and PsA.

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    C. Groves M. Chandramohan N. S. Chew T. Aslam P. S. HelliwellSt. Lukes Hospital, Bradford Teaching NHSFoundation Trust, Bradford, UK

    P. S. Helliwell (&)Leeds Institute of Rheumatic and MusculoskeletalMedicine, University of Leeds, Leeds, UKe-mail:

    Rheumatol Ther (2017) 4:7184

    DOI 10.1007/s40744-017-0053-7

  • Keywords: Enthesitis; Disease activity;Magnetic resonance imaging; Psoriaticarthritis; Rheumatoid arthritis; Ultrasound


    Enthesitis is an important aspect of spondy-loarthropathy. It plays a pivotal part in thespinal changes which occur in ankylosingspondylitis (AS) and may have a similar role inthe peripheral arthritis of psoriatic arthritis(PsA) and other spondyloarthropathies. Enthe-sitis is assessed separately in clinical studies ofAS and PsA and was placed in the outer circle(recommended for clinical trials) of domainsdetermined for PsA at the Outcomes inRheumatology Clinical Trials (OMERACT)meeting in Malta 2006 [1]. Further, enthesitisassessment is included in the domains in threecomposite measures of disease activity in PsA[24].

    RA is a different disease to PsA in terms ofgenetics, pathogenesis, presentation and out-come. It has been hypothesised that the pri-mary pathological lesion occurs in thesynovium in RA and at the enthesis in PsA [5].According to this hypothesis, synovitis in PsA isconsidered to be secondary to the extra-capsulardisease. On the other hand, a number ofauthors have recognised the occurrence ofenthesitis as part of the RA disease spectrum[68]. It is therefore clear that, by the time thepatient presents, both synovitis and enthesitismay occur in both conditions, occasionallymaking it difficult to distinguish between themon radiological grounds [9]. However, in estab-lished disease, differences have been descri-bedsymmetrical involvement, periarticularosteopenia and marginal erosions in RA; rela-tively preserved bone stock, paramarginal ero-sions, osteolysis, perisostitis and periarticularnew bone in PsA [10].

    A clinical enthesis index specific to PsA hasrecently been developed [11]. This indexexamines tenderness at six sites: lateral epi-condyles of the humerus, medial condyles ofthe femur and the insertion of the Achillestendon. The proximity of the lateral epicondyleof the humerus to the elbow joint (EJ)

    exemplifies the difficulties of separating enthe-seal from articular tenderness, particularlywhen both occur together. The aim of the studyreported here was threefold: firstly, to examinethe relationship between enthesitis and syn-ovitis by comparing data from clinical andimaging examinations of this anatomical areain PsA and RA; secondly, to examine the rela-tionship between clinical enthesitis and enthe-sitis found on imaging; thirdly, to compareultrasound (US) and magnetic resonance imag-ing (MRI) in terms of identifying features ofenthesitis. We hypothesised (1) that synovitiswould be more prominent in RA, and enthesitisin PsA; (2) that there would be a poor relation-ship between clinical enthesitis and enthesitisidentified by US and MRI; (3) that US wouldprovide more information than MRI on enthe-sitis at the elbow.


    Full ethical committee approval was given forthis study, and all patients provided theirsigned, informed consent to participate (Brad-ford REC approval 09/H1302/113). Subjectswere seen in rheumatology out-patient clinicsand, after consent procedures had been com-pleted, examined using a standard clinical pro-tocol. Patients with a physician diagnosis of PsAand RA were eligible if they complained of painin the elbow region. The protocol consisted ofgathering sufficient clinical information toassess the Classification of Psoriatic Arthritis(CASPAR) criteria [12], an acute phase markerand a swollen joint count. It included anassessment of the entheses at the elbow,namely, the common extensor origin (CEO) atthe lateral epicondyle, the common flexor ori-gin (CFO) at the medial epicondyle and thetriceps insertion. Pressure was exerted at theenthesis sufficient to blanch the thumb nail ofthe examiner (approximately 4 kg). In addition,the examiner assessed the presence of soft-tissueswelling at the enthesis and performed stresstesting at each site (for medial and lateral epi-condyles, resisted extension and flexion of thewrist with the arm fully extended; for triceps,resisted extension of the elbow).

    72 Rheumatol Ther (2017) 4:7184

  • Active inflammatory arthritis in the EJ wasassessed by palpation. For the radio-humeralcomponent (RHJ) the examiner faced thepatient and grasped the hand of the patient in agentle handshake (with the right hand for theright RHJ and the left hand for the left RHJ).With the thumb of the other hand the examinerthen palpated over the RHJ while supinating/pronating the forearm. Tenderness and pain onmovement indicated a positive test. Swelling atthis location could not reliably be identified.For the EJ the examiner palpated the joint lineanteriorly and the groove between the lateralepicondyle and the olecranon process, notingsoft-tissue swelling and tenderness at this point.Articular damage was scored if the patient hadmore than 50% loss of movement and/or hadbony swelling of the joint margins.

    The US and MRI examinations were carriedout on the same day as the clinical evaluation,with the US images assessed by one radiologistand the MRI images assessed by a second radi-ologist; each radiologist was blinded to thediagnosis and to the findings of the otherimaging modality. After each radiologicalexamination, the radiologists made a decisionon the diagnosis based on their respectiveinterpretation of the imaging data. Each radi-ologist had over 15 years of experience in mus-culoskeletal radiology. A third radiologistperformed a second reading of both the MRIand (static) US scans; this radiologist was alsoblinded to the diagnosis and to the findings ineach imaging modality.

    Ultrasound Protocol

    The scans were performed on a Siemens S2000machine using a 10-15 MHz linear probe (Sie-mens AG, Munich, Germany). The sono-graphic assessments were made at the CEO, theCFO and the attachment of the triceps tendonat the olecranon. The CEO (anatomically at thelateral epicondyle of the elbow) was examinedwith the patient seated and the hand restingon the knee with the elbow slightly flexed andthe wrist in gentle internal rotation. The CFO(anatomically at the medial epicondyle of theelbow) was examined with the arm fully

    extended and the arm resting on the knee withthe palm facing anteriorly. Grey scale imagingin the longitudinal and transverse planes wasused to assess the enthesis for the presence oferosions, enthesophytes, entheseal thickeningand p