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Muhsen A, Hertz A, Amital H. The association between physical trauma and autoimmune articular and dermatological disorders. Autoimmun Rev 2025; 24:103711. [PMID: 39586388 DOI: 10.1016/j.autrev.2024.103711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Accepted: 11/22/2024] [Indexed: 11/27/2024]
Abstract
OBJECTIVE This review investigates the association between physical trauma and the onset and progression of various inflammatory diseases, including psoriatic arthritis (PsA), rheumatoid arthritis (RA), spondyloarthropathies (SpA), and Familial Mediterranean Fever (FMF). In addition, we will refer to the linkage between physical injury and skin manifestations in patients with psoriasis, sarcoidosis and systemic sclerosis. The aim is to summarize the current evidence and explore the potential mechanisms through which trauma may affect these conditions. METHODS A detailed literature review was conducted, focusing on studies linking physical trauma with the development of psoriasis, SpA, PsA, RA, FMF, systemic sclerosis and sarcoidosis. The review includes observational data, case reports, and experimental studies that highlight the impact of trauma on disease initiation and exacerbation. RESULTS Physical trauma is implicated in the pathogenesis of several dermatological and rheumatological conditions. Biomechanical stress and microdamage at entheses contribute to the development of SpA. In PsA, trauma is associated with the onset of enthesitis and arthritis, supported by increased prevalence in affected patients and is often regarded as "deep Koebner phenomenon". The Koebner phenomenon links skin trauma with psoriasis, where new lesions appear at injury sites. RA shows a notable association with physical trauma, with retrospective studies suggesting that trauma can trigger disease onset, although the exact mechanisms remain unclear. The concept of the synovio-entheseal complex is discussed in order to elucidate how mechanical stress and immune responses interplay in SpA. Physical exertion or injury might precipitate FMF attacks, though existing data remain limited. Sarcoidosis has been linked to tattoo-related trauma, suggesting a potential role of localized injury in sarcoid-like reactions. Several case reports describe the occurrence of dermatologic manifestations of scleroderma, including morphea in patients with localized disease and perifollicular hypopigmentation in patients with systemic sclerosis. CONCLUSION This review consolidates current evidence on the relationship between physical trauma and various inflammatory conditions, emphasizing the need for further research to fully understand these connections. These findings highlight the importance of considering trauma in the clinical management of these diseases and suggest avenues for future investigation.
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Affiliation(s)
- Aia Muhsen
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Adi Hertz
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Howard Amital
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
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Rothschild B. Entheseal surface (Sharpey's fiber insertion) alterations identify past trauma; bone base robusticity, level of routine activity. Anat Rec (Hoboken) 2024; 307:3884-3891. [PMID: 38838074 DOI: 10.1002/ar.25515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
Sharpey's fiber alterations, referred to as entheseal reaction or enthesopathy, have long been considered an indicator of daily activities. Such semantic transformation seems to conflate processes which alter the characteristics of tendonous and ligamentous attachments to bone with the rugosity and extent of their base/footprint. Rather than reflecting normal activities, it is suggested that surface reactions are actually the response to the application of sudden or unconditioned repetitive stresses-analogous to stress fractures. Thus, they are distinct from enlargement of the base/footprint, the bone remodeling process responsible for the robusticity of the area to which the enthesis attaches, which is actually a measure of actual muscle activity. Surface reactions in attachment areas represent injury, be it mechanical stress fracture-equivalents or inflammation-derived. Bone base/footprint is the reaction of the enthesis to stresses of routine physical activities. The character of underlying bone supporting Sharpey's fibers may be augmented by applied stress, but there is neither a physiologic mechanism nor is there evidence for significant addition of Sharpey's fibers beyond ontogeny. Behavior is responsible for the physiologic response of robusticity; spiculation, pathology.
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Rothschild BM. Clinical implications of reconsideration of enthesitis/enthesopathy/enthesial erosion, as tendon attachment-localized avulsions and stress fracture equivalents. World J Orthop 2024; 15:902-907. [DOI: 10.5312/wjo.v15.i10.902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 08/27/2024] [Accepted: 09/13/2024] [Indexed: 10/11/2024] Open
Abstract
Recognizing the mechanical origin of enthesitis/enthesopathy and the avulsion-nature of what had previously been considered erosions, it seems inappropriate to attribute it to stresses related to a person’s normal activities. Conversely, sudden or unconditioned repetitive stresses appears the more likely culprit. Studies of enthesial reaction have lacked standardization as to findings present among individuals who appear to be healthy. Clinical evaluation by palpation and manipulation may be as effective as application of radiologic techniques. Recognition of the mechanical nature of the disease, including individuals with inflammatory arthritis suggests prescription of mechanical solutions that reduce stresses across the involved enthesis.
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Affiliation(s)
- Bruce M Rothschild
- Department of Medicine, Indiana University Ball Memorial Hospital, Muncie, IN 47303, United States
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Iyer P, Hwang M, Ridley L, Weisman MM. Biomechanics in the onset and severity of spondyloarthritis: a force to be reckoned with. RMD Open 2023; 9:e003372. [PMID: 37949613 PMCID: PMC10649803 DOI: 10.1136/rmdopen-2023-003372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023] Open
Abstract
Increasing evidence suggests that there is a pivotal role for physical force (mechanotransduction) in the initiation and/or the perpetuation of spondyloarthritis; the review contained herein examines that evidence. Furthermore, we know that damage and inflammation can limit spinal mobility, but is there a cycle created by altered spinal mobility leading to additional damage and inflammation?Over the past several years, mechanotransduction, the mechanism by which mechanical perturbation influences gene expression and cellular behaviour, has recently gained popularity because of emerging data from both animal models and human studies of the pathogenesis of ankylosing spondylitis (AS). In this review, we provide evidence towards an appreciation of the unsolved paradigm of how biomechanical forces may play a role in the initiation and propagation of AS.
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Affiliation(s)
- Priyanka Iyer
- Division of Rheumatology, Department of Medicine, UC Irvine Healthcare, Orange, California, USA
| | - Mark Hwang
- Rheumatology, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - Lauren Ridley
- Rheumatology, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
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Canoso JJ, Saavedra MA, Naredo E. To Diagnose Enthesitis Clinically, Should the Entheses Be Put to Work? J Rheumatol 2022; 49:974-976. [PMID: 35365581 DOI: 10.3899/jrheum.211052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Juan J Canoso
- J.J. Canoso, MD, Department of Medicine, ABC Medical Center, Mexico City, Mexico, and Division of Rheumatology, Tufts University School of Medicine, Boston, Massachusetts, USA;
| | - Miguel A Saavedra
- M.A. Saavedra, MD, Department of Medicine, Specialties Hospital "Antonio Fraga Mouret," National Medical Center La Raza, and Postgraduate Division, National Autonomous University of Mexico, Mexico City, Mexico
| | - Esperanza Naredo
- E. Naredo, MD, Department of Rheumatology, Bone and Joint Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, and Universidad Autónoma de Madrid, Madrid, Spain
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Liu CH, Raj S, Chen CH, Hung KH, Chou CT, Chen IH, Chien JT, Lin IY, Yang SY, Angata T, Tsai WC, Wei JCC, Tzeng IS, Hung SC, Lin KI. HLA-B27-mediated activation of TNAP phosphatase promotes pathogenic syndesmophyte formation in ankylosing spondylitis. J Clin Invest 2020; 129:5357-5373. [PMID: 31682238 DOI: 10.1172/jci125212] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 09/03/2019] [Indexed: 12/31/2022] Open
Abstract
Ankylosing spondylitis (AS) is a type of axial inflammation. Over time, some patients develop spinal ankylosis and permanent disability; however, current treatment strategies cannot arrest syndesmophyte formation completely. Here, we used mesenchymal stem cells (MSCs) from AS patients (AS MSCs) within the enthesis involved in spinal ankylosis to delineate that the HLA-B27-mediated spliced X-box-binding protein 1 (sXBP1)/retinoic acid receptor-β (RARB)/tissue-nonspecific alkaline phosphatase (TNAP) axis accelerated the mineralization of AS MSCs, which was independent of Runt-related transcription factor 2 (Runx2). An animal model mimicking AS pathological bony appositions was established by implantation of AS MSCs into the lumbar spine of NOD-SCID mice. We found that TNAP inhibitors, including levamisole and pamidronate, inhibited AS MSC mineralization in vitro and blocked bony appositions in vivo. Furthermore, we demonstrated that the serum bone-specific TNAP (BAP) level was a potential prognostic biomarker to predict AS patients with a high risk for radiographic progression. Our study highlights the importance of the HLA-B27-mediated activation of the sXBP1/RARB/TNAP axis in AS syndesmophyte pathogenesis and provides a new strategy for the diagnosis and prevention of radiographic progression of AS.
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Affiliation(s)
- Chin-Hsiu Liu
- Division of Allergy, Immunology and Rheumatology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan.,PhD Program in Translational Medicine, Kaohsiung Medical University and Academia Sinica, Taipei, Taiwan.,Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Sengupta Raj
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, United Kingdom
| | - Chun-Hsiung Chen
- Division of Allergy, Immunology and Rheumatology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kuo-Hsuan Hung
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Chung-Tei Chou
- National Yang-Ming University, Taipei, Taiwan.,Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ing-Ho Chen
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jui-Teng Chien
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Department of Orthopedics, Chiayi Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi County, Taiwan
| | - I-Ying Lin
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Shii-Yi Yang
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Takashi Angata
- Institute of Biological Chemistry, Academia Sinica, Taipei, Taiwan
| | - Wen-Chan Tsai
- Division of Rheumatology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University and Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - I-Shiang Tzeng
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Chieh Hung
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan.,Integrative Stem Cell Center, Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan.,Institute of New Drug Development, New Drug Development Center, China Medical University, Taichung, Taiwan
| | - Kuo-I Lin
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
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Zhang B, Qu TB, Pan J, Wang ZW, Zhang XD, Ren SX, Wen L, Chen T, Ma DS, Lin Y, Cheng CK. Open Patellar Tendon Tenotomy and Debridement Combined with Suture-bridging Double-row Technique for Severe Patellar Tendinopathy. Orthop Surg 2017; 8:51-9. [PMID: 27028381 DOI: 10.1111/os.12220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/05/2015] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To create a new surgical procedure for chronic severe patellar tendinopathy and to evaluate its clinical efficacy. METHODS In this retrospective study, the data of 12 patients with severe patellar tendinopathy in 14 knees who had undergone surgical treatment at Beijing Chao-Yang Hospital between 1 March 2009 and 1 August 2013 were analyzed. Inclusion criteria included severe patellar tendinopathy (Phase III), conservative therapy for more than 6 months, American Society of Anesthesiology status Grade I-II, and body mass index <30. Patients with severe osteoporosis, complete tendon disruption (Phase IV) and those who were unable to cooperate were excluded. There were 8 men (10 knees) and 4 women (4 knees) cases. The patients' ages ranged from 38 to 54 years (mean, 45.3 years). All surgeries had been performed by the same physician. Surgical treatment comprised incising open patellar midline tenotomy, complete debridement and suture-bridging double-row fixation. Isotonic and kinetic chain exercises were implemented after the second post-operative week. A gradual increase to full weight-bearing was allowed after the third post-operative week and a gradual return to unrestricted use of the leg after the eighth post-operative week. Preoperative and postoperative visual analogue scale (VAS) scores and Lysholm knee scores were obtained from the medical records or at recent postoperative follow-up visits and the results compared using Student's two-tailed paired t-test. RESULTS VAS scores decreased by a mean of 6.7 points (range, 1.1-7.8 points) during follow-up (minimum duration 14 months; range, 14-44 months) and Lysholm scores increased from 55.7 ± 6.5 points to 90.4 ± 6.2 points. Three cases (4 knees) achieved excellent outcomes (≥95 points) and 9 cases (10 knees) good outcomes (range, 86-94 points). No intraoperative or postoperative complications occurred. There were significant differences between preoperative and postoperative VAS and Lysholm scores (P < 0.01). CONCLUSIONS All study patients achieved good or excellent outcomes. No patellar tendon rupture or suture fixation failure occurred during follow-up. Suture-bridging double-row fixation is a simple and reliable method that not only improves patients' clinical symptoms, but also restores knee joint function.
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Affiliation(s)
- Bo Zhang
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Tie-Bing Qu
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jiang Pan
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhi-Wei Wang
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiao-Dong Zhang
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Shi-Xiang Ren
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liang Wen
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Tong Chen
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - De-Si Ma
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuan Lin
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Cheng-Kung Cheng
- International Research Center for Implantable and Interventional Medical Devices, Beihang University, Beijing, China.,Department of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan
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8
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Affiliation(s)
- Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, , Leeds, UK
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9
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Falsetti P, Acciai C, Lenzi L, Frediani B. Ultrasound of enthesopathy in rheumatic diseases. Mod Rheumatol 2014. [DOI: 10.3109/s10165-008-0129-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Paolo Falsetti
- Department of Clinical Medicine and Immunological Sciences, Rheumatology Section, University of Siena,
viale Bracci, 53100 Siena, Italy
- Department of Rehabilitation, S. Donato Hospital,
via P. Nenni 52100 Arezzo, Italy
| | - Caterina Acciai
- Department of Clinical Medicine and Immunological Sciences, Rheumatology Section, University of Siena,
viale Bracci, 53100 Siena, Italy
- Department of Rehabilitation, S. Donato Hospital,
via P. Nenni 52100 Arezzo, Italy
| | - Lucia Lenzi
- Department of Rehabilitation, S. Donato Hospital,
via P. Nenni 52100 Arezzo, Italy
| | - Bruno Frediani
- Department of Clinical Medicine and Immunological Sciences, Rheumatology Section, University of Siena,
viale Bracci, 53100 Siena, Italy
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10
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Foot tendinopathies in rheumatic diseases: etiopathogenesis, clinical manifestations and therapeutic options. Clin Rheumatol 2012; 32:547-55. [DOI: 10.1007/s10067-012-2158-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 12/19/2012] [Indexed: 10/27/2022]
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Integrative structural biomechanical concepts of ankylosing spondylitis. ARTHRITIS 2011; 2011:205904. [PMID: 22216409 PMCID: PMC3246302 DOI: 10.1155/2011/205904] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 10/06/2011] [Accepted: 10/07/2011] [Indexed: 12/17/2022]
Abstract
Ankylosing spondylitis (AS) is not fully explained by inflammatory processes. Clinical, epidemiological, genetic, and course of disease features indicate additional host-related risk processes and predispositions. Collectively, the pattern of predisposition to onset in adolescent and young adult ages, male preponderance, and widely varied severity of AS is unique among rheumatic diseases. However, this pattern could reflect biomechanical and structural differences between the sexes, naturally occurring musculoskeletal changes over life cycles, and a population polymorphism. During juvenile development, the body is more flexible and weaker than during adolescent maturation and young adulthood, when strengthening and stiffening considerably increase. During middle and later ages, the musculoskeletal system again weakens. The novel concept of an innate axial myofascial hypertonicity reflects basic mechanobiological principles in human function, tissue reactivity, and pathology. However, these processes have been little studied and require critical testing. The proposed physical mechanisms likely interact with recognized immunobiological pathways. The structural biomechanical processes and tissue reactions might possibly precede initiation of other AS-related pathways. Research in the combined structural mechanobiology and immunobiology processes promises to improve understanding of the initiation and perpetuation of AS than prevailing concepts. The combined processes might better explain characteristic enthesopathic and inflammatory processes in AS.
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Villotte S, Castex D, Couallier V, Dutour O, Knüsel CJ, Henry-Gambier D. Enthesopathies as occupational stress markers: evidence from the upper limb. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 2010; 142:224-34. [PMID: 20034011 DOI: 10.1002/ajpa.21217] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Enthesopathies--that is, "musculo-skeletal stress markers"--are frequently used to reconstruct past lifestyles and activity patterns. Relatively little attention has been paid in physical anthropology to methodological gaps implicit in this approach: almost all methods previously employed neglect current medical insights into enthesopathies and the distinction between healthy and pathological aspects has been arbitrary. This study presents a new visual method of studying fibrocartilaginous enthesopathies of the upper limb (modified from Villotte: Bull Mém Soc Anthropol Paris n.s. 18 (2006) 65-85), and application of this method to 367 males who died between the 18th and 20th centuries, from four European identified skeletal collections: the Christ Church Spitalfields Collection, the identified skeletal collection of the anthropological museum of the University of Coimbra, and the Sassari and Bologna collections of the museum of Anthropology, University of Bologna. The analysis, using generalized estimating equations to model repeated binary outcome variables, has established a strong link between enthesopathies and physical activity: men with occupations involving heavy manual tasks have significantly (P-value < 0.001) more lesions of the upper limbs than nonmanual and light manual workers. Probability of the presence of an enthesopathy also increases with age and is higher for the right side compared with the left. Our study failed to distinguish significant differences between the collections when adjusted for the other effects. It appears that enthesopathies can be used to reconstruct past lifestyles of populations if physical anthropologists: 1) pay attention to the choice of entheses in their studies and 2) use appropriate methods.
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Affiliation(s)
- Sébastien Villotte
- Laboratoire d'Anthropologie des Populations du Passé, UMR PACEA 5199, CNRS - Université Bordeaux 1, Talence, France.
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Falsetti P, Acciai C, Lenzi L, Frediani B. Ultrasound of enthesopathy in rheumatic diseases. Mod Rheumatol 2008; 19:103-13. [PMID: 19002749 DOI: 10.1007/s10165-008-0129-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 09/08/2008] [Indexed: 11/24/2022]
Abstract
Enthesopathy is the pathologic change of the insertion of tendons, ligaments and joint capsules on the bone. It is a cardinal feature of spondyloarthropathies (SpA), but it can occur in other rheumatic disease. Recent studies using magnetic resonance imaging (MRI) and ultrasonography (US) have demonstrated that enthesopathy can often be asymptomatic, in both the axial and peripheral skeleton. Therefore, a systematic US study of peripheral entheses could be useful in the diagnostic process of patients with rheumatic diseases, in particular SpA. Recently, power Doppler US (PDUS) has been proved to be useful for differentiating mechanical/degenerative and inflammatory enthesopathy and for monitoring the efficacy of therapy. This article reviews the main histopathologic aspects of enthesopathy and describes the normal US features of enthesis and the basic US features of enthesopathy, in its various stages. The usefulness of US and PDUS in the diagnosis and assessment of enthesopathy is discussed on the basis of the literature and our experience.
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Affiliation(s)
- Paolo Falsetti
- Department of Clinical Medicine, Rheumatology Section, University of Siena, viale Bracci, 53100 Siena, Italy.
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François RJ, Braun J, Khan MA. Entheses and enthesitis: a histopathologic review and relevance to spondyloarthritides. Curr Opin Rheumatol 2001; 13:255-64. [PMID: 11555725 DOI: 10.1097/00002281-200107000-00003] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There are two types of entheses: fibrous, by Sharpey's fibers in membranous bone, and fibrocartilaginous, on endochondral bone, with discontinuous cement lines at the interface between insertion and bone. The connection of hyaline cartilage to subchondral bone is a kind of fibrocartilaginous enthesis. Fibrocartilages are structurally, chemically, and biomechanically intermediate between tendon and cartilage. Enthesitis is not the sole pathologic feature of spondyloarthritides. Synovitis and subchondral bone marrow changes outside the ligamentous insertions, and cartilage proliferation, are important too. In the subentheseal bone marrow and in the synovium, CD8+ T cells play a central role. Imaging of early changes is better achieved by ultrasonography and even better by magnetic resonance imaging than by radiography. No single immunologic target can be identified. The G1 domain of aggrecan is the best candidate, but this does not apply to fibrous entheses. In these complex pathologic conditions, no single abnormality can thus far be designated as a unique hallmark.
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Affiliation(s)
- R J François
- Laboratoire de Rhumatologie, Hôpital Militaire Reine Astrid, Brussels, Belgium.
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