Inflamed retrocalcaneal bursa and Achilles tendonitis in psoriatic arthritis demonstrated by ultrasonography.
ABSTRACT To demonstrate the use of high resolution ultrasound measurements and power Doppler mode in the diagnosis and follow up of a patient with psoriatic arthritic with retrocalcaneal bursitis and Achilles tendonitis.
An outpatient based ATL HDI 3000 ultrasound equipment was used with a CL10-5 MHZ 26 mm probe and musculoskeletal software. Real time B mode and power Doppler mode were used to detect changes in structure and blood flow.
Unilateral retrocalcaneal bursitis and Achilles tendonitis were demonstrated by sonography. Power Doppler mode was useful to demonstrate an increased blood flow around an abnormal retrocalcaneal bursa. A follow up examination showed marginal thickening of the Achilles tendon without any bursitis.
Ultrasonography is an objective method in the confirmation of clinical diagnosis after physical examination. During the examination it is possible to gain not only qualitative but also quantitative data. A comparative study with quantitative data is possible in longitudinal studies.
- Arthritis & Rheumatism 07/1995; 38(6):736-42. · 7.48 Impact Factor
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ABSTRACT: The authors examined the role of ultrasound (US) in diagnosis and management of heel pain in chronic inflammatory arthritis. Nineteen patients underwent US examination. Eight patients (2 with previously unsuccessful nonguided injections), had 11 US-guided corticosteroid injections for treatment of retrocalcaneal bursitis (n = 6), plantar fasciitis (n = 3), and posterior tibial tenosynovitis (n = 2). US-demonstrated Achilles tendon rupture (n = 2), Achilles tendinitis (n = 8), posterior tibial tenosynovitis (n = 6), peroneus longus tenosynovitis (n = 2), retrocalcaneal bursitis (n = 13), and plantar fasciitis (n = 4). Loss of smooth bone contour (n = 13) correlated with bone erosions on plain radiographs in all but one case. Ten of 11 guided injections resulted in full resolution of heel pain. The diverse causes of heel pain are highlighted, and the ability of US to provide information with management implications is confirmed. US-guided corticosteroid injection is beneficial, especially after failure of nonguided injection.Seminars in Arthritis and Rheumatism 07/1996; 25(6):383-9. · 3.81 Impact Factor
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ABSTRACT: The aim of this pictorial essay is to describe the sonographic guided approach to investigation and local injection therapy of a small joint in a patient with psoriatic arthritis (PA). Sonographic pictures are obtained using a high frequency ultrasonography apparatus equipped with a 13-MHz transducer. Ultrasonography allows a careful morphostructural assessment of soft tissue involvement in PA patients. Sonographic findings include joint cavity widening, capsular thickening, synovial proliferation, synovial fluid changes, tendon sheath widening. Ultrasound guided placement of the needle within the joint and injection of corticosteroid under sonographic control can be easily performed. High frequency ultrasonography is a quick and safe procedure that allows a useful diagnostic and therapeutic approach in patients with arthritis of small joints.Annals of the Rheumatic Diseases 11/1999; 58(10):595-7. · 9.11 Impact Factor
NOW AND THEN
Inflamed retrocalcaneal bursa and Achilles
tendonitis in psoriatic arthritis demonstrated by
P V Balint, R D Sturrock
Objective—To demonstrate the use of high
resolution ultrasound measurements and
power Doppler mode in the diagnosis and
follow up of a patient with psoriatic
arthritic with retrocalcaneal bursitis and
Methods—An outpatient based ATL HDI
with a CL10–5 MHZ 26 mm probe and
musculoskeletal software. Real time B
mode and power Doppler mode were used
to detect changes in structure and blood
Results—Unilateral retrocalcaneal bursi-
tis and Achilles tendonitis were demon-
strated by sonography. Power Doppler
mode was useful to demonstrate an in-
creased blood flow around an abnormal
retrocalcaneal bursa. A follow up exami-
nation showed marginal thickening of the
Achilles tendon without any bursitis.
Conclusions—Ultrasonography is an ob-
jective method in the confirmation of
clinical diagnosis after physical examina-
tion. During the examination it is possible
to gain not only qualitative but also quan-
titative data. A comparative study with
quantitative data is possible in longitudi-
(Ann Rheum Dis 2000;59:931–933)
Over the past five years a number of editorials
have been written about the use of ultrasonog-
raphy in rheumatology practice.1–6Recently,
Grassi and colleagues reported the use of
ultrasonography in the evaluation of a patient
with psoriatic arthritis.7We report the use of
ultrasonography in following the natural his-
tory of Achilles tendonitis in a patient with
HLA-B27 negative psoriatic arthritis.
A 35 year old man with a two year history of
HLA-B27 negative psoriatic arthritis presented
to the rheumatology clinic with increasing right
heel pain. He was receiving sulfasalazine 2.5 g
and indometacin 75 mg twice daily for his
arthritis. Physical examination revealed a swol-
len and tender right Achilles tendon. In view of
his increased disease activity his dose of
sulfasalazine was increased from 2.5 to 3.5
ATL HDI 3000 ultrasound equipment with a
CL 10–5 MHZ 26 mm probe (linear array,
small footprint hockey-stick style transducer)
was used to image both Achilles tendons with-
out applying pressure. During the examination
the patient was in a prone position with his feet
freely hanging over the edge of the examination
table in a neutral position.After static examina-
tion a dynamic examination was performed
with the foot in slight dorsal and plantar
flexion. The Achilles tendon thickness was
measured on both sides. The power Doppler
mode was also used with the following
parameters: medium flow optimum, low wall
filter, dynamic range 55 dB, pulse repetition
first occasion.The left Achilles tendon thickness was in the normal range (0.47 cm).The
right Achilles tendon thickness was 0.95 cm.The retrocalcaneal bursa diameters were 0.59
cm and 0.42 cm.
Measurements of the bursa and the Achilles tendon in the sagittal plane on the
Ann Rheum Dis 2000;59:931–933931
Centre for Rheumatic
Glasgow G31 2ER, UK
P V Balint
R D Sturrock
Correspondence to: Dr
Accepted for publication
7 June 2000
frequency 1000 Hz. After one year a follow up
examination was performed. Scans were stored
in a magnetic optical disk drive.
Real time B mode ultrasonography confirmed
a thickening of the Achilles tendon and
retrocalcaneal fluid accumulation on the right
side. Left Achilles tendon thickness was in the
normal range (0.47 cm). The right Achilles
tendon thickness was 0.95 cm. The retrocalca-
neal bursa diameters were 0.59 cm and 0.42
cm (fig 1).
Power Doppler sonography showed in-
creased blood flow around the bursa in the
longitudinal and transverse section. One year
later when symptoms had clinically resolved,
repeat ultrasound examination did not detect a
power Doppler signal or fluid collection (figs 2
and 3). The right Achilles tendon was,
however, still thicker than the left side 0.60 cm
and 0.48 cm respectively (fig 4).On the normal
left Achilles tendon the diVerence in thickness
between the two examinations was only 0.01
cm, which demonstrates a small intraobserver
shows the patient’s first sagittal sonogram.The right image shows the control sonogram in the same position.PR =
proximal;D = distal;S = skin surface;A = Achilles tendon;C = calcaneus;F = fluid in the retrocalcaneal bursa.The green
frame signifies the area of a power Doppler scan and the red colour may indicate increased blood flow.
The middle image shows the sagittal scanning position of the distal part of the Achilles tendon.The left image
shows the patient’s first transverse sonogram.The right image shows the control sonogram in the same position.M =
medial;L = lateral;S = skin surface;A = Achilles tendon;F = fluid in the retrocalcaneal bursa.The green frame signifies
the area of a power Doppler scan and the red colour may indicate increased blood flow.
The middle image shows the transverse scanning position of the distal part of the Achilles tendon.The left image
occasion.The left Achilles tendon thickness was again in the normal range (0.48 cm).The
right Achilles tendon thickness (shown on the left hand side of the figure) was 0.60 cm.No
fluid could be detected on this occasion.
Measurements of the Achilles tendon in the sagittal plane on the second
Clinical examination will easily detect a
swollen Achilles tendon in most cases. How-
ever, to distinguish between Achilles tendoni-
tis, paratenonitis, and retrocalcaneal bursitis,
ultrasonography is required. The Achilles
tendon is a relatively large superficial structure,
which is easily imaged by ultrasound. Previ-
ously, this technique was described without8
and with a stand-oV pad9and pitfalls have been
recognised.10Normal and abnormal retrocalca-
previously.11–13Ultrasound guided aspiration
and corticosteroid injection have been used
with excellent results.14 15Cunnane and col-
leagues treated six of 13 patients with retrocal-
caneal bursitis with guided corticosteroid
injection and all responded well.15This group
included two patients who had had a number
of unsuccessful non-guided injections.Interest-
ingly, in all 13 cases retrocalcaneal bursitis was
associated with postero-superior calcaneal ero-
sions. In our case we could not demonstrate
any bony changes, probably owing to the short
duration of symptoms.
This case illustrates that ultrasonography
can detect pathological changes in Achilles
tendonitis and can monitor changes over a long
period of time. The use of the power Doppler
mode may be helpful in detecting increased
blood flow due to inflammation, but standardi-
sation of the technique to ensure reproducibil-
ity is diYcult.
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Achilles tendonitis in psoriatic arthritis