https://doi.org/10.4081/reumatismo.2024.1717
Ultrasound assessment of Achilles enthesitis: a dedicated training program
Submitted: 18 February 2024
Accepted: 28 April 2024
Published: 24 September 2024
Accepted: 28 April 2024
Abstract Views: 159
PDF: 59
SUPPLEMENTARY MATERIAL: 8
SUPPLEMENTARY MATERIAL: 8
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Objective. To describe an intensive and multimodal ultrasound (US) training program focused on Achilles enthesitis and to illustrate the learning curve of trainees without experience.
Methods. 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.
Results. 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).
Conclusions. 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.
Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum 2006; 54: 2665-73.
DOI: https://doi.org/10.1002/art.21972
Rudwaleit M, van der Heijde D, Landewé R, Akkoc N, Brandt J, Chou CT, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011; 70: 25-31.
DOI: https://doi.org/10.1136/ard.2010.133645
Coates LC, Kavanaugh A, Mease PJ, Soriano ER, Acosta-Felquer ML, Armstrong AW, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 treatment recommendations for psoriatic arthritis. Arthritis Rheumatol 2016; 68: 1060-71.
DOI: https://doi.org/10.1002/art.39573
Gossec L, Baraliakos X, Kerschbaumer A, de Wit M, McInnes I, Dougados M, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis 2020; 79: 700-12.
DOI: https://doi.org/10.1136/annrheumdis-2020-217163
Bruyn GA, Iagnocco A, Naredo E, Balint PV, Gutierrez M, Hammer HB, et al. OMERACT definitions for ultrasonographic pathologies and elementary lesions of rheumatic disorders 15 years on. J Rheumatol 2019; 46: 1388-93.
DOI: https://doi.org/10.3899/jrheum.181095
Tom S, Zhong Y, Cook R, Aydin SZ, Kaeley G, Eder L, et al. Development of a preliminary ultrasonographic enthesitis score in psoriatic arthritis - GRAPPA ultrasound working group. J Rheumatol 2019; 46: 384-90.
DOI: https://doi.org/10.3899/jrheum.171465
Smerilli G, Di Matteo A, Cipolletta E, Grassi W, Filippucci E. Enthesitis in psoriatic arthritis, the sonographic perspective. Curr Rheumatol Rep 2021; 23: 75.
DOI: https://doi.org/10.1007/s11926-021-01039-1
Smerilli G, Cipolletta E, Di Carlo M, Di Matteo A, Grassi W, Filippucci E. Power doppler ultrasound assessment of A1 pulley. A new target of inflammation in psoriatic arthritis? Front Med 2020; 7: 204.
DOI: https://doi.org/10.3389/fmed.2020.00204
Molina Collada J, Macía-Villa C, Plasencia C, Álvaro-Gracia JM, de Miguel E. Doppler enthesitis: a potential useful outcome in the assessment of axial spondyloarthritis and psoriatic arthritis. Clin Rheumatol 2021; 40: 2013-20.
DOI: https://doi.org/10.1007/s10067-020-05450-4
Balint PV, Terslev L, Aegerter P, Bruyn GAW, Chary-Valckenaere I, Gandjbakhch F, et al. Reliability of a consensus-based ultrasound definition and scoring for enthesitis in spondyloarthritis and psoriatic arthritis: an OMERACT US initiative. Ann Rheum Dis 2018; 77: 1730-5.
DOI: https://doi.org/10.1136/annrheumdis-2018-213609
Filippucci E, Unlu Z, Farina A, Grassi W. Sonographic training in rheumatology: a self teaching approach. Ann Rheum Dis 2003; 62: 565-7.
DOI: https://doi.org/10.1136/ard.62.6.565
Taggart A, Filippucci E, Wright G, Bell A, Cairns A, Meenagh G, et al. Musculoskeletal ultrasound training in rheumatology: the Belfast experience. Rheumatology 2006; 45: 102-5.
DOI: https://doi.org/10.1093/rheumatology/kei162
Gutiérrez M, Di Geso L, Rovisco J, Di Carlo M, Ariani A, Filippucci E, et al. Ultrasound learning curve in gout: a disease-oriented training program. Arthritis Care Res 2013; 65: 1265-74.
DOI: https://doi.org/10.1002/acr.22009
Torralba KD, Cannella AC, Kissin EY, Bolster MB, Salto LM, Higgs J, et al. Musculoskeletal ultrasound instruction in adult rheumatology fellowship programs. Arthritis Care Res 2020; 72: 859-70.
DOI: https://doi.org/10.1002/acr.23336
Miguel C, De Miguel E, Batlle-Gualda E, Rejón E, Lojo L. Teaching enthesis ultrasound: experience of an ultrasound training workshop. Rheumatol Int 2012; 32: 4047-52.
DOI: https://doi.org/10.1007/s00296-011-2082-9
Zengin O, Onder ME. Educational quality of YouTube videos on musculoskeletal ultrasound. Clin Rheumatol 2021; 40: 4243-51.
DOI: https://doi.org/10.1007/s10067-021-05793-6
Terslev L, Naredo E, Iagnocco A, Balint PV, Wakefield RJ, Aegerter P, et al. Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise. Arthritis Care Res 2014; 66: 741-8.
DOI: https://doi.org/10.1002/acr.22191
Möller I, Janta I, Backhaus M, Ohrndorf S, Bong DA, Martinoli C, et al. The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology. Ann Rheum Dis 2017; 76: 1974-9.
DOI: https://doi.org/10.1136/annrheumdis-2017-211585
Kaeley GS. Enthesitis in psoriatic arthritis (Part 2): imaging. Rheumatology 2020; 59: i15-20.
DOI: https://doi.org/10.1093/rheumatology/keaa040
Filippucci E, Aydin SZ, Karadag O, Salaffi F, Gutierrez M, Direskeneli H, et al. Reliability of high-resolution ultrasonography in the assessment of Achilles tendon enthesopathy in seronegative spondyloarthropathies. Ann Rheum Dis 2009; 68: 1850-5.
DOI: https://doi.org/10.1136/ard.2008.096511
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-74.
DOI: https://doi.org/10.2307/2529310
Eder L, Aydin SZ, Kaeley GS, Maksymowych WP, Østergaard M. Options for assessing joints and entheses in psoriatic arthritis by ultrasonography and magnetic resonance imaging: how to move forward. J Rheumatol Suppl 2018; 94: 44-7.
DOI: https://doi.org/10.3899/jrheum.180140
Eder L, Aydin SZ, Kaeley GS. The role of ultrasound in research and clinical practice in psoriatic arthritis: highlights from the GRAPPA ultrasound workshop. J Rheumatol Suppl 2021; 97: 55-7.
DOI: https://doi.org/10.3899/jrheum.201677
Ayan G, Tinazzi I, Bakirci S, Gazel U, Solmaz D, Kalyoncu U, et al. Disease activity at the entheses and joints are correlated in psoriatic arthritis when explored with ultrasound. Clin Exp Rheumatol 2022; 40: 44-8.
DOI: https://doi.org/10.55563/clinexprheumatol/frrq75
Smerilli G, Cipolletta E, Destro Castaniti GM, Di Matteo A, Di Carlo M, Moscioni E, et al. Doppler signal and bone erosions at the enthesis are independently associated with ultrasound joint erosive damage in psoriatic arthritis. J Rheumatol 2023; 50: 70-5.
DOI: https://doi.org/10.3899/jrheum.210974
Aguila Maldonado R, Ruta S, Valuntas ML, García M. Ultrasonography assessment of heel entheses in patients with spondyloarthritis: a comparative study with magnetic resonance imaging and conventional radiography. Clin Rheumatol 2017; 36: 1811-7.
DOI: https://doi.org/10.1007/s10067-017-3723-5
Di Matteo A, Cipolletta E, Destro Castaniti GM, Smerilli G, Airoldi C, Aydin SZ, et al. Reliability assessment of the definition of ultrasound enthesitis in SpA: results of a large, multicentre, international, web-based study. Rheumatology 2022; 61: 4863-74.
DOI: https://doi.org/10.1093/rheumatology/keac162
Filippucci E, Smerilli G, Di Matteo A, Grassi W. Ultrasound definition of enthesitis in spondyloarthritis and psoriatic arthritis: arrival or starting point? Ann Rheum Dis 2021; 80: 1373-5.
DOI: https://doi.org/10.1136/annrheumdis-2021-220478
Helliwell PS. Assessment of enthesitis in psoriatic arthritis. J Rheumatol 2019; 46: 869-70.
DOI: https://doi.org/10.3899/jrheum.181380
Aydin SZ, Bakirci S, Kasapoglu E, Castillo-Gallego C, Alhussain FA, Ash ZR, et al. The relationship between physical examination and ultrasonography of large entheses of the Achilles tendon and patellar tendon origin. J Rheumatol 2020; 47: 1026-30.
DOI: https://doi.org/10.3899/jrheum.190169
Yamada Y, Inui K, Okano T, Mandai K, Mamoto K, Koike T, et al. Ultrasound assessment, unlike clinical assessment, reflects enthesitis in patients with psoriatic arthritis. Clin Exp Rheumatol 2021; 39: 139-45.
DOI: https://doi.org/10.55563/clinexprheumatol/u8qc6c
Fiorenza A, Bonitta G, Gerratana E, Marino F, Sarzi-Puttini P, Salaffi F, et al. Assessment of enthesis in patients with psoriatic arthritis and fibromyalgia using clinical examination and ultrasound. Clin Exp Rheumatol 2020; 38: 31-9.
van der Ven M, Karreman MC, Weel AE, Tchetverikov I, Vis M, Nijsten TEC, et al. Adding ultrasound to clinical examination reduced frequency of enthesitis in primary care psoriasis patients with musculoskeletal complaints. Clin Exp Rheumatol 2016; 34: 1020-5.
Naredo E, Bijlsma JW, Conaghan PG, Acebes C, Balint P, Berner-Hammer H, et al. Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses. Ann Rheum Dis 2008; 67: 1017-22.
DOI: https://doi.org/10.1136/ard.2007.082560
How to Cite
Smerilli, G., Cipolletta, E., Destro Castaniti, G., Pieroni, G., Sartini, G., Cenci, A., … Filippucci, E. (2024). Ultrasound assessment of Achilles enthesitis: a dedicated training program. Reumatismo. https://doi.org/10.4081/reumatismo.2024.1717
Copyright (c) 2024 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
Similar Articles
- F.M. Perrotta, E. Lubrano, New approved drugs for psoriatic arthritis , Reumatismo: Vol. 68 No. 2 (2016)
- M. Catanoso, N. Pipitone, C. Salvarani, Epidemiology of psoriatic arthritis , Reumatismo: Vol. 64 No. 2 (2012)
- G. Lapadula, A. Marchesoni, F. Salaffi, R. Ramonda, C. Salvarani, L. Punzi, L. Costa, F. Caso, D. Simone, G. Baiocchi, C. Scioscia, M. Di Carlo, R. Scarpa, G. Ferraccioli, Evidence-based algorithm for diagnosis and assessment in psoriatic arthritis: results by Italian DElphi in psoriatic Arthritis (IDEA) , Reumatismo: Vol. 68 No. 3 (2016)
- S.L. Bello, L. Serafino, C. Bonali, N. Terlizzi, C. Fanizza, C. Anecchino, G. Lapaldula, Incidence of influenza-like illness into a cohort of patients affected by chronic inflammatory rheumatism and treated with biological agents , Reumatismo: Vol. 64 No. 5 (2012)
- A. Marino, I. Pagnini, S. Savelli, D. Moretti, G. Simonini, R. Cimaz, Elbow monoarthritis: an atypical onset of juvenile idiopathic arthritis , Reumatismo: Vol. 64 No. 3 (2012)
- S. Iervolino, M. Lofrano, M.N.D. Di Minno, F. Foglia, R. Scarpa, R. Peluso, IgA deficiency evidence after anti-TNF-α treatment in a psoriatic arthritis patient: case report , Reumatismo: Vol. 64 No. 1 (2012)
- L. Bogliolo, G. Crepaldi, R. Caporali, Biomarkers and prognostic stratification in psoriatic arthritis , Reumatismo: Vol. 64 No. 2 (2012)
- S. Canestri, M.C. Totaro, E. Serone, B. Tolusso, D. Frezza, E. Gremese, G. Ferraccioli, Association between the response to B cell depletion therapy and the allele*2 of the HS1,2A enhancer in seropositive rheumatoid arthritis patients , Reumatismo: Vol. 64 No. 6 (2012)
- L. Punzi, R. Ramonda, Psoriatic arthritis. When the heterogeneity requires normality , Reumatismo: Vol. 64 No. 2 (2012)
- M. Taraborelli, F. Inverardi, M. Fredi, A. Ceribelli, I. Cavazzana, A. Tincani, F. Franceschini, Anti-cyclic citrullinated peptide antibodies in systemic lupus erythematosus patients with articular involvement: a predictive marker for erosive disease? , Reumatismo: Vol. 64 No. 5 (2012)
You may also start an advanced similarity search for this article.
