Ultrasound evaluation of greater trochanter pain syndrome in patients with spondyloarthritis: are there any specific features?

Although greater trochanter pain syndrome (GTPS) is a prevalent cause of musculoskeletal pain in the general population, there is lack of imaging studies searching for differential features of inflammatory enthesitis in GTPS. We analyzed the features of GTPS using sonography and magnetic resonance imaging (MRI) to identify useful differential signs between spondyloarthritis (SpA) and other inflammatory or non-inflammatory musculoskeletal diseases. All patients with unilateral GTPS attended by our Arthritis Unit between February 2011 and March 2012 were included. Patients were classified as having SpA or mechanical (without inflammatory musculoskeletal disease) GTPS. Rheumatoid arthritis (RA) patients were also included as inflammatory controls. Ultrasound scans of the painful and contralateral, asymptomatic, greater trochanter were made. We assessed the gluteus medius and gluteus minimus tendons for signs suggestive of tendinopathy. Random MRI of the same regions was made in a subgroup of patients to validate the ultrasound findings. A total of 107 patients with unilateral GTPS were included, of whom 96 were female, with a mean age of 61.6 years: 34 had SpA, 48 had non-inflammatory musculoskeletal disease, and 25 had RA. No specific sonographic features for SpA were found. Pathological findings were more frequent in patients without musculoskeletal inflammatory disease (mainly bursitis and erosions). A large number of alterations were found in the asymptomatic side (around 40 % had cortical irregularities and 20 % bursa effusion). Signs of enthesopathy were more prevalent in the gluteus minimus tendon, regardless of the diagnosis (54.2 % had erosions, 39.3 % bursitis, 38.3 % calcifications and 37.4 % tendinosis). No patient had power Doppler signal. Age was the main factor in the appearance of tendinopathy. MRI confirmed the changes detected by ultrasound in all 40 patients evaluated. GTPS in patients with SpA has similar sonographic findings to those observed in patients with RA and patients without musculoskeletal inflammatory disease. Neither sonography nor MRI was clinically useful in classifying GTPS as a manifestation of SpA.

Incidence of full-thickness rotator cuff tear after subacromial corticosteroid injection: a 12-week prospective study.

INTRODUCTION: Rotator cuff tears (RCT) are a common source of shoulder pain, with an incidence ranging between 5% and 40%. The influence of corticosteroid injections on the incidence of RCT remains unknown. The aim of this study was to estimate the incidence of full-thickness RCT 12 weeks after a subacromial corticosteroid injection in patients with shoulder pain. PATIENTS AND METHOD: We made a prospective, open-label study in patients with unilateral painful shoulder without previous local corticosteroid injection. Ultrasound assessments were made at the first (baseline) and last (Week 12) visits by an experienced radiologist. A rheumatologist did the clinical examination. Patients with full-thickness RCT at the first visit were excluded. All patients received a subacromial injection of triamcinolone acetate 40 mg. RESULTS: One hundred and two patients with shoulder pain were initially evaluated: 49 (48%) were excluded due to full-thickness RCT on ultrasound assessment. Therefore, 53 patients completed the study (34 female, mean age 60.8 years, mean time of evolution 9.6 months). In the first ultrasound evaluation, 24 patients (45.3%) had a partial-thickness tear. At 12 weeks after the corticosteroid injection, 9 (17%) patients developed full-thickness RCT, 66.6% of which occurred in patients with previous partial-thickness RCT. Corticosteroid injection significantly improved symptoms (p = 0.0001 for pain VAS score) and range of motion (p = 0.002 for forward elevation and external rotation). CONCLUSIONS: Seventeen percent of patients with shoulder pain suffered a full-thickness RCT 12 weeks after subacromial corticosteroid injection. Corticosteroid injection is highly effective in improving clinical symptoms of rotator cuff tendinopathy at 12 weeks.

Usefulness of high-resolution ultrasound for small nerve blocks: visualization of intercostobrachial and medial brachial cutaneous nerves in the axillary area.

INTRODUCTION: High-resolution ultrasound (HRU) allows one to identify small nerves, but in the clinical setting, intercostobrachial nerve (ICBN) and medial brachial cutaneous nerve (MBCN) are not identified with conventional portable ultrasound (CPU) devices. The aim of this study is to identify both nerves and describe their relation with specific anatomical structures which could be easily identified with the ultrasound devices available in the clinical setting. METHODS: 21 healthy patients were scanned using HRU bilaterally in the axillary area located over the conjoint tendon to find the ICBN and MBCN and describe their anatomic relations. 5 fresh cadavers were used to validate the previous anatomical findings. ICBN and MBCN ultrasound-guided block was performed with 5 mL of methylene blue and iodine contrast, and the distribution was assessed by both CT scan and dissection. RESULTS: ICBN and MBCN were identified in all cases. The average distance of the ICBN branches to the artery was 35±6 mm in men and 27±5 mm in women. Constant identification of the muscle-tendon junction of the latissimus dorsi muscle with respect to the location of the branches of the ICBN nerve was observed. Dissection and CT scan confirmed these findings. CONCLUSION: HRU is a useful tool to identify ICBN and MBCN nerves, and to describe structures which can be easily identified with CPU use in the clinical setting.

Patients with rheumatoid arthritis in clinical remission and ultrasound-defined active synovitis exhibit higher disease activity and increased serum levels of angiogenic biomarkers.

INTRODUCTION: The aim of this study was to identify and characterize subclinical synovitis in patients with rheumatoid arthritis (RA) in clinical remission using power Doppler ultrasound (PDUS) and serum levels of biomarkers of inflammation and/or angiogenesis. METHODS: We selected patients with RA in clinical remission defined as a Disease activity score of 28 joints (DAS28)-erythrocyte sedimentation rate (ESR) <2.6 for more than six months tested by two independent rheumatologists. Clinical, epidemiological, demographic and serological data were analyzed. PDUS of knees and hands was performed by a sonographer. Synovial hypertrophy (SH) and PDUS signal were scored (grades 0 to 3). SH ≥2 and a PDUS signal was classified as active synovitis. Serum levels of biomarkers of inflammation/angiogenesis were determined by Quantibody Human Array. RESULTS: This study included 55 patients, of whom 25 (45.4%) met criteria for ultrasound-defined active synovitis. Patients with active synovitis had higher DAS28-C reactive protein (P = 0.023), DAS28-ESR (P = 0.06), simplified disease activity score, SDAI (P = 0.064), and only 12% were taking oral glucocorticoids (≤5 mg/day) compared with 40% of patients without active synovitis (P = 0.044). Patients with synovitis also had significantly higher serum levels of the angiogenic biomarkers angiopoietin-2 (P = 0.038), vascular endothelial growth factor-D (P = 0.018), placental growth factor (P = 0.043), stromal cell-derived factor-1 (P = 0.035), matrix metallopeptidase-2 (P = 0.027) and basic fibroblast growth factor (bFGF) (P = 0.007), but not of pro-inflammatory cytokines. CONCLUSIONS: Nearly half of the patients with RA in clinical remission had ultrasound-defined active synovitis, higher disease activity and less frequent oral glucocorticoid consumption than patients without active synovitis. This clinical situation was associated with a specific biological profile characterized by an excess of angiogenic mediators rather than persistent proinflammatory cytokine responses.