Publish in this journal
Journal Information
Vol. 12. Issue 4.
Pages 206-209 (July - August 2016)
Vol. 12. Issue 4.
Pages 206-209 (July - August 2016)
Brief report
DOI: 10.1016/j.reumae.2015.08.002
Full text access
Discriminant Validity Study of Ultrasound Achilles Enthesis
Estudio sobre la validez discriminante de la ecografía de entesis aquílea
María Rosa Expósito Molineroa,
Corresponding author

Corresponding author.
, Eugenio de Miguel Mendietab
a Sección de Reumatología, Hospital Comarcal de Laredo, Cantabria, Spain
b Servicio de Reumatología, Hospital La Paz, Madrid, Spain
Article information
Full Text
Download PDF
Tables (2)
Table 1. Variables Corresponding to Each Study Group.
Table 2. Comparison Among the Study Groups.
Show moreShow less

We want to know if the ultrasound examination of the Achilles tendon in spondyloarthritis is different compared to other rheumatic diseases.

Materials and methods

We studied 97 patients divided into five groups: rheumatoid arthritis, spondyloarthritis, gout, chondrocalcinosis and osteoarthritis, exploring six elementary lesions in 194 Achilles entheses examined.


In our study the total index ultrasonographic Achilles is higher in spondyloarthritis with significant differences. The worst elementary spondyloarthritis lesions for discriminations against other pathologies were calcification.


This study aims to demonstrate the discriminant validity of Achilles enthesitis observed by ultrasound in spondyloarthritis compared with other rheumatic diseases that may also have ultrasound abnormalities such enthesis level.

Achilles’ tendon
Rheumatoid arthritis
Gouty arthritis

Analizar si la exploración ecográfica del tendón de Aquiles es diferente en las espondiloartritis respecto de otras enfermedades reumáticas.

Material y métodos

Se estudia a 97 pacientes divididos en 5 grupos: artritis reumatoide, espondiloartritis, gota, condrocalcinosis y artrosis, explorándose 6 lesiones elementales en las 194 entesis de Aquiles examinadas.


En nuestro estudio, el índice total ecográfico en tendón de Aquiles es mayor en el grupo de espondiloartritis con diferencias significativas. La lesión elemental que peor discrimina las espondilitis respecto de otras patologías es la presencia de calcificaciones.


Este estudio pretende demostrar la validez discriminante de la entesitis aquílea observada por ecografía en las espondiloartritis en comparación con otras enfermedades reumatológicas que también pueden presentar alteraciones ecográficas a nivel de dicha entesis.

Palabras clave:
Tendón de Aquiles
Artritis reumatoide
Artritis gotosa
Full Text

Enthesitis is the most characteristic condition in spondyloarthritides (SpA). In their article, “The enthesis organ concept and its relevance to the spondyloarthropathies”,1 Michael Benjamin and Dennis McGonagle propose this concept and use it to explain their understanding of this “organ”. It is thought to have a biomechanical basis that, in a context of genetic predisposition, triggers an autoinflammatory process that causes the disease affecting the entheseal fibrocartilage.2–4 The enthesis organ concept provides an explanation for the connection among bursitis, synovitis and enthesitis.5,6 The Achilles tendon has been considered an example of an enthesis organ.

On the other hand, ultrasound is a highly valuable tool in the diagnosis and assessment of the activity of inflammatory diseases. Several studies have validated ultrasound for the evaluation of entheses.

The ultrasound index of Balint et al. (the Glasgow Ultrasound Enthesitis Scoring System [GUESS])7 rates the Achilles tendon, plantar tendon, distal and proximal patellar ligaments and quadriceps tendon. The Sonographic Enthesitic Index of Alcalde et al.8 examines the same entheses, but distinguishes between acute and chronic lesions. D‘Agostino et al.9,10 introduced Doppler imaging to assess activity. Hamdi et al.11 correlated the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES for ultrasound) and a Doppler score with the visual analog scale (VAS) for pain, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), and the Ankylosing Spondylitis Quality of Life (ASQoL) instrument. Chronic ultrasound lesions did not correlate with any parameter.

In their study, De Miguel et al.12,13 used the Madrid Sonography Enthesitis Index (MASEI) to explore 6 entheses (the 5 mentioned above and a triceps tendon) and 6 variables (including Doppler signal) associated with the elementary lesions. They reported a sensitivity of 83.3% and a specificity of 82.8%. This may be the most sensitive method for evaluating inflammatory lesions and structural damage.

Evaluation of the discriminant validity of enthesis ultrasound has been limited to studies involving mechanical processes, healthy processes and SpA14 and, in some cases, rheumatoid arthritis (RA) (De Miguel et al.13; D’Agostino et al.9). However, until now, it has not been studied in other enthesopathies, like the microcrystalline diseases, which also affect the entheses.

Thus, the main objective of this study is to compare the discriminant validity of enthesis ultrasound in different models of rheumatic diseases.

On the other hand, the assessment of several entheses is too time-consuming to be easily carried out in routine practice; therefore, to improve the feasibility of this study of the discriminant power of ultrasound, we have focused on the Achilles enthesis, as it is the most representative example of these structures.

Materials and Methods

We performed a cross-sectional, observational, analytical study consisting of 5 arms. The study population was formed by the systematic consecutive recruitment of the first 3 patients to come to a hospital rheumatology department for examination of the lesions to be studied between September and November 2012, provided they consented to being enrolled. They were paired by sex and age. The study was approved by the hospital ethics committees. In addition to demographic data and the Disease Activity Score in 28 Joints (DAS28) for each patient, we recorded the BASDAI and VAS corresponding to the entheses examined.

Each patient underwent ultrasound of the Achilles tendon. The sonographer was blinded to the patient's clinical and diagnostic data. Ninety-seven patients (194 Achilles tendons) were examined and, according to the criteria they met for each disease, were included in 1 of 5 groups: AR (n=20), SpA (n=21), gout (n=17), chondrocalcinosis (CC; n=15) and osteoarthritis (OA; n=24).

Ultrasound Examination

The activity and structural damage were assessed by means of the ultrasound examination of 6 elementary lesions of the Achilles tendon. For this purpose, the sonographer underwent training in enthesis ultrasound and a rotation in the unit in which the MASEI had been created, achieving a good overall reliability, according to the kappa statistic and intraclass correlation coefficient.

The findings were scored according to the MASEI for the assessment of the elementary lesions:

  • Calcifications: none=0; <5mm=1; 5–10mm=2, and ossification >10mm=3.

  • Structure and thickness were scored as 0 when absent and 1 when present.

  • Bursa: present (>2mm)=1 and absent (<2mm)=0.

  • Erosions and Doppler signal: absent=0 and present=3.

We used a Logiq 5 ultrasound system from General Electric Healthcare, with a 12-MHz linear probe for gray scale images and a 6.6-MHz probe for power Doppler, with a 29-dB gain and a pulse repetition frequency of 0.4kHz.

Statistical Analysis

Analysis of variance (ANOVA) was performed to compare the ultrasound findings in the different subgroups. The values are expressed as the mean±standard deviation.

For the quantitative comparison between SpA and the other diseases, we used Student's t test for independent samples.

ResultsDemographic Data

Of the 97 patients, 49 were men (50.51%) and 48, women (49.48%) (Table 1). The mean age was 55.1±9.94 years. There were age-related differences in the numbers of patients with gout, CC and OA, as these diseases develop in older patients.

Table 1.

Variables Corresponding to Each Study Group.

  Achilles tendons (n)  Age (years)  Men (n)  Women (n)  Tendon VAS (0–10cm)  Ultrasound index (0–12) 
Rheumatoid arthritis  40  53.05  10  10  1.55  6.75 
Spondyloarthritis  42  50.02  10  11  2.28  9.61 
Gout  34  60.23  8.82 
Chondrocalcinosis  30  59.8  0.8  5.2 
Osteoarthritis  48  54.74  13  11  0.58  3.92 

VAS, visual analog scale.

The mean DAS28 was 3.3 in patients with RA and the BASDAI was 2.93 in those with SpA. The mean VAS score for the entheses was 1.4/10, being ≥2 in the patients with SpA and gout, 1.55 in those with RA and <1 in those with OA and CC.

Ultrasound Findings

The highest score on the ultrasound index corresponded to SpA and the lowest to OA. Table 2 shows the scores for the different elementary lesions.

Table 2.

Comparison Among the Study Groups.

  SD  SD  SD  SD  SD   
Age (years)  53.05  11.816  50.10  9.402  59.88  8.978  59.87  7.736  54.83  8.339  .007 
Calcification  2.60  0.940  3.00  1.483  3.06  1.197  3.60  0.737  2.79  0.977  .109 
Structure  1.15  0.875  1.33  0.913  1.41  0.795  0.53  0.834  0.42  0.717  .000 
Thickness  1.15  0.875  1.33  0.913  1.41  0.795  0.53  0.834  0.29  0.464  .000 
Erosion  0.90  1.714  2.00  2.191  0.71  1.312  0.00  0.000  0.00  0.000  .000 
Bursa  0.50  0.513  1.24  0.944  1.00  0.935  0.60  0.737  0.21  0.415  .000 
Doppler  0.45  1.099  0.71  1.309  1.24  2.386  0.00  0.000  0.13  0.612  .045 
Achilles MASEI  6.75  3.567  9.62  5.162  8.82  4.261  5.27  2.120  3.96  1.853  .000 
Tendon VAS  1.55  1.849  2.29  2.004  2.00  1.118  0.80  1.082  0.58  0.717  .001 

CC, chondrocalcinosis; GT, gout; M, mean; MASEI, Madrid Sonography Enthesitis Index; OA, osteoarthritis; RA, rheumatoid arthritis; SD, standard deviation; SpA, spondyloarthritis; VAS, visual analog scale.

The data are expressed as the mean±standard deviation.

The findings in SpA were compared with those recorded for each of the other 4 groups (Table 2).

  • 1.

    Spondyloarthritis vs RA: The overall ultrasound values and the value for retrocalcaneal bursitis were significantly higher in SpA. There were no significant differences in calcifications, structure, thickness or Doppler signal. The difference in the values for erosions nearly reached statistical significance.

  • 2.

    Spondyloarthritis vs gout: The only significant difference was recorded for erosions, which were more common in SpA.

  • 3.

    Spondyloarthritis vs CC: The values for structure, thickness, erosions, bursitis and Doppler signal were significantly higher in SpA, as was the overall ultrasound score. The value for calcifications was higher in CC, although the difference did not reach statistical significance.

  • 4.

    Spondyloarthritis vs OA: The values were significantly higher in SpA, with the exception of calcifications.


Until now, there had been no real discriminant validity studies of enthesis ultrasound; the studies had been limited to isolated reports involving healthy individuals or inflammatory diseases like RA.9,13,14 However, the entheses are frequently affected in microcrystalline diseases and in long-standing OA. In this respect, our study is original as it demonstrates, for the first time, the power of certain elementary lesions to discriminate among different diseases, and especially that of the MASEI score for Achilles enthesis, as compared to different models of rheumatic disease (autoimmune, degenerative and microcrystalline); this index only lacks discriminant validity in the evaluation of gout, although the score is also lower in the latter case.

We find it interesting that calcifications in the enthesis have no discriminant value, and that they are even slightly more intense in microcrystalline diseases. The presence of a Doppler signal was greater in SpA, but the difference was significant only with respect to CC and OA. Erosions are the most specific lesions for the diagnosis of SpA, showing significant differences with respect to all of the other diseases studied, with the exception of RA. On the other hand, retrocalcaneal bursitis was also more common in SpA, significantly more so than in RA, CC and OA.

A limitation to the study is the more advanced age of patients with microcrystalline diseases (gout and CC), a bias that is difficult to correct because these diseases develop at later ages. However, if this bias were to exist, it would be reflected in a greater frequency of calcific lesions, which would increase their overall incidence and, thus, their power as discriminating factors with respect to SpA. Thus, we consider that the discriminant validity is maintained. On the other hand, the inclusion of only elderly patients with inflammatory diseases would create a selection bias that would reduce the validity of the study, since the differential diagnosis is most important in the initial phases. Another limitation is the failure to carry out a collective study of the images or assess inter-reader agreement, although the criteria and measurements were standardized in the training received by the sonographers.

In conclusion, we present the first study using ultrasound in an enthesis to assess its value in discriminating among different diseases. We found that the incidences of some lesions, such as erosions and bursae, and the presence of Doppler signals differ significantly depending on the underlying disease. The MASEI in Achilles tendon shows a potential ability to differentiate between SpA and the other diseases studied, with the exception of gout. These findings should lead to further studies to confirm the discriminatory power of enthesis ultrasound.

Ethical DisclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of Interest

The authors declare they have no conflicts of interest.


We wish to thank the members of the nursing staff of the rheumatology department for their help and our patients for their generous collaboration in the study.

M. Benjamin, D. Mc Gonagle.
The enthesis organ concept and its relevance to the spondyloarthropathies.
Adv Exp Med Biol, 649 (2009), pp. 57-70
M. Benjamin, B. Moriggl, E. Brenner, P. Emery, D. McGonagle, S. Redman.
The enthesis organ concept: why enthesopathies may not present as focal insertional disorders.
Arthritis Rheum, 50 (2004), pp. 3306-3313
M. Benjamin, H. Toumi, J.R. Ralphs, G. Bydder, T.M. Best, S. Milz.
Where tendons and ligaments meet bone: attachment sites (‘entheses’) in relation to exercise and/or mechanical load.
M. Benjamin, D. McGonagle.
The anatomical basis for disease localisation in seronegative spondyloarthropathy at entheses and related sites.
J Anat, 199 (2001), pp. 503-526
J.L. Fernandez-Sueiro.
Enthesis as a target element in spondylarthritides.
Reumatol Clin, 2 (2006), pp. 31-35
D. McGonagle, H. Marzo-Ortega, P. O’Connor, W. Gibbon, P. Hawkey, K. Henshaw, et al.
Histological assessment of the early enthesitis lesion in spondyloarthropathy.
Ann Rheum Dis, 61 (2002), pp. 534-537
P.V. Balint, D. Kane, H. Wilson, I.B. McInnes, R.D. Sturrock.
Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy.
Ann Rheum Dis, 61 (2002), pp. 905-910
M. Alcalde, J.C. Acebes, M. Cruz, L. González-Hombrado, G. Herrero-Beaumont, O. Sánchez-Pernaute.
A Sonographic Enthesitic Index of lower limbs is a valuable tool in the assessment of ankylosing spondylitis.
Ann Rheum Dis, 66 (2007), pp. 1015-1019
M.A. D’Agostino, R. Said-Nahal, C. Hacquard-Bouder, J.L. Brasseur, M. Dougados, M. Breban.
Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler. A cross-sectional study.
Arthritis Rheum, 48 (2003), pp. 523-533
M.A. D’Agostino, P. Aegerter, S. Jousse-Joulin, I. Chary-Valckenaere, B. Lecoq, P. Gaudin, et al.
How to evaluate and improve the reliability of power doppler ultrasonography for assessing enthesitis in spondylarthritis.
Arthritis Rheum, 61 (2009), pp. 61-69
W. Hamdi, M. Chelli-Bouaziz, M.S. Ahmed, M.M. Ghannouchi, D. Kaffel, M.F. Ladeb, et al.
Correlations among clinical, radiographic, and sonographic scores for enthesitis in ankylosing spondylitis.
Joint Bone Spine, 10 (2010), pp. 29-40
E. De Miguel Mendieta, E. Rejón Geib.
Índices ecográficos en espondiloartritis.
Reumatol Clin, 6 (2010), pp. 37-40
E. De Miguel, S. Muñoz-Fernandez, C. Castillo, T. Cobo-Ibáñez, E. Martín-Mola.
Diagnostic accuracy of enthesis ultrasound in the diagnosis of early spondyloarthritis.
Ann Rheum Dis, 12 (2010), pp. 3-12
E. Filippucci, S. Zehra Aydin, O. Karadag, F. Salaffi, M. Gutierrez, H. Direskeneli, et al.
Reliability of high-resolution ultrasonography in the assessment of Achilles tendon enthesopathy in seronegative spondyloarthropathies.
Ann Rheum Dis, 68 (2009), pp. 1850-1855

Please cite this article as: Expósito Molinero MR, de Miguel Mendieta E. Estudio sobre la validez discriminante de la ecografía de entesis aquílea. Reumatol Clin. 2016;12:206–209.

Copyright © 2015. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
Reumatología Clínica (English Edition)

Subscribe to our newsletter

Article options
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.