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Ankle pain can present a clinical dilemma to the foot and ankle surgeons, with a multitude of entities to which the symptoms could potentially be attributed. Enthesopathy around the ankle joint could be due to overuse, injury, inflammation or infection. Calcific ligamentous enthesopathy around the ankle is a well-recognised condition with a spectrum of causes. To our knowledge, a clinically symptomatic presentation of calcific enthesopathy specifically affecting the entheses of the superior extensor retinaculum has not been described in the literature. We report the first case of symptomatic calcific enthesopathy of the superior extensor retinaculum in a healthy young female, and highlight the role of radiological interventions in its diagnosis. The condition was managed successfully by ultrasound-guided barbotage. Calcific enthesopathy of the attachment of the superior extensor retinaculum is a rare condition that should be considered in the differential diagnosis of patients with medial ankle pain. [ABSTRACT FROM AUTHOR]

Familial Mediterranean fever (FMF) and spondyloarthritis (SpA) may show several common signs. This study aimed to evaluate the frequency of SpA and its manifestations in FMF, the impact of SpA on FMF, and the associations of non-episodic findings (heel enthesitis, protracted arthritis, and sacroiliitis) with the FMF features. Demographic, clinical, imaging, and genetic data were retrieved from medical records of the patients with adult FMF. To identify patients who met the classification criteria for SpA, data including rheumatologic inquiry were recorded. Patients with SpA and those who did not meet the criteria were compared in terms of FMF features. Regression analyses were performed to determine the factors that were most associated with sacroiliitis, enthesitis, and protracted arthritis. Of the 283 patients with FMF, 74 (26.1%) met the SpA criteria (64 axial, 10 peripheral); and 65 (22.9%) patients had sacroiliitis, 27 (9.5%) protracted arthritis, and 61 (21.6%) heel enthesitis. Patients with SpA were older and had more FMF severity, and heel pain rate than those without; however, genetic features, CRP, resistance to colchicine, and heel enthesitis did not differ. A meaningful number of patients without SpA had also displayed heel enthesitis, protracted arthritis, inflammatory back pain, heel pain, family history of SpA, and elevated CRP. Age was found to be the main predictor of heel enthesitis and protracted arthritis was linked with FMF severity. A significant number of patients with FMF meet the peripheral SpA classification criteria as well as axial SpA. SpA and its shared manifestations with FMF may have an impact on FMF. [ABSTRACT FROM AUTHOR]

The grave situated in the central part of the reformed church in Silická Brezová in Slovakia contained the human skeletal remains of one individual. The aim of this study was to confirm the presence of ankylosing spondylitis on these skeletal remains. Determine the sex, age at death, stature, and ancestry of the individual by anthropological methods, and also record and identify other pathological manifestations of diseases. A macroscopic examination has been carried out, with the analysis of the palaeopathological conditions of the remains, and subsequently an X-ray and CT completed analysis. The skeleton belonged to a male of European origin, aged between 45 and 60 years at the time of death. Stature calculated from the maximal length of his femur was 163.12 ± 3.48 cm. Pathological features were identified on the many bones. Ankylosis affected almost the whole spinal cord, including the sacroiliac joints. The skeleton also presented the manifestation of many entheseal changes. Presence of the ankylosing spondylitis was confirmed by a combination of standard anthropological methods and modern diagnostic methods (X-ray and CT analysis). It is a specific disease with a prevalence between 0.1 and 1% worldwide. There is a potential for further genetic research to determine the degree of genetic relatedness with an individual living in this village who has been diagnosed with the same disease. [ABSTRACT FROM AUTHOR]

Mechanical stress is involved in the onset of sports‐related enthesopathy. Although the amount of exercise undertaken is a recognized problem during disease onset, changes in muscle contraction type are also involved in the increase in mechanical stress during exercise. This study aimed to clarify the effects of increased mechanical stress associated with muscle contraction type and amount of exercise on enthesis. Twenty mice underwent treadmill exercise, and the muscle contraction type and overall load during exercise were adjusted by varying the angle and speed conditions. Histological analysis was used to the cross‐sectional area of the muscle; area of the enthesis fibrocartilage (FC), and expression of inflammation‐, degeneration‐, and calcification‐related factors in the FC area. In addition, the volume and structure of the bone and FC area were examined using microcomputer imaging. Molecular biological analysis was conducted to compare relative expression levels of inflammation and cytokine‐related factors in tendons. The Overuse group, which increased the amount of exercise, showed no significant differences in parameters compared to the sedentary mice (Control group). The mice subjected to slow‐speed downhill running (Misuse group) showed pathological changes compared to the Control and Overuse groups, despite the small amount of exercise. Thus, the enthesis FC area may be altered by local mechanical stress that would be increased by eccentric muscle contraction rather than by mechanical stress that increases with the overall amount of exercise. Clinical Significance: The muscle contraction type might be more involved in the onset of sports‐related enthesopathy rather than the amount of exercise. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to assess the effectiveness of conventional and targeted disease-modifying antirheumatic drugs (cDMARDs and tDMARDs, respectively) in treating enthesitis in psoriatic arthritis (PsA).Methods: Patients with active enthesitis, defined as ≥ 1 tender entheses (of the 29 enthesis sites included in the Spondyloarthritis Research Consortium of Canada Enthesitis Index, the Leeds Enthesitis Index, and the Maastricht Ankylosing Spondylitis Enthesitis Score), who were enrolled in a large PsA cohort were included. Medications at baseline were classified into 3 mutually exclusive categories: (1) no treatment or nonsteroidal antiinflammatory drugs (NSAIDs) only; (2) cDMARDs ± NSAIDs; and (3) tDMARDs ± cDMARDs/NSAIDs. Complete resolution of enthesitis (no tender enthesis) at 12 months was the primary outcome. Logistic regression models were developed to determine the association between medication category and enthesitis resolution.Results: Of the 1270 patients studied, 628 (49.44%) had enthesitis. Of these, 526 patients (51.71% males; mean [SD] age 49.02 [13.12] years; mean enthesitis score 2.13 [2.16]; median enthesitis score 2 [IQR 1-2]), with adequate follow-up were analyzed. Complete resolution of enthesitis was noted in 453 (86.12%) patients, within a mean period of 8.73 (3.48) months from baseline. In the regression analysis, though not significant, DMARDs (categories II and III) had higher odds ratios (ORs) compared to category 1 for resolution of enthesitis. Enthesitis resolution was associated with lower joint activity (OR 0.97, 95% CI 0.95-0.99; P = 0.01) and male sex (OR 1.66, 95% CI 0.97-2.84; P = 0.06).Conclusion: Resolution of enthesitis was observed in 86% of patients in an observational setting regardless of the medication used. Future effectiveness studies may warrant evaluation of enthesitis using advanced imaging. [ABSTRACT FROM AUTHOR]

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Objectives: Referral of patients from dermatology to rheumatology practices due to psoriasis is unnecessary delayed. Many times musculoskeletal symptoms are the first reason for consultation. We aimed to estimate the proportion of ARP-PsA (arthralgia with risk to progression) defined by patients with arthralgia and the presence of psoriasis and/or a family history. Also, identify clinical, laboratory, and imaging prognostic factors of PsA progression within the ARP-PsA group over a one-year follow-up period., Methods: Patients were included in a comprehensive arthralgia evaluation program, with the ARP-PsA criteria defined as arthralgia with Pso and/or a family history of Pso, not referred from dermatology. Baseline characteristics were analyzed, and the progression to PsA at one year was assessed. Multivariate analysis identified predictor features for progression., Results: Of the 1419 patients, 8.4% met ARP-PsA criteria, and 29% of this subgroup developed PsA at one year. Baseline differences between those who developed PsA and those who did not included family history, Pso duration, pain severity, joint count, and imaging findings (X-ray and ultrasound). Multivariate analysis revealed the predictive significance of a combination of Pso plus family history of psoriasis disease, synovitis by Power Doppler ultrasound, ultrasound enthesopathy findings, and low tender joint count., Conclusion: The frequency of patients ARP-PsA was 8.4%, of whom 29% developed PsA at 1-year. The main predictor variables for this progression were identified., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Research progress from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) pilot award program was presented and discussed at the GRAPPA 2023 annual meeting. Topics included identification of protein biomarkers associated with enthesitis in psoriatic arthritis (PsA), the role of HLA-B27 on gut microbial dysbiosis in PsA, single-cell profiling of synovial fluid vs psoriatic skin lesions in PsA, and the role of mechanotransduction in hyperactivation of transforming growth factor-β via αVβ6 integrin in psoriatic epidermis., (Copyright © 2024 by The Journal of Rheumatology.)

Objective: To construct a predictive model for Psoriatic Arthritis (PsA) based on clinical and ultrasonic characteristics in patients with plaque psoriasis (PsP)., Patients and Methods: Demographic, clinical, and ultrasound data were collected from patients with PsP and PsA between May 2019 and December 2022., Results: A total of 212 patients with PsP and 123 with PsA in the training cohort, whereas the validation cohort comprised 91 patients with PsP and 49 with PsA. The multivariate logistic regression identified nail psoriasis (odds ratio [OR] 1.88, 95% CI: 1.07-3.29), synovitis (OR 18.23, 95% CI: 4.04-82.33), enthesitis (OR 3.71, 95% CI: 1.05-13.14), and bone erosion (OR 11.39, 95% CI: 3.05-42.63) as effective predictors for PsA. The area under the curve was 0.750 (95% CI, 0.691-0.806) and 0.804 (95% CI, 0.723-0.886) for the training and validation cohorts, respectively. The Hosmer-Lemeshow goodness-of-fit test showed good consistency for both the training cohort (p  =  0.970) and the validation cohort (p  =  0.967). Calibration curves also indicated good calibration for both cohorts. The DCA revealed that the predictive model had good clinical utility., Conclusions: We have developed a quantitative, intuitive, and convenient predictive model based on nail psoriasis, synovitis, enthesitis, and bone erosion to assess the risk of PsA in patients with plaque psoriasis., (© 2024 Deutsche Dermatologische Gesellschaft (DDG).)

Axial Spondyloarthritis (axSpA) is a chronic, inflammatory, immune-mediated rheumatic disease that comprises two subsets, non-radiographic and radiographic axSpA, and belongs to a heterogeneous group of spondyloarthritides (SpA). Over the years, the concept of SpA has evolved significantly, as reflected in the existing classification criteria. Considerable progress has been made in understanding the genetic and immunological basis of axSpA, in studying the processes of chronic inflammation and pathological new bone formation, which are pathognomonic for the disease. As a result, new medication therapies were developed, which bring more effective ways for disease control. This review presents a brief overview of the literature related to these aspects of disease after summarising the available information on the topic that we considered relevant. Specifically, it delves into recent research illuminating the primary pathological processes of enthesitis and associated osteitis in the context of inflammation in axSpA. The exploration extends to discussion of inflammatory pathways, with a particular focus on Th1/Th17-mediated immunity and molecular signaling pathways of syndesmophyte formation. Additionally, the review sheds light on the pivotal role of cytokine dysregulation, highlighting the significance of the IL-23/17 axis and TNF-α in this intricate network of immune responses which is decisive for therapeutic approaches in the disease., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Abstract Background There is no report of the application of intraoperative computed tomography to the extremities, and its usefulness is not mentioned. Case presentation We present a case of a patient with the elbow pain and loss of the forearm rotation due to the prominent bicipital tuberosity of the radius, which was diagnosed as enthesopathy. Surgical treatment to excise the prominent part of the bicipital tuberosity of the radius was recommended. However, it is difficult to perform the appropriate excision of the abnormal prominent part because of complications such as bicipital tendon rupture. The patient was successfully treated by surgical resection under the control of intraoperative computed tomography. Conclusions Intraoperative computed tomography scan is a useful tool to assess the remaining volume of the abnormal bones.

Background: There is no much information about the entheseal involvement among hemodialysis (HD) patients. The aim of this study was to assess the frequency and distribution of ultrasonographic (US) entheseal alterations in HD patients and to evaluate the association between US abnormalities and both clinical and laboratory data. Methods: This study was conducted on 41 HD patients and 23 sex- and age- matched controls. All participants were evaluated clinically for any signs of enthesopathy. Six entheses sites were scanned bilaterally using grey scale (GS) and power Doppler (PD) US and were scored using Madrid Sonography Enthesitis Index (MASEI) scoring system. Results: In HD patients, at least one clinical sign suggestive of enthesopathy was found in 69 (14%) of 492 entheses. HD patients had statistically significant higher scores of structural tendon abnormalities (p < 0.001), enthesis thickening (p < 0.001), bone erosions (p < 0.001) and calcification (p = 0.037) than the healthy controls. Total MASEI score was higher in HD patients than healthy controls (median;18 vs 8, p < 0.001), also, MASEI-inflammatory (median;11 vs 3, p < 0.001) and damage scores (median;6 vs 0, p < 0.001). There was a statistically significant positive association between total MASEI score and both age (p = 0.032) and duration of HD (p = 0.037). Duration of HD was predictive for both MASEI-damage component (p = 0.004) and total MASEI score (p = 0.014). Conclusion: There is a high prevalence of subclinical enthesopathy in HD patients. The entheseal US alterations is much higher in HD patients than in healthy subjects. The duration of HD is the significant predictor of enthesopathy in HD patients. [ABSTRACT FROM AUTHOR]

Context X-linked hypophosphatemia (XLH) is a rare and progressive metabolic phosphate-wasting disorder characterized by lifelong musculoskeletal comorbidities. Despite considerable physical disability, there are currently no disease-specific physical therapy (PT) recommendations for XLH designed to improve engagement and confidence in performing activities of daily living (ADL). Objective The objective of this patient-centered study was to develop an evidence-based PT program to address gaps in the management of adult XLH without imposing unintended harm. Methods Creation of the program was informed by a prior controlled clinical study to evaluate the physical and functional effect of XLH on adulthood, and guided by the physical presentation of participants, subjective data and patient goals acquired at intake, and by performance on multiple active range of motion (ROM) movements from the standing position. A weekly standardized interview process was used to assess progression of physical and functional abilities, gains and concerns, and to obtain timely feedback to inform future exercise modifications. Outcomes were evaluated using validated functional tools and subjective data obtained throughout the study. Results A remote 12-week PT program was created based on collected data. Open and closed kinetic-chain exercises were developed and implemented. Functional improvements were documented, and weekly surveys indicated improved abilities and confidence to engage in ADL. Minimal improvements were observed in active upper and lower extremity ROM, reflective of substantial bony restrictions characteristic of XLH. Conclusion This study represents the first disease-specific PT recommendations for XLH to mitigate the unique physical challenges of the adult disorder that can be modified to adapt to the current progression status of the adult disorder. [ABSTRACT FROM AUTHOR]

Homozygous ENPP1 mutations are associated with autosomal recessive hypophosphatemic rickets type 2 (ARHR2), severe ossification of the spinal ligaments, and generalized arterial calcification of infancy type 1. There are a limited number of reports on phenotypes associated with heterozygous ENPP1 mutations. Here, we report a series of three probands and their families with heterozygous and compound heterozygous ENPP1 mutations. The first case (case 1) was a 47‐year‐old male, diagnosed with early‐onset osteoporosis and low‐normal serum phosphate levels, which invoked suspicion for hypophosphatemic rickets. The second and third cases were 77‐ and 54‐year‐old females who both presented with severe spinal ligament ossification and the presumptive diagnosis of diffuse idiopathic skeletal hyperostosis (DISH). Upon workup, fibroblast growth factor 23 (FGF23) was noted to be relatively high in case 2 and serum phosphorous was low‐normal in case 3, and the diagnoses of X‐linked hypophosphatemic rickets (XLH) and ARHR2 were considered. Genetic testing for genes related to congenital hypophosphatemic rickets was therefore performed, revealing heterozygous ENPP1 variants in cases 1 and 2 (case 1, c.536A>G, p.Asn179Ser; case 2, c.1352A>G, p.Tyr451Cys) and compound heterozygous ENPP1 variants in case 3 constituting the same variants present in cases 1 and 2 (c.536A>G, p.Asn179Ser and c.1352A>G, p.Tyr451Cys). Several in silico tools predicted the two variants to be pathogeneic, a finding confirmed by in vitro biochemical analysis demonstrating that the p.Asn179Ser and p.Tyr451Cys ENPP1 variants possessed a catalytic velocity of 45% and 30% compared with that of wild‐type ENPP1, respectively. Both variants were therefore categorized as pathogenic loss‐of‐function mutations. Our findings suggest that ENPP1 mutational status should be evaluated in patients presenting with the diagnosis of idiopathic DISH, ossification of the posterior longitudinal ligament (OPLL), and early‐onset osteoporosis. © 2022 American Society for Bone and Mineral Research (ASBMR). [ABSTRACT FROM AUTHOR]

The tibialis posterior muscle plays an important role in maintaining the correct arching of the foot in the standing position and while walking, allowing proper arching, rolling and shock absorption of the foot. It works with the peroneus longus muscle, forming the so-called tendon stirrup of the foot. Changes in the distal attachment of the tibialis posterior muscle to the navicular bone can cause pain symptoms on the inner edge of the foot called enthesopathy. Enthesopathy is a painful lesion at the attachment of the muscle tendon to the bone. It is most often the result of excessive loads and disturbances in the biomechanics of a muscle, which leads to the formation of inflammation accompanied by pain located at the attachment site and deterioration of the muscle function. Treatment of the above diseases is not described in the literature; hence there are no clear guidelines for conducting medical treatment. The aim of the study is to assess the effect of applying Kinesio Taping in combination with the transverse massage of the distal tendon attachment on the static and dynamic parameters of the foot.

The article presents data on epidemiology, pathogenesis, clinical manifestations, diagnosis and therapy of enthesopathy in spondyloarthritis. The approaches to assessment of this pathology are examined and detailed, modern clinical and ultrasound indices are given. The features of enthesopathy in diseases that included in the group of spondyloarthridies are described.

BACKGROUND:Much controversy exists regarding the optimal surgical intervention for lateral epicondylitis because of a multitude of options available and the lack of comparative studies. Knowledge of the current practice trends would help guide the design of comparative studies needed to determine which surgical technique results in the best outcome. PURPOSE:To review the latest practice trends for the surgical treatment of lateral epicondylitis among newly trained surgeons in the United States utilizing the American Board of Orthopaedic Surgery (ABOS) database. STUDY DESIGN:Cross-sectional study; Level of evidence, 3. METHODS:The ABOS database was utilized to identify surgical cases for lateral epicondylitis submitted by Part II board certification examination candidates from 2004 through 2013. Inclusion criteria were predetermined using a combination of International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Cases were organized by open and arthroscopic treatment groups and by fellowship training and were analyzed to determine differences in surgical techniques, complication rates, and concomitant procedures. RESULTS:In total, 1150 surgeons submitted 2106 surgical cases for the treatment of lateral epicondylitis. The number of surgical cases for lateral epicondylitis performed per 10,000 submitted cases significantly decreased from 26.7 in 2004 to 21.1 in 2013 (P = .002). Among all cases, 92.2% were open and 7.8% were arthroscopic, with no change in the incidence of arthroscopic surgeries over the study period. Shoulder and elbow (18.1%) and sports medicine (11.4%) surgeons were more likely to perform surgery arthroscopically compared with hand surgeons (6.1%) (P < .001). There was no difference in overall self-reported complication rates between open (4.4%) and arthroscopic (5.5%) procedures (P = .666). Percutaneous tenotomy, debridement only, and debridement with tendon repair comprised 6.4%, 46.3%, and 47.3% of open treatment, respectively. Sports medicine, hand, and shoulder and elbow surgeons were more likely to repair the tendon after debridement compared with other surgeons, who were more likely to perform debridement alone (P < .001). Hand surgeons were most likely to perform concomitant procedures, of which the majority were neuroplasties. CONCLUSION:Although comparative studies are ultimately necessary for determining the optimal surgical technique, researchers should be mindful of the differences in practices according to training and the extent to which concomitant procedures are being performed, as both these factors may confound any future results.

Enthesitis is a cardinal feature of spondylarthritis (SpA), and the pelvis is a common site of enthesitis. This study aimed to establish the association between pelvic enthesis involvement on pelvic X-ray and SpA diagnosis through a radiographic enthesis index (REI) and to assess the reliability and accuracy of this REI. The participants were SpA patients and a control group composed of patients with chronic lumbar pain without SpA. Three blinded observers assessed each pelvic radiography three times. Three zones were used: Zone I (ZI), the iliopubic ramus; Zone II (ZII), the pubic symphysis, and Zone III (ZIII), the ischiopubic ramus. A grading system was created from 0 to 3 [Grade 0, normal; Grade 1, minimal changes (subcortical bone demineralization and/or periosteal wishkering, seen as radiolucency and trabeculation of the cortical bone upon tendon insertion); Grade 2, destructive changes (Grade 1 findings and erosions at the enthesis site); and Grade 3, findings of Grade 2 plus >2 mm whiskering out of the cortical bone) for the REI. The sum of the results of the three zones was called the total REI. For statistical analysis, we used the weighted kappa statistic adjusted for prevalence and bias using Gwet's agreement coefficient. We enrolled 161 patients, 111 of them with SpA (39.6 % with axial SpA and 47.7 % with peripheral SpA) and 50 without SpA. In the SpA group, 36.7 % and 25.7 % had REI Grades 2 and 3 in ZIII, respectively, while only 6 % of the controls had these grades. For ZI, the frequency of Grades 1 to 3 was 42.3 % in the SpA group (8.1 %, 14.4 %, and 19.8 %, respectively), compared to only 2 % in the controls. ZII was unaffected in most of the patients with SpA (82.9 %) and in the controls (98 %). In the control group, Grade 0 was the most common REI grade in all three zones. The agreement was almost perfect for each zone and between the independent readers. The ROC-curve analysis showed that the highest performance areas were the total REI, ZIII, and ZI. Most (75 %) of the SpA patients without sacroiliitis on X-ray were REI-positive. The sensitivity of the REI for SpA diagnosis was 82 %, while the sensitivity of sacroiliitis on X-ray was 38.7 %. The assessment of pelvic enthesis using the REI on pelvic radiography may be useful for SpA diagnosis. Total REI, ZIII, and ZI had the highest accuracy and almost perfect reliability. The REI is especially helpful in patients without sacroiliitis on imaging. [ABSTRACT FROM AUTHOR]

Background. The purpose of this study was to determine structural and pathological differences of Achilles tendon insertion between insertional Achilles tendinopathy (IAT) and midportion Achilles tendinopathy (MidAT) in both injured and uninjured sides. Methods. Patients (n = 34; 58.8% male) with unilateral Achilles tendinopathy (50% with IAT; 50% with MidAT) were recruited. Median age 52 years and Victorian Institute of Sport Assessment -- Achilles (VISA-A) score mean 59, and 17 (12 male) had MidAT, median (range) age of 58 (48) years, and VISA-A score mean (SD) 59.1 (19.7). Ultrasound imaging was used to evaluate structural measurements at the insertion (insertional length, bone-to-insertion length, and tendon insertion angle), tendon length (calcaneus to soleus), tendon thickness at the calcaneal edge, and the presence of pathological changes (boney deformity and/or calcification). A 2 x 2 mixed Analysis of Variance (group by side) was used to compare IAT and MidAT groups and injured and uninjured sides. Results. Tendon thickness at the calcaneus on the injured side was significantly greater than the uninjured side in the IAT group but not in the MidAT group (p = .001). VISA-A score was 59.9 (18.7) in IAT group and 59.1 (19.7) for MidAT group (p = 0.909). There were no significant group-by-side interactions for structural measurements at insertion site. Conclusions. Calcaneal edge tendon thickness was the only significant structural difference observed between involved and uninvolved sides in IAT, although this was not found in in MidAT. [ABSTRACT FROM AUTHOR]

Aim: To investigate the prevalence and features of degenerative enthesopathic changes in a large cohort of healthy individuals by musculoskeletal ultrasound (MSUS) and their relation to age and other demographic features. Methods: In this cross‐sectional study, 147 healthy subjects (1470 entheses) were examined by MSUS according to the Outcome Measures in Rheumatology guidelines: Achilles tendon, plantar fascia, patellar, and quadriceps insertions of both lower limbs. Results: The mean age (±SD) of the participants was 43.68 (±14.53) years and 57.1% were female. Enthesopathy has been detected in at least 1 area in 113 subjects (76.87%). Thickening (21.6%) and hypoechogenicity (15.3%) were the most frequent inflammatory findings while enthesophyte (10.13%) was the most prevalent structural one. Age and male gender were significantly correlating with inflammatory (rs =.341, P =.001/r =.310, P =.001), structural (rs =.354, P =.001/r =.166, P =.04) and total scores (rs =.406, P =.001/r =.302, P =.001). More inflammatory changes were noticed in the age group 36‐55 years. Body mass index had a positive correlation with inflammatory (rs =.290, P =.001) and total scores (rs = 0.298, P =.001) but not with structural lesions (rs =.154, P =.062). Conclusions: Thickening, hypoechogenicity, cortical irregularities, and enthesophytes are frequent degenerative features of enthesopathy. These findings need to be redefined to be more specific for spondyloarthritides. Enthesopathy should be interpreted with caution in the light of the clinical picture, especially in elderly and obese male patients. [ABSTRACT FROM AUTHOR]

Iliotibial band (ITB) pathology is one of the main causes of lateral knee pain. The enthesopathy of the ITB at its insertion post total knee replacement (TKR) is a rare cause of lateral knee pain. We describe a series of cases of ITB enthesopathy with sonographic findings and management. [ABSTRACT FROM AUTHOR]

Ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) deficiency leads to cardiovascular calcification in infancy, fibroblast growth factor 23 (FGF23)‐mediated hypophosphatemic rickets in childhood, and osteomalacia in adulthood. Excessive enthesis mineralization and cervical spine fusion have been previously reported in patients with biallelic ENPP1 deficiency, but their effect on quality of life is unknown. We describe additional musculoskeletal complications in patients with ENPP1 deficiency, namely osteoarthritis and interosseous membrane ossification, and for the first time evaluate health‐related quality of life (HRQoL) in patients with this disease, both subjectively via narrative report, and objectively via the Brief Pain Inventory–Short Form, and a Patient Reported Outcome Measurement Information System Physical Function (PROMIS PF) short form. Residual pain, similar in magnitude to that identified in adult patients with X‐linked hypophosphatemia, was experienced by the majority of patients despite use of analgesic medications. Impairment in physical function varied from mild to severe. To assess murine ENPP1 deficiency for the presence of enthesopathy, and for the potential response to enzyme replacement therapy, we maintained Enpp1asj/asj mice on regular chow for 23 weeks and treated cohorts with either vehicle or a long‐acting form of recombinant ENPP1. Enpp1asj/asj mice treated with vehicle exhibited robust calcification throughout their Achilles tendons, whereas two‐thirds of those treated with ENPP1 enzyme replacement exhibited complete or partial suppression of the Achilles tendon calcification. Our combined results document that musculoskeletal complications are a significant source of morbidity in biallelic ENPP1 deficiency, a phenotype which is closely recapitulated in Enpp1asj/asj mice. Finally, we show that a long‐acting form of recombinant ENPP1 prevents the development of enthesis calcification at the relatively modest dose of 0.3 mg/kg per week, suggesting that suppression of enthesopathy may be attainable upon dose escalation. © 2021 American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by US Government employees and their work is in the public domain in the USA. [ABSTRACT FROM AUTHOR]

Background: Enthesopathy is a main characteristic of ankylosing spondylitis (AS). However, ultrasonographic features of supraspinous enthesis in AS have not yet been reported. Methods: Forty-seven AS patients and 22 healthy individuals were enrolled and completed the study. L4 supraspinous entheses were assessed through an ultrasound (US) unit with the participants in a lateral decubitus position. Entheseal echogenicity was interpreted upon inspection of the US image. An entheseal grayscale (GS) value determination, along with an echotexture analysis using a gray-level co-occurrence matrix algorithm, was performed. The thoracolumbar fascia just above the enthesis was also analyzed. An enthesis-to-fascia ratio (EFR) of each texture feature was used for the purpose of intergroup comparison. Results: The prevalence of abnormal entheseal echogenicity in the AS and healthy groups was 19.1% and 13.6%, respectively (P = 0.42). The AS group experienced a higher GS EFR (0.56 [0.10–1.08] vs. 0.40 [0.12–0.89], P = 0.007), higher contrast EFR (0.62 [0.15–1.23] vs. 0.49 [0.23–1.33], P = 0.049), higher variance EFR (0.44 [0.06–1.21] vs. 0.35 [0.13–1.10], P = 0.023), and lower homogeneity EFR (1.07 [0.97–1.27] vs. 1.11 [1.04–1.19], P = 0.011) in comparison to the healthy group. Conclusion: Echotexture analysis identified the subtle structural changes in L4 supraspinous enthesis in AS patients. It proved to be superior to the inspection method and may possess the potential for providing early detection of supraspinous enthesopathy in AS.

Background: The aim of this study was to evaluate lower extremity cartilage thickness in axial spondyloarthritis (SpA) patients and healthy controls using ultrasound (US) and to determine the relationship between the indices, quality of life, enthesopathy, and cartilage thickness of patients with axial SpA. Materials and Methods: This study included 73 axial SpA patients and 30 healthy controls. The patients with axial SpA were divided into two groups as with and without heel enthesitis. Demographic data, disease duration, and medical treatments of patients were recorded. The cartilage (hip, talar, and knee), plantar fascia, and Achilles tendon thicknesses of both healthy controls and axial SpA patients were measured by US. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Functional Index (BASFI), patient global assessment (PGA), and Ankylosing Spondylitis Quality of Life (ASQoL) scores of patients were evaluated. Results: There was no difference between the groups in terms of demographic data and body mass index. The axial SpA groups with and without heel enthesitis were similar in terms of medical treatment and disease duration. The axial SpA patients with heel enthesitis had thinner cartilages than those without heel enthesitis (P < 0.05). The axial SpA patients without heel enthesitis had thinner cartilage thicknesses than the healthy control group (P < 0.05). There were statistically significant differences between the two groups in terms of the BASDAI, BASFI, BASMI, and ASQoL scores. These indices were negatively correlated with cartilage thickness (P < 0.05; r: −0.420). Conclusion: Lower extremity cartilage thickness is associated with disease activity, quality of life, and spinal mobility in patients with axial SpA.

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., (© 2024 American Association for Anatomy.)

Chronic pain located on the lateral surface of the elbow in the area of the lateral epicondyle of the humerus is characteristic for a disease called tennis elbow, which belongs to the group of enthesopathies, i. e. diseases related to bone tendon attachment. The cause of the disease are micro-injuries caused by repetitive movements and chronic overloads. Degenerative changes occur in the tendons of the finger and wrist extensor muscles which attach to the lateral epicondyle of the humerus. The problem usually affects the extensor carpi radialis brevis muscle. A typical location for pain is the lateral side of the elbow joint but it can often radiate to the forearm and wrist. In our paper we presented the most commonly used and most effective methods of treatment of the disease. The least invasive methods of physiotherapy and rehabilitation include home exercise, ultrasound and phonophoresis, cryotherapy, light therapy, laser therapy and radial shock wave terapy. We compared the efficacy of pharmacological methods such as non-steroidal anti-inflammatory drugs, steroid injections with lidocaine, platelet-rich plasma, hyaluronic acid, botulinum toxin, collagen. We also mentioned the indications and surgical techniques of the tennis elbow.

Shoulder pain and weakness are common symptoms in athletes who play sports connected with overhead throwing. Suprascapular neuropathy may be one of the reason of such signs.The aim of the study was to find out if ultrasound examination of the shoulder in athletes reveals signs of suprascapular neuropathy.

Background: Psoriasis is associated with spondyloarthropathy in 10%–30% of cases. Enthesitis is major feature of psoriatic arthritis. Ultrasonography can detect subclinical entheseal abnormalities in psoriasis patients. Objectives: To determine the prevalence of subclinical enthesopathy in psoriasis vulgaris using ultrasonography and evaluating its correlation with severity and duration of psoriasis. Materials and Methods: This study included 50 patients of psoriasis vulgaris and 50 healthy controls. Sonographic evaluation of six sites bilaterally (proximal plantar fascia, distal Achilles tendon, distal and proximal patellar ligaments, distal quadriceps, and brachial triceps tendons) were done in each subject. All Ultrasonographic findings were identified according to MASEI (Madrid sonography enthesitis index). Enthesopathy scores of patients and controls were compared and receiver operating characteristic curve was used to determine cut off value of MASEI, above which ultrasound enthesitis of clinical significance could be diagnosed. Results: 31 (62%) psoriasis patients had subclinical enthesopathy of clinical significance as compared to only 5 (10%) of controls. Mean MASEI score between psoriasis cases and control was statistically different, 12.72 ± 7.55 (Mean ± SD) and (5.14 ± 4.69), respectively (P value 0.000001).The receiver operating characteristic curve established an ultrasound score of> 11 as the best cut-off to differentiate between subject with enthesopathy of clinical significance from those with enthesopathy of unknown significance. No statistically significant correlation was found between the degree of enthesopathy (MASEI score) and duration and severity of the psoriasis. Conclusion: Ultrasonography can effectively screen subclinical entheseal abnormalities in psoriasis patients.

Objective: The aim of this study was to explore the prevalence and distribution of lower extremity entheseal abnormities by musculoskeletal ultrasound (US) in a cohort of gout patients, taking spondyloarthritis (SpA) patients and asymptomatic hyperuricemia (HUA) patients as controls. Method: One hundred participants with gout, fifty patients with SpA, and twenty-nine patients with asymptomatic HUA were recruited. US was used to assess the bilateral quadriceps, patellar and Achilles tendons, and plantar fascia entheses according to the Outcome Measures in Rheumatology (OMERACT) definitions. Results: The US examination revealed the presence of one or more abnormalities in at least one enthesis in 45 out of 100 subjects (45.0%) and 152 out of 1000 entheses (15.2%) in the gout patients. Among the affected entheses, the patellar insertion of the quadriceps tendon was the most commonly involved area (38.0% in the gout patients versus 48.0% in the SpA patients with at least one pathological US finding, p = 0.241). There were no significant group differences in entheseal power Doppler (PD) signals, bone erosion, or enthesophytes. The patients with lower limb entheseal involvement in the gout group had an older age, longer disease duration, higher percentage of chronic tophaceous gout, and higher levels of inflammatory biomarkers of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Multivariate logistic regression analysis revealed that age (OR = 1.052, p = 0.001) and the ESR (OR = 1.023, p = 0.028) were correlated with lower limb enthesopathy in gout patients. In the subgroup analysis of gout patients without active inflammation, age (OR = 1.119, p = 0.001) and serum uric acid (UA, OR = 1.012, p = 0.002) were correlated with lower limb enthesopathy in gout. Conclusion: Lower extremity entheseal involvement might be neglected but should be considered as an important element in the evaluation of gout patients. Enthesopathy most frequently involves in the patellar insertion of the quadriceps tendon and is characterized by entheseal hypoechogenicity and/or thickening. Key Points • Lower extremity enthesopathy might be neglected as an important element in gout. • Enthesopathy is most frequently involved in the patellar insertion of the quadriceps tendon in gout. • Age and ESR are correlated with lower limb enthesopathy in gout patients. [ABSTRACT FROM AUTHOR]

X-linked hypophosphatemia (XLH) is the most common form of inheritable rickets. The disease is caused principally by PHEX mutations leading to increased concentrations of circulating intact FGF23, hence renal phosphate wasting, hypophosphatemia, and decreased circulating levels of 1,25(OH) 2 vitamin D. The chronic hypophosphatemia leads to rickets and osteomalacia through a combination of mechanisms, including a lack of endochondral ossification and impaired mineralization. Imaging has a major role in determining the diagnosis of rickets and its cause, detecting complications as early as possible, and helping in treatment monitoring. [ABSTRACT FROM AUTHOR]

Background and objectives: Diffuse idiopathic skeletal hyperostosis (DISH) is a bone formation disease in which only skeletal signs are considered in classification criteria. The aim of the study was to describe different phenotypes in DISH patients based on clinicoradiological features. Materials and Methods: We evaluated 97 patients who met the Resnick or modified Utsinger classification criteria for DISH and were diagnosed at our hospital from 2004 to 2015. Patients were stratified into: (a) peripheral pattern (PP)—Resnick criteria not met but presenting ≥3 peripheral enthesopathies; (b) axial pattern (AP)—Resnick criteria met but <3 enthesopathies; and (c) mixed pattern (MP)— Resnick criteria met with ≥3 enthesopathies. Statistical analysis was carried out to identify variables that might predict classification in a given group. Results: Fifty-six of the 97 patients included (57.7%) were male and 72.2% fulfilled the Resnick criteria. Applying our classification, 39.7% were stratified as MP, 30.9% as AP and 29.4% as PP. Clinical enthesopathy was reported in 40.2% of patients during the course of the disease. Sixty-eight patients were included in a comparative analysis of variables between DISH patterns. The results showed a predominance of women (p < 0.004), early onset (p < 0.03), hip involvement (p < 0.003) and enthesitis (p < 0.001) as hallmarks of PP. Asymptomatic patients were most frequently observed in AP (28.6%, MP 3.8%, PP 5.0%) while MP was characterized by a more extensive disease. Conclusions: We believe DISH has distinct phenotypes and describe a PP phenotype that is not usually considered. Extravertebral manifestations should be included in the new classification criteria in order to cover the entire spectrum of the disease. [ABSTRACT FROM AUTHOR]

Background: X-linked hypophosphatemia (XLH) is a rare genetic disorder characterized by lower limb deformity, gait and joint problems, and pain. Hence, quality of life is substantially impaired. This study aimed to assess lower limb deformity, specific radiographic changes, and gait deviations among adolescents and adults with XLH. Design: Data on laboratory examination and gait analysis results were analyzed retrospectively. Deformities, osteoarthritis, pseudofractures, and enthesopathies on lower limb radiographs were investigated. Gait analysis findings were compared between the XLH group and the control group comprising healthy adults. Patients and Controls: Radiographic outcomes were assessed retrospectively in 43 patients with XLH (28 female, 15 male). Gait analysis data was available in 29 patients with confirmed XLH and compared to a healthy reference cohort (n=76). Results: Patients with XLH had a lower gait quality compared to healthy controls (Gait deviation index GDI 65.9% +/- 16.2). About 48.3% of the study population presented with a greater lateral trunk lean, commonly referred to as waddling gait. A higher BMI and mechanical axis deviation of the lower limbs were associated with lower gait scores and greater lateral trunk lean. Patients with radiologic signs of enthesopathies had a lower GDI. Conclusions: This study showed for the first time that lower limb deformity, BMI, and typical features of XLH such as enthesopathies negatively affected gait quality among adolescents and adults with XLH. [ABSTRACT FROM AUTHOR]

This case report describes the successful surgical treatment of a 9-year-old Warmblood gelding used for showjumping that presented with a 2/5 right hindlimb lameness, which had persisted for more than 2 years and was caused by chronic-active proximal suspensory ligament desmopathy and second and fourth metatarsal exostosis. Previous treatment methods including extracorporeal shockwave therapy, local corticosteroid injections and subsequent plantar fasciotomy and neurectomy of the deep branch of the lateral plantar nerve were unsuccessful. As the full extent, as well as the severity and location of the lesions could not be reliably determined using ultrasonography and radiography, computed tomography was helpful to delineate the extent of the pathology at the origin of the suspensory ligament. The horse was successfully treated by proximal resection of the fourth metatarsal bone in combination with partial removal of plantar metatarsal bone exostoses impinging on the suspensory ligament. The horse was sound 3 months following surgical treatment. It remained free of lameness at subsequent follow-up examinations at 6, 9, 12 and 18 months post-surgery, and was competing successfully 9 months after surgery. The favorable clinical outcome and rapid post-surgical recovery support the authors´ hypothesis that pressure reduction via proximal ostectomy of the fourth metatarsal bone and partial removal of metatarsal bone exostoses reduced osseous impingement on the suspensory ligament and created increased space for the pathologically altered soft tissue structures to heal. [ABSTRACT FROM AUTHOR]

Context: Adults with X-linked hypophosphatemia (XLH) present complications other than osteomalacia.Objective: To describe the incidence and severity of comorbidities in adults with XLH.Methods: This observational retrospective study included a total of 25 adults with XLH with thorough investigations, including spinal computed tomography scans, x-rays of hip/knee joints and Achilles tendons, abdominal ultrasounds, and audiograms. The index of ossification of the anterior/posterior longitudinal ligament and yellow ligament (OA/OP/OY index) and the sum of OA/OP/OY index (OS index) were utilized to evaluate the severity of spinal ligament ossification. The Kellgren-Lawrence (KL) classification was adopted to evaluate the severity of the hip/knee osteophytes.Results: The participants consisted of 13 male patients and 12 female patients from 21 families, with a median age of 43 (range, 18-72) years. In all, 20 patients (80%) showed spinal ligament ossification. The median OA/OP/OY/OS indices were 2 (0-22), 0 (0-15), 6 (0-13), and 12 (0-41), respectively. Hip/knee osteophytes were reported in 24 (96%) and 17 cases (68%). The median KL grade was 3 in the hip joint and 2 in the knee joint, and 18 cases (72%) developed enthesopathy in the Achilles tendon. Nephrocalcinosis and hearing impairment were observed in 18 (72%) and 8 (32%) cases.Conclusion: This study revealed a high prevalence and severity of ectopic ossification and disclosed the incidence of nephrocalcinosis and hearing impairment in adults with XLH. In cases with severe spinal ligament ossification or noticeable osteophytes around the hip/knee joints, undiagnosed XLH should be considered as a possible underlying condition. [ABSTRACT FROM AUTHOR]

Extracorporeal shockwave therapy (ESWT) for the treatment of musculoskeletal diseases is a field that is developing rapidly and attracting increasing attention. Studies exploring the effects of shockwave therapy on enthesopathy have resulted in equivocal findings. Therefore, the purpose of this review article is to collectively review and analyze published literature on the effects of shockwave therapy on enthesopathy in human studies. This is a literature review study however, systematic search was performed on Scopus, EBSCOhost (Medline, CINAHL, and Sport Discus), and Google Scholar databases. The search resulted in 112 articles, nine relevant articles that met the inclusion criteria were selected for analysis in this review. Shockwave therapy can be safe and effective to reduce pain, improve functions and activities as it accelerates the entheses healing. The exact mechanisms of shockwave therapy on enthesopathy are still debatable. Further investigation is needed to confirm and validate the findings of previous related studies. [ABSTRACT FROM AUTHOR]

Background. Autologous platelet-rich plasma (PRP) therapy has been applied in treatment of medial or lateral elbow epicondylitis; however, its efficacy is variable possibly due to differences in PRP platelet or neutrophil concentrations. We prepared neutrophil- reduced PRP with optimized platelet concentrations, and investigated therapeutic effects of the platelet-optimized PRP for elbow epicondylitis. Methods. We treated 65 elbows of 60 patients (9 women and 51 men) with mean age of 50 years. Neutrophil-reduced PRP with optimized platelet concentrations were used in 41 lateral epicondylitis and 24 medial epicondylitis cases. Visual analogue pain scores (VAS) and modified Mayo Elbow Performance scores (MEPS) were obtained for each elbow at pre-PRP therapy and at 3, 6 or 12 months after the treatment. Results. In 57 enthesopathies (34 lateral and 23 medial elbow epicondylitis), VAS or modified MEPS values at 3 months after treatment were significantly lower or higher, respectively, than those obtained before treatment; and this tendency was more manifested at 6 and 12 months after treatment. The PRP therapies were relatively less effective in 3 cases with complete tears at insertional site(s) of common tendons, 3 cases of lateral epicondylitis with synovial fringes, one with entrapment of the posterior interosseous nerve and in one welfare-reliant patient. Following the treatment with platelet-optimized PRP, VAS or modified MEPS values were lower or higher, respectively, than those reported in previous studies where not optimized PRP preparations were used. Conclusions. The platelet-optimized PRP therapy is effective for treatment of enthesopathy in elbow epicondylitis and this efficacy is higher than with PRP therapies without optimized platelet concentrations. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate lower extremity cartilage thickness in axial spondyloarthritis (SpA) patients and healthy controls using ultrasound (US) and to determine the relationship between the indices, quality of life, enthesopathy, and cartilage thickness of patients with axial SpA. Materials and Methods: This study included 73 axial SpA patients and 30 healthy controls. The patients with axial SpA were divided into two groups as with and without heel enthesitis. Demographic data, disease duration, and medical treatments of patients were recorded. The cartilage (hip, talar, and knee), plantar fascia, and Achilles tendon thicknesses of both healthy controls and axial SpA patients were measured by US. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Functional Index (BASFI), patient global assessment (PGA), and Ankylosing Spondylitis Quality of Life (ASQoL) scores of patients were evaluated. Results: There was no difference between the groups in terms of demographic data and body mass index. The axial SpA groups with and without heel enthesitis were similar in terms of medical treatment and disease duration. The axial SpA patients with heel enthesitis had thinner cartilages than those without heel enthesitis (P < 0.05). The axial SpA patients without heel enthesitis had thinner cartilage thicknesses than the healthy control group (P < 0.05). There were statistically significant differences between the two groups in terms of the BASDAI, BASFI, BASMI, and ASQoL scores. These indices were negatively correlated with cartilage thickness (P < 0.05; r: −0.420). Conclusion: Lower extremity cartilage thickness is associated with disease activity, quality of life, and spinal mobility in patients with axial SpA. [ABSTRACT FROM AUTHOR]

Background. Autologous platelet-rich plasma (PRP) injection is an alternative but widely accepted method for the treatment of degenerative changes in tendon attachments known as enthesopathies. The PRP is considered a safe source for high concentrations of the growth factors involved in the healing process. Despite initial promising outcomes, many recent studies report conflicting results for this treatment. This may be due to differences in the concentrations of platelets and growth factors in PRPs obtained using different methods. Objectives. The aim of this study was to compare PRP preparation systems in terms of morphotic components and selected growth factors to find the most appropriate procedure for the treatment of enthesopathies. Materials and methods. Whole blood samples from 6 healthy male volunteers were collected. Using different commercial kits (Mini GPS III System, Arthrex ACP, and Xerthra, Dr. PRP), 4 PRPs were prepared from the blood of each participant. All samples were analyzed for the content of morphotic components and the following growth factors: transforming growth factor-ß1 (TGF-ß1), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), and platelet-derived growth factor AA (PDGF-AA). Results. The Mini GPS III produced PRP with the highest concentration of platelets and white blood cells (WBC) compared to the other systems included in the study. Significant differences in the levels of EGF and PDGF-AA were found only between the Mini GPS III and Arthrex ACP. There was positive correlation between the content of platelets and the levels of PDGF-AA and EGF. The red blood cells (RBC) concentration positively correlated with PDGF-AA, EGF and VEGF. Conclusions. This study showed differences between the morphotic components and levels of selected growth factors in PRP obtained with the different preparation methods. Due to insufficient data, we cannot argue for or against any of the studied protocols for the treatment of enthesopathy. Further studies on a larger population are required to validate our results. [ABSTRACT FROM AUTHOR]

The surgical treatment of Achilles tendinopathy can be considered after the failure of conservative treatment, and the surgical methods may be divided into two groups; treatments for insertional and non-insertional tendinopathy. In the case of insertional tendinopathy, debridement including tendon and calcification of the diseased lesion, reattachment of the tendon, and calcaneal ostectomy of the Haglund lesion are the primary treatments. If reattachment is not possible, reconstruction should be performed by other methods such as tendon transfer. As a result of surgery for insertional tendinopathy, there is an improvement in the pain and function after surgery, but there are some patients whose pain does not completely disappear. Some residual pain may persist; therefore, the overall success rate of the surgery can be expected to be 80% to 90%. For the patients of non-insertional tendinopathy, conservative treatment through eccentric exercise is the primary treatment, and most of them have reported good results. In case of failure after various conservative treatments, debridement of the diseased lesion and repair of the remaining tendon would be the primary surgical treatments. If the remaining tendon is not sufficient, reconstruction such as tendon transfer should be considered. [ABSTRACT FROM AUTHOR]

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ossification of ligaments and entheses, and most commonly affects the spinal column. The prevalence of DISH is increasing with age and is considered uncommon before the age of 50 years, with an estimated prevalence of less than 5 %. DISH is known to be highly associated with metabolic syndrome and obesity. We aim to assess the prevalence of DISH among young (≤50 yr.) patients suffering from severe obesity (BMI of 35 kg/m2 or higher). A retrospective analysis assessing chest and spine radiographs (including Computed Tomography, CT) of patients with BMI≥35 visiting the bariatric ambulatory clinic in an academic medical center from 2013 to 2022. Patients included in the analysis were 31–50 years old. Diagnosis of DISH was made according to the Resnick criteria. The prevalence of DISH was calculated. Demographic, clinical and laboratory data were collected and compared between the DISH and non-DISH groups. 183 young (mean age: 40.4; 118 females, 64.2 %) obese (BMI median: 40.6; range 35–73) patients were included in the radiographic review. DISH was diagnosed in 33 patients (18.0 %; 95 % CI: 13.1–24.2 %) which was significantly higher than the expected 10 % (Z = 3.62, p <.001); another 8 patients (4.4 %; 95 % CI: 2.2–8.4 %) were considered as "near DISH" (not fulfilling yet the Resnick criteria) as it represents a pre-disease state. Patients diagnosed with DISH were significantly older than patients without DISH (t = 4.54, p <.001), as the prevalence of DISH increased by age (linear association=14.95, p <.001). There was a statistically significantly higher prevalence of hypertension (χ2 = 8.30, p <.004), smoking (χ2 = 4.69, p <.03) and OSA (χ2 = 6.16, p <.013) in the DISH group as compared to their non-DISH counterparts. The prevalence of DISH among obese young patients was 18 %, which is much higher than in the general population. Early-onset DISH should be regarded as a musculoskeletal obesity-related complication. [ABSTRACT FROM AUTHOR]