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Do ankle, hindfoot, and heel ultrasound findings predict the symptomatology and quality of life in rheumatoid arthritis patients?

Oana Șerban
Oana Șerban
, 
Iulia Papp
Iulia Papp
, 
Corina Delia Bocșa
Corina Delia Bocșa
, 
Mihaela Cosmina Micu
Mihaela Cosmina Micu
, 
Maria Bădărînză
Maria Bădărînză
, 
Adriana Albu
Adriana Albu
 and 
Daniela Fodor
Daniela Fodor
   | Jun 15, 2020
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Article Category: research-article
Published Online: Jun 15, 2020
Page range: 70 - 82
Received: Nov 14, 2019
Accepted: Feb 16, 2020
DOI: https://doi.org/10.15557/jou.2020.0012
Keywords
© 2021 Polish Ultrasound Society. Published by Medical Communications Sp. z o.o.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Fig. 1.

Patient selection diagram. RA – rheumatoid arthritis; SpA – spondyloarthritis; SLE – systemic lupus erythematosus
Patient selection diagram. RA – rheumatoid arthritis; SpA – spondyloarthritis; SLE – systemic lupus erythematosus

Fig. 2.

Example of RA patients with hindfoot valgus. A. Clinical aspect of the left rearfoot of the patient, the blue lines depict the malalignment of the mid-calcaneal axis and mid-tibial axis, with the outward deviation of the mid-calcaneal axis. B. Baropodometric aspect of the left foot showing flat foot pattern with increased surface and pressure of the midfoot (MF) and increased pressure of the lateral and medial heel (LH, MH) represente by the predominant red color. C. Grade 2 subtalar joint synovitis (arrow) visible from the medial approach; T – extensor hallucis longus tendon; 1 – tibia; 2 – talus; 3 – calcaneus. D. Subtalar joint (arrow) visible from the lateral approach without visible synovitis; 1 – fibula; 2 – talus; 3 – calcaneus
Example of RA patients with hindfoot valgus. A. Clinical aspect of the left rearfoot of the patient, the blue lines depict the malalignment of the mid-calcaneal axis and mid-tibial axis, with the outward deviation of the mid-calcaneal axis. B. Baropodometric aspect of the left foot showing flat foot pattern with increased surface and pressure of the midfoot (MF) and increased pressure of the lateral and medial heel (LH, MH) represente by the predominant red color. C. Grade 2 subtalar joint synovitis (arrow) visible from the medial approach; T – extensor hallucis longus tendon; 1 – tibia; 2 – talus; 3 – calcaneus. D. Subtalar joint (arrow) visible from the lateral approach without visible synovitis; 1 – fibula; 2 – talus; 3 – calcaneus

Logistic regression for the prediction of symptomatic ankle

Predictor Unadjusted OR p-value Adjusted OR * p-value
BMI 1.1 0.027 1.34 0.001
Cortisone therapy 0.36 0.069
DAS28-CRP 1.7 0.01
RAPID3 1.13 0.005 1.2 0.028
Hindfoot valgus 3.45 0.022
Flat foot 1.7 0.284
TT SH PD+ 5.45 0.048
Lat ST SH 3.03 0.033 1.93 0.007
Post ST SH 11.18 0.03
Retrocalcaneal bursitis 3.18 0.03
Perifasciitis 3.8 0.047

Comparison of ultrasound findings for the ankle tendons between healthy controls (HC) and rheumatoid arthritis (RA) patients

Tendon US finding Grading HC (n = 70) RA (n = 70) p-value Asymptomatic RA ankle (n = 42 ankles) Symptomatic RA ankle (n = 28 ankles) p-value
TA TS Overall 0 5 (7.1) 0.048 4 (9.5) 1 (3.6) 0.641
Grade 1 0 4 (5.7) 0.075
Grade 2 0 0
Grade 3 0 1 (1.4)
PD+ Overall 0 1 (1.4) 0.316 0 1 (3.6) 0.400
Tendinosis Overall 2 (2.9) 1 (1.4) 0.559 1 (2.4) 0 0.411
EHL TS Overall 0 3 (4.3) 0.245 2 (4.8) 1 (3.6) 0.810
Grade 1 0 1 (1.4) 0.225
Grade 2 0 2 (2.9)
Grade 3 0 0
PD+ Overall 0 2 (2.9) 0.496 1 (2.4) 1 (3.6) 0.770
Tendinosis Overall 0 0 n/a 0 0 n/a
EDL TS Overall 0 2 (2.9)a 0.496 2 (4.8) 0 0.513
PD+ Overall 0 0 n/a 0 0 n/a
Tendinosis Overall 0 0 n/a 0 0 n/a
TP TS Overall 3 (4.3) 13 (18.6) 0.008 9 (21.4) 4 (14.3) 0.452
Grade 1 3 (4.3) 11 (15.7) 0.061
Grade 2 0 1 (1.4)
Grade 3 0 1 (1.4)
PD+ Overall 0 3 (4.2) 0.245 2 (4.8) 1 (3.6) 0.810
Tendinosis Overall 9 (12.9) 4 (5.7) 0.145 2 (4.8) 2 (7.1) 0.674
FHL TS Overall 0 3 (4.3)a 0.245 2 (4.8) 1 (3.6) 0.810
PD+ Overall 0 0 n/a 0 0 n/a
Tendinosis Overall 0 0 n/a 0 0 n/a
FDL TS Overall 0 2 (2.9)a 0.496 1 (2.4) 1 (3.6) 0.770
PD+ Overall 0 0 n/a 0 0 n/a
Tendinosis Overall 0 0 n/a 0 0 n/a
Peroneal TS Overall 0 7 (10.0) 0.013 5 (11.9) 2 (7.1) 0.694
Grade 1 0 6 (8.6) 0.025
Grade 2 0 1 (1.4)
Grade 3 0 0
PD+ Overall 0 1 (1.4) 0.316 1 (2.4) 0 0.411
Tendinosis Overall 0 7 (10.0) 0.013 4 (9.5) 3 (10.7) 0.871

Comparison of ultrasound findings for the ankle joint, tendon and heel structures between healthy controls (HC) and rheumatoid arthritis (RA) patients

US finding HC (n = 70) RA (n = 70) p-value Asymptomatic RA ankle (n = 42 ankles) Symptomatic RA ankle (n = 28 ankles) p-value
Joints
TT SH 8 (11.4) 49 (70.0) <0.001 28 (66.7) 21 (75.0) 0.456
PD+ 0 8 (11.4) 0.006 2 (4.8) 6 (21.4) 0.032
Osteophytes 4 (5.7) 7 (10.0) 0.346 5 (11.9) 2 (7.2) 0.694
Erosions 0 4 (5.7) 0.120 3 (7.1) 1 (3.6) 0.645
ST SH 3 (4.3) 47 (67.1) <0.001 31 (73.8) 16 (57.1) 0.146
PD+ 0 11 (15.7) 0.001 7 (16.7) 4 (14.3) 0.789
Osteophytes 8 (11.4) 1 (1.4) 0.033 0 1 (3.6) 0.400
Erosions 0 5 (7.1) 0.058 2 (4.8) 3 (10.7) 0.383
TN SH 9 (12.9) 44 (62.9) <0.001 26 (61.9) 18 (64.3) 0.840
PD+ 0 11 (15.7) 0.001 6 (14.3) 5 (17.9) 0.745
Osteophytes 26 (37.2) 16 (22.9) 0.065 10 (23.8) 6 (21.4) 0.816
Erosions 0 7 (10.0) 0.013 4 (9.5) 3 (10.7) 0.871
Tendons
TA TS 0 5 (7.1) 0.048 4 (9.5) 1 (3.6) 0.641
PD+ 0 1 (1.4) 0.316 0 1 (3.6) 0.400
Tendinosis 2 (2.9) 1 (1.4) 0.559 1 (2.4) 0 0.411
EHL TS 0 3 (4.3) 0.245 2 (4.8) 1 (3.6) 0.810
PD+ 0 2 (2.9) 0.496 1 (2.4) 1 (3.6) 0.770
Tendinosis 0 0 n/a 0 0 n/a
EDL TS 0 2 (2.9) 0.496 2 (4.8) 0 0.513
PD+ 0 0 n/a 0 0 n/a
Tendinosis 0 0 n/a 0 0 n/a
TP TS 3 (4.3) 13 (18.6) 0.008 9 (21.4) 4 (14.3) 0.452
PD+ 0 3 (4.2) 0.245 2 (4.8) 1 (3.6) 0.810
Tendinosis 9 (12.9) 4 (5.7) 0.145 2 (4.8) 2 (7.1) 0.674
FHL TS 0 3 (4.3) 0.245 2 (4.8) 1 (3.6) 0.810
PD+ 0 0 n/a 0 0 n/a
Tendinosis 0 0 n/a 0 0 n/a
FDL TS 0 2 (2.9) 0.496 1 (2.4) 1 (3.6) 0.770
PD+ 0 0 n/a 0 0 n/a
Tendinosis 0 0 n/a 0 0 n/a
Peroneal TS 0 7 (10.0) 0.013 5 (11.9) 2 (7.1) 0.694
PD+ 0 1 (1.4) 0.316 1 (2.4) 0 0.411
Tendinosis 0 7 (10.0) 0.013 4 (9.5) 3 (10.7) 0.871
Heel
Achilles tendon Enthesophytes 42 (60.0) 55 (78.6) 0.017 33 (78.6) 22 (78.6) 0.99
Retrocalcaneal bursitis 0 22 (31.4) <0.001 9 (21.4) 13 (46.4) 0.027
Posterior calcaneal erosions 4 (5.7) 11 (15.7) 0.046 5 (11.9) 6 (21.4) 0.328
Plantar fascia Plantar fasciitis 14 (20.0) 45 (64.3) <0.001 24 (57.1) 21 (75) 0.127
Perifasciitis 0 12 (17.1) <0.001 4 (9.5) 8 (28.6) 0.038
Inferior calcaneal erosions 0 11 (15.7) 0.001 7 (16.7) 4 (14.3) 0.789

Medial heel and lateral heel plantar pressure related to the presence of subtalar joint synovitis

Plantar region RA ST- RA ST+ p-value
Medial heel
Maximum pressure (kPa) 165 (55.5–267.5) 70 (41.5–184.5) 0.049
Mean pressure (kPa) 83 (29–134.5) 34 (19–81) 0.038
Lateral heel
Maximum pressure (kPa) 171 (52.5–290) 68 (43–180) 0.046
Mean pressure (kPa) 79 (27.5–121) 34 (18.5–79.5) 0.048
Total maximum pressure (kPa) 203.9 (58.85–267.15) 121.1 (45.45–193.05) 0.026
RA lat ST- RA lat ST+
Medial heel
Maximum pressure (kPa) 127 (49.5–237) 35 (31–101) 0.034
Mean pressure (kPa) 70 (25–96.5) 16 (15–53) 0.048
Lateral heel
Maximum pressure (kPa) 131 (51–249) 38 (31.5–94) 0.030
Mean pressure (kPa) 67 (24.5–106.5) 19 (15.5–48.5) 0.048
Total maximum pressure (kPa) 149.5 (54.25–266.25) 36.3 (30.25–86.85) 0.008

Demographic data of rheumatoid arthritis (RA) patients

RA (n = 35 patients) Asymptomatic ankle (n = 42 ankles) Symptomatic ankle (n = 28 ankles) p-value*
Sex (female) 30 (85.7) 38 (90.5) 22 (78.6) 0.183
Age 59.2 ± 11.25 59.5 ± 11.48 58.75 ± 10.88 0.737
BMI 26.49 ± 5.64 24.63 ± 5.18 27.74 ± 5.59 0.027
Flat foot 37 (52.9) 20 (47.6) 17 (60.7) 0.282
Calcaneus valgus 34 (48.6) 19 (45.2) 15 (53.6) 0.494
Disease duration (mo) 36 (12–132) 42 (18.75–105) 36 (12–192) 0.981
Seropositive 31 (88.6) 38 (90.5) 24 (85.7) 0.705
Disease stage
  I 5 (14.3) 6 (14.3) 4 (14.3) 0.975
  II 11 (31.4) 14 (33.3) 8 (28.6)
  III 14 (40) 16 (38.1) 12 (42.9)
  IV 5 (14.3) 6 (14.3) 4 (14.3)
Disease duration
  <6 months 5 (14.3) 4 (9.5) 6 (21.4) 0.183
  6–12 months 2 (5.7) 4 (9.5) 0 0.144
  1–2 years 4 (11.4) 5 (11.9) 3 (10.7) 0.878
  ≥2 years 24 (68.6) 29 (69.0) 19 (67.9) 0.916
Smokers 6 (17.1) 6 (14.3) 6 (21.4) 0.524
Treatment
  sDMARD 33 (94.3) 40 (95.2) 26 (92.9) >0.99
  Cortison 14 (40) 12 (28.6) 16 (57.1) 0.017
  bDMARD 7 (20) 10 (23.8) 4 (14.3) 0.329
  CDAI 19.87 ± 12.7 17.05 ± 11.32 24.11 ± 13.63 0.059
  DAS28-CRP 3.5 ± 1.34 3.15 ± 1.27 4.01 ± 1.28 0.013
  RAPID3 11.43 ± 6.6 9.54 ± 6.4 14.27 ± 5.89 0.002
  RAQoL 13 (4.5–19.5) 9.5 (1–17) 15 (7–22.75) 0.037

Comparison of ultrasound findings for the ankle joint between healthy controls (HC) and rheumatoid arthritis (RA) patients

Joint US finding Grading HC (n = 70) RA (n = 70) p-value Asymptomatic RA ankle (n = 42 ankles) Symptomatic RA ankle (n = 28 ankles) p-value
TT SH Overall 8 (11.4) 49 (70.0) <0.001 28 (66.7) 21 (75.0) 0.456
Grade 1 8 (11.4) 41 (58.6) <0.001 26 (61.9) 15 (53.6) 0.097
Grade 2 0 8 (11.4) 2 (4.8) 6 (21.4)
Grade 3 0 0 0 0
PD+ Overall 0 8 (11.4) 0.006 2 (4.8) 6 (21.4) 0.032
Osteophytes Overall 4 (5.7) 7 (10.0)a 0.346 5 (11.9) 2 (7.2) 0.694
Erosions Overall 0 4 (5.7) 0.120 3 (7.1) 1 (3.6) 0.645
Grade 1 0 3 (4.3) 0.128 2 (4.8) 1 (3.6) 0.689
Grade 2 0 1 (1.4) 1 (2.4) 0
Grade 3 0 0 0 0
ST SH Overall 3 (4.3) 47 (67.1) <0.001 31 (73.8) 16 (57.1) 0.146
Grade 1 3 (4.3) 36 (51.4) <0.001 24 (57.1) 12 (42.9) 0.261
Grade 2 0 10 (14.3) 7 (16.7) 3 (10.7)
Grade 3 0 1 (1.4) 0 1 (3.6)
PD+ Overall 0 11 (15.7) 0.001 7 (16.7) 4 (14.3) 0.789
Osteophytes Overall 8 (11.4) 1 (1.4)a 0.033 0 1 (3.6) 0.400
Erosions Overall 0 5 (7.1) 0.058 2 (4.8) 3 (10.7) 0.383
Grade 1 0 2 (2.9) 0.075 1 (2.4) 1 (3.6) 0.596
Grade 2 0 3 (4.3) 1 (2.4) 2 (7.2)
Grade 3 0 0 0 0
TN SH Overall 19 (12.9) 44 (62.9) <0.001 26 (61.9) 18 (64.3) 0.840
Grade 1 9 (12.9) 33 (47.1) <0.001 20 (47.6) 13 (46.4) 0.920
Grade 2 0 11 (15.7) 6 (14.3) 5 (17.9)
Grade 3 0 0 0 0
PD+ Overall 0 11 (15.7) 0.001 6 (14.3) 5 (17.9) 0.745
Osteophytes Overall 26 (37.2) 16 (22.9) 0.065 10 (23.8) 6 (21.4) 0.816
Grade 1 24 (34.3) 15 (21.4) 0.180 9 (21.4) 6 (21.4) 0.712
Grade 2 2 (2.9) 1 (1.4) 1 (2.4) 0
Grade 3 0 0 0 0
Erosions Overall 0 7 (10.0)a 0.013 4 (9.5) 3 (10.7) 0.871

Comparison of ultrasound findings for heel structures between healthy controls (HC) and rheumatoid arthritis (RA) patients

Heel US finding Grading HC (n = 70) RA (n = 70) p-value Asymptomatic ankle (n = 42 ankles) Symptomatic ankle (n = 28 ankles) p-value
Achilles tendon Enthesophytes Overall 42 (60.0) 55 (78.6) 0.017 33 (78.6) 22 (78.6) 0.99
Grade 1 40 (57.1) 30 (42.9) <0.001
Grade 2 2 (2.9) 24 (34.3)
Grade 3 0 1 (1.4)
Retrocalcaneal bursitis Overall 0 22 (31.4) <0.001 9 (21.4) 13 (46.4) 0.027
Grade 1 0 20 (28.6) <0.001
Grade 2 0 2 (2.9)
Grade 3 0 0
Posterior calcaneal erosions Overall 4 (5.7) 11 (15.7) 0.046 5 (11.9) 6 (21.4) 0.328
Grade 1 4 (5.7) 4 (5.7) 0.025
Grade 2 0 7 (10.0)
Grade 3 0 0
Plantar fascia Plantar fasciitis Overall 14 (20.0) 45 (64.3) <0.001 24 (57.1) 21 (75) 0.127
Perifasciitis Overall 0 12 (17.1) <0.001 4 (9.5) 8 (28.6) 0.038
Inferior calcaneal erosions Overall 0 11 (15.7) 0.001 7 (16.7) 4 (14.3) 0.789
Grade 1 0 8 (11.4) 0.003
Grade 2 0 3 (4.3)
Grade 3 0 0

Differences in the midfoot and rearfoot plantar pressures in rheumatoid arthritis (RA) patients and healthy control (HC) subjects

Plantar region HC RA p-value
Midfoot
Maximum pressure (kPa) 34.5 (26–48) 84 (22–160.5) 0.022
Mean pressure (kPa) 16 (10–21) 27 (10–61.5) 0.011
Surface (cm2) 25.55 (20.1–33.4) 16.3 (5.8–28.9) <0.001
Medial heel
Maximum pressure (kPa) 71 (62–79) 121.5 (47–223) 0.115
Mean pressure (kPa) 37 (32–41) 61 (21–89) 0.333
Surface (cm2) 20.85 (19–22.9) 14.75 (10.2–19.2) <0.001
Lateral heel
Maximum pressure (kPa) 64.5 (57–72) 125.5 (47–236) 0.052
Mean pressure (kPa) 34 (30–29) 61 (23–101) 0.213
Surface (cm2) 21.75 (19.8–24.2) 16.35 (10.2–19.6) <0.001
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