Skip to main content

Main menu

  • Home
  • Content
    • First Release
    • Current
    • Archives
    • Collections
    • Audiovisual Rheum
    • COVID-19 and Rheumatology
  • Resources
    • Guide for Authors
    • Submit Manuscript
    • Author Payment
    • Reviewers
    • Advertisers
    • Classified Ads
    • Reprints and Translations
    • Permissions
    • Meetings
    • FAQ
    • Policies
  • Subscribers
    • Subscription Information
    • Purchase Subscription
    • Your Account
    • Terms and Conditions
  • About Us
    • About Us
    • Editorial Board
    • Letter from the Editor
    • Duncan A. Gordon Award
    • GDPR Policy
    • Accessibility
  • Contact Us
  • JRheum Supplements
  • Services

User menu

  • My Cart
  • Log In

Search

  • Advanced search
The Journal of Rheumatology
  • JRheum Supplements
  • Services
  • My Cart
  • Log In
The Journal of Rheumatology

Advanced Search

  • Home
  • Content
    • First Release
    • Current
    • Archives
    • Collections
    • Audiovisual Rheum
    • COVID-19 and Rheumatology
  • Resources
    • Guide for Authors
    • Submit Manuscript
    • Author Payment
    • Reviewers
    • Advertisers
    • Classified Ads
    • Reprints and Translations
    • Permissions
    • Meetings
    • FAQ
    • Policies
  • Subscribers
    • Subscription Information
    • Purchase Subscription
    • Your Account
    • Terms and Conditions
  • About Us
    • About Us
    • Editorial Board
    • Letter from the Editor
    • Duncan A. Gordon Award
    • GDPR Policy
    • Accessibility
  • Contact Us
  • Follow jrheum on Twitter
  • Visit jrheum on Facebook
  • Follow jrheum on LinkedIn
  • Follow jrheum on RSS
Research ArticleGout

Ultrasound Characteristics of the Achilles Tendon in Tophaceous Gout: A Comparison with Age- and Sex-matched Controls

Matthew Carroll, Nicola Dalbeth, Bruce Allen, Sarah Stewart, Tony House, Mark Boocock, Christopher Frampton and Keith Rome
The Journal of Rheumatology October 2017, 44 (10) 1487-1492; DOI: https://doi.org/10.3899/jrheum.170203
Matthew Carroll
From the Health and Rehabilitation Research Institute, Auckland University of Technology; Faculty of Medical and Health Sciences, The University of Auckland; Department of Rheumatology, Auckland District Health Board; Horizon Radiology Ltd., Auckland University of Technology North Shore Campus, Auckland; Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Nicola Dalbeth
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Bruce Allen
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sarah Stewart
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Tony House
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mark Boocock
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Christopher Frampton
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Keith Rome
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: krome@aut.ac.nz
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
  • eLetters
PreviousNext
Loading

Abstract

Objective. To investigate the frequency and distribution of characteristics of the Achilles tendon (AT) in people with tophaceous gout using musculoskeletal ultrasound (US).

Methods. Twenty-four participants with tophaceous gout and 24 age- and sex-matched controls without gout or other arthritis were recruited. All participants underwent a greyscale and power Doppler US examination. The AT was divided into 3 anatomical zones (insertion, pre-insertional, and proximal to the mid-section). The following US characteristics were assessed: tophus, tendon echogenicity, tendon vascularity, tendon morphology, entheseal characteristics, bursal morphology, and calcaneal bone profile.

Results. The majority of the participants with tophaceous gout were middle-aged men (n = 22, 92%) predominately of European ethnicity (n = 14, 58%). Tophus deposition was observed in 73% (n = 35) of tendons in those with gout and in none of the controls (p < 0.01). Intratendinous hyperechoic spots (p < 0.01) and intratendinous power Doppler signal (p < 0.01) were more frequent in participants with gout compared to controls. High prevalence of entheseal calcifications, calcaneal bone cortex irregularities, and calcaneal enthesophytes were observed in both gout participants and controls, without differences between groups. Intratendinous structural damage was rare. Hyperechoic spots were significantly more common at the insertion compared to the zone proximal to the mid-section (p < 0.01), but between-zone differences were not observed for other features.

Conclusion. US features of urate deposition, tophus, and vascularization are present throughout the AT in patients with tophaceous gout. Despite crystal deposition, intratendinous structural changes are infrequent. Many characteristics observed in the AT in people with tophaceous gout, particularly at the calcaneal enthesis, are not disease-specific.

Key Indexing Terms:
  • GOUT
  • ACHILLES TENDON
  • TOPHI
  • ULTRASOUND

Gout is a form of inflammatory arthritis caused by monosodium urate (MSU) crystal deposition1. Gout can clinically manifest as acute inflammatory arthritis, tophus formation, joint damage, and altered tendon and ligament structure and function2. Tophus formation has been identified as a risk factor for the development of musculoskeletal disability and the mechanical obstruction of joint movement, and is linked to a reduction in quality of life3,4.

The Achilles tendon (AT) is involved in everyday activities, including walking, and is the main plantarflexor in gait. Alteration to the internal structure of the tendon by the degenerative process reduces the tendon’s ability to respond to load, and subsequently predisposes to further injury. The presence of MSU crystals in the AT has been previously reported5,6,7. In a dual-energy computed tomography (CT) study, 1 in 4 people with tophaceous gout had evidence of urate crystal deposition affecting the AT, with 38% of these having only nonentheseal involvement, 40% having both entheseal and nonentheseal involvement, and 22% with only entheseal involvement6.

Imaging provides important insights into the pathology of gout. Ultrasound (US) has been used to assess and characterize urate deposition, structural damage, and inflammation in terms of synovitis and tenosynovitis in people with gout8,9. The aim of our current study was to investigate the frequency and distribution of US characteristics of the AT in people with tophaceous gout compared to age- and sex-matched controls.

MATERIALS AND METHODS

Participants

Twenty-four participants with tophaceous gout were recruited from rheumatology outpatient clinics at the Auckland District Health Board, Auckland, New Zealand, together with 24 age- and sex-matched control participants recruited from public advertising of Auckland University of Technology (AUT) staff. This sample size is similar to previous imaging studies of foot disease in gout10. Participants with tophaceous gout fulfilled the 1977 American Rheumatism Association classification criteria for gout11 and were to have clinical evidence of at least one palpable tophus. Participants with gout were excluded if they were experiencing an episode of acute arthritis at the time of the study visit. The study was approved by the AUT Ethics Committee (AUTEC 13/100). All participants provided written informed consent prior to entry into the study. Demographic data were obtained from all participants including age, sex, ethnicity, body mass index, current medications, and medical history. Additionally, gout disease characteristics were documented for participants with gout including disease duration and flare history, serum urate, and tophus count.

US image acquisition

The US examination was performed at the AUT Horizon Scanning Clinic by a single musculoskeletal radiologist (BA) who was blinded to the participants’ diagnostic group. A Philips iU22 unit equipped with a broadband 12–14MHz linear probe was used. All settings were standardized to optimize visualization of superficial and deep structures of the AT. Greyscale scanning used a dynamic range of 40–50dB and a gain of 60dB. Power Doppler settings used a pulse repetition frequency of 500Hz, and a low wall filter of 42Hz, with the color gain increased to the highest value not generating signal under the bony cortex and optimized for low flow. All participants assumed a prone position during scanning with the knee fully extended for optimal visualization of the AT. Bilateral systematic longitudinal and transverse imaging of the enthesis and body of the AT were conducted in greyscale and power Doppler modes in accordance with the Outcome Measures in Rheumatology US task force9.

US image interpretation

All images were stored in a picture archiving and communications system (PACS). Six months following the completion of all data acquisition, the static US images were reviewed by a single radiologist (BA) with over 20 years of experience in musculoskeletal imaging for features of urate deposition, inflammation, structure, and damage. All characteristics assessed within the AT were also recorded with respect to their location in accordance with the following 3 divisions: zone 1 (insertional zone): calcaneal enthesis to 2 cm proximal; zone 2 (pre-insertional): 2 cm to 6 cm proximal to calcaneal enthesis; and zone 3 (proximal to mid-section): 6 cm proximal to enthesis to myotendinous junction of the gastrocnemius. The 3 zones were defined from previous work on the AT that indicated a relative zone of hypovascularity within 2 cm to 6 cm proximal to the calcaneal insertion12,13. All US characteristics were defined in accordance with standardized definitions as follows.

Features of urate deposition

Intratendinous tophi were defined as the presence of hyperechoic heterogeneous or homogeneous lesions with poorly defined contours surrounded by an anechoic halo14 and were recorded for each zone of the AT. Intratendinous hyperechoic spots were defined as bright foci consistent with either aggregate formation on the collagen fibril or calcified tophi (relative to the tendon fibers), with or without acoustic shadow, seen in 2 perpendicular planes7,15 within the AT. Additionally, intratendinous focal hyperechoic areas were defined as a lack of the homogeneous fibrillar pattern with loss of the tightly packed echogenic lines after correcting for anisotropy15. The presence of tophi within the retrocalcaneal bursa were also recorded and defined as aggregates located in the bursa that were heterogeneous and hyperechoic (relative to subdermal fat) with poorly defined margins with or without areas of acoustic shadowing7. Additionally, the presence of bursal snowstorm was recorded if echogenic aggregates were observed within the bursa16.

Features of inflammation

Tendon vascularity was assessed within each zone of the AT and defined as the presence of the power Doppler signal17. The enthesis of the AT, defined as the area within 2 mm of the bony cortex, was also assessed for the presence of vascularity using the same definition15. Retrocalcaneal bursitis was defined as a bursa with a well-defined compressible, anechoic, or hypoechoic area inside with maximal diameter larger than 2 mm as viewed in the longitudinal plane18. Bursal size was also recorded using digital calipers and bursal size score graded using a semiquantitative scale (0 = < 2 mm, 1 = between 2–4 mm, and 2 = > 4 mm)17. Bursal vascularity was defined as the presence of power Doppler activity within the bursa17.

Features of structure and damage

AT entheseal thickness was measured on a longitudinal scan at the insertion of the deeper margin of the AT into the calcaneal bone using digital callipers19. AT thickness was also scored on a semiquantitative scale (1 = < 5.3 mm, 2 = 5.3–6.3 mm, and 3 = > 6.3 mm)17. AT length was also measured at the insertion of the deeper margin into the calcaneal bone using digital callipers20. A partial tendon tear was defined as a focal discontinuity21 while a complete tendon rupture was defined as a complete loss of tendon substance22, both of which were visualized with the US beam exactly perpendicular to the tendon to avoid anisotropy. Bone erosions were defined as a cortical breakage with a step-down contour defect, seen in 2 perpendicular planes, at the insertion of the enthesis to the bone23 and graded on a 3-grade semiquantitative scale (0 = no bone erosion, 1 = between 0.1 and 2 mm, and 2 = > 2 mm)17. Bone cortex irregularities were defined as a loss of the normal regular bone contour without any clear sign of enthesophyte and/or erosion15. Enthesophytes were defined as a step up of bony prominence at the end of the normal bone contour, seen in 2 perpendicular planes, with or without acoustic shadow15. The presence of calcifications at the AT enthesis was defined as intratendinous hyperechoic spots15.

Interobserver reliability

To assess interobserver agreement of the US characteristics, randomly selected images from 12 participants with gout and 12 controls were uploaded to PACS and were independently scored by a second musculoskeletal radiologist (TH) with over 25 years of clinical experience, who was blinded to all clinical details and US scores from the first radiologist. Reliability was determined using the κ statistic. Values of 0 to 0.2 were considered poor, 0.2 to 0.4 fair, 0.4 to 0.6 moderate, 0.6 to 0.8 good, and 0.8 to 1.0 excellent24.

Statistical analysis

Participant characteristics were described as mean (SD) or frequency (%). Because US characteristics were nested within participants (i.e., assessed bilaterally and within 3 zones), a general estimating equation (GEE) approach was used to determine whether there were significant differences between the gout and control groups for both the binary and continuous US characteristics. Between-zone differences in the US characteristics were also analyzed within the GEE models. All tests were 2-tailed, and p values < 0.05 were considered significant. Data were analyzed using SPSS V.20 (SPSS).

RESULTS

The participant demographic and clinical characteristics are shown in Table 1. The majority of the participants with tophaceous gout were middle-aged (mean 61.9 yrs old), men (n = 22, 92%), and predominately of European ethnicity (n = 14, 58%). There were more participants of European ethnicity in the control group (p < 0.01). Participants with tophaceous gout had longstanding disease with a mean (SD) serum urate level of 0.37 (0.11) mmol/l. Hypertension and cardiovascular disease were significantly more frequent in participants with tophaceous gout (p < 0.01 and p = 0.03, respectively). The majority of participants with gout were treated with urate-lowering therapy (n = 22, 92%).

View this table:
  • View inline
  • View popup
Table 1.

Participant demographic and clinical characteristics. Values mean (SD) unless otherwise specified.

Interreader reliability

Interobserver reliability demonstrated that κ values were excellent for intratendinous tophus (κ = 0.91), intratendinous focal hyperechoic areas (κ = 1.00), intratendinous hyperechoic spots (κ = 0.93), intratendinous power Doppler signal (κ = 0.87), tendon tears (κ = 1.00), entheseal focal hyperechoic areas (κ = 1.00), entheseal calcifications (κ = 0.92), entheseal vascularity (κ = 0.84), bursal snowstorm appearance (κ = 1.00), bursal power Doppler signal (κ = 1.00), and calcaneal bone erosions (κ = 1.00). Kappa values were good for calcaneal bone cortex irregularities (κ = 0.77) and calcaneal enthesophytes (κ = 0.68).

US features of urate deposition

The presence of intratendinous tophus was significantly more common in the participants with gout compared to the controls (n = 35 tendons, 73% vs n = 0 tendons, 0%, respectively; p < 0.01; Table 2). Intratendinous hyperechoic spots were also more common in participants with gout compared to controls (n = 39 tendons, 81% vs n = 9 tendons, 19%, respectively; p < 0.01). Intratendinous focal hyperechoic areas, intrabursal tophus, and bursal snowstorm appearance were uncommon and could not be analyzed statistically using the GEE model.

View this table:
  • View inline
  • View popup
Table 2.

Features of urate deposition. Values are n/N (%) unless otherwise specified.

US features of inflammation

Intratendinous power Doppler signal was more prevalent in participants with tophaceous gout compared to control participants (n = 39 tendons, 81% vs n = 9 tendons, 19%, respectively; p < 0.01; Table 3). No differences were found for entheseal vascularity between participants with gout and controls (n = 10 tendons, 21% vs n = 7 tendons, 15%, respectively; p = 0.65). Retrocalcaneal bursitis and bursal Doppler signal were uncommon and could not be analyzed statistically using the GEE model.

View this table:
  • View inline
  • View popup
Table 3.

Features of inflammation. Values are n/N (%) unless otherwise specified.

US features of structure and damage

Figure 1 illustrates (a) intratendinous urate deposits that appear as hyperechoic bands (arrows) on collagen fibrils in the mid-portion of the AT; (b) intratendinous tophus deposition to the proximal zone of the AT (arrows); and (c) intratendinous vascularization to the mid-portion of the AT (arrows). Partial tears were observed in 2 tendons (4%) in participants with gout and in none of the controls, while neither group demonstrated AT ruptures (Table 4). There was no significant difference in mean tendon thickness (4.7 mm vs 4.3 mm; p = 0.85) or mean tendon length (57.9 mm vs 57.3 mm; p = 0.90) between participants with gout and controls. The presence of entheseal calcifications (n = 28 tendons, 59%; vs n = 19 tendons, 40%; p = 0.43), calcaneal bone cortex irregularities (n = 13 tendons, 27%; vs n = 9 tendons, 19%; p = 0.43), or calcaneal enthesophytes (n = 33 tendons, 69%; vs n = 29 tendons, 60%; p = 0.64) was not significantly different between tophaceous gout and control groups.

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

(a) Intratendinous urate deposits appear as hyperechoic bands (arrows) on collagen fibrils in the mid-portion of the Achilles tendon. (b) Intratendinous tophus deposition to the proximal zone of the Achilles tendon (arrows). (c) Intratendinous vascularization to the mid-portion of the Achilles tendon (arrows).

View this table:
  • View inline
  • View popup
Table 4.

Features of structure and damage. Values are n/N (%) unless otherwise specified.

Owing to the similarities in the tendon thickness and calcaneal bone erosion scores between groups, these variables could not be analyzed using the GEE model.

US features by AT zone

No significant differences were found for intratendinous tophus presence (p = 0.07) and intratendinous power Doppler signal (p = 0.60) between the 3 zones of the AT in people with tophaceous gout (Table 5). A significant difference was observed for the presence of intratendinous hyperechoic spots by AT zone (p < 0.01). Pairwise comparisons revealed that hyperechoic spots were significantly more common in zone 1 compared to zone 3 (p < 0.01).

View this table:
  • View inline
  • View popup
Table 5.

Ultrasound characteristics by zone of tendon. Values are n (%) unless otherwise specified.

DISCUSSION

The aim of our current study was to investigate the frequency and distribution of US characteristics of the AT in people with tophaceous gout. Our findings demonstrate that, compared with age- and sex-matched control participants, people with tophaceous gout have both disease-specific and nonspecific features, including a higher prevalence of tophus, intratendinous power Doppler signal, and intratendinous hyperechoic spots. Despite these findings, structural damage in the AT was minimal in participants with gout.

Our current study showed that tophi were present in 73% of tendons in participants with tophaceous gout, which is higher than that reported in previous imaging studies (range, 22%–34% of tendons)5,7. However, clinical evidence of palpable tophi was not an inclusion criterion in these prior studies, suggesting that MSU deposition within the AT may be more prevalent in patients with gout who have advanced tophaceous disease. Chhana, et al25 reported that MSU crystals directly interact with tenocytes to reduce cell viability and function, and these interactions may contribute to tendon damage in people with advanced gout. Despite the frequent deposition of tophus in our current study, disruption of collagen fibrillar echotexture was rarely observed.

Our current results demonstrated tophus deposition present in all 3 zones of the AT, with the enthesis and body of the AT being the most prevalent sites. In a dual-energy CT study, Dalbeth, et al6 reported that 38% of AT examined had only nonentheseal involvement, 40% had both entheseal and nonentheseal involvement, and 22% had only entheseal involvement. Intratendinous hyperechoic spots were observed significantly more often in participants with gout in all tendon zones, but significantly higher in the insertional zone. Hyperechoic spots are representative of either intratendinous aggregate formation on the collagen fibril or calcified tophi7. However, in agreement with Ventura-Ríos, et al5, we also observed intratendinous hyperechoic spots in some control participants. Hyperechoic changes and calcifications within the AT in healthy populations may be related to biomechanical factors or asymptomatic calcific tendinopathy26. In participants with tophaceous gout, power Doppler signal was observed in all zones of the AT with no difference between the 3 zones. Our data show that a positive Doppler signal is not only a synovial feature in tophaceous gout, but also extends to the intratendinous structure. The high prevalence of intratendinous vascularization observed in our current study contrasts with Ventura-Ríos, et al5, who reported no positive Doppler signal in the AT in participants with gout. We observed the Doppler signal was also present in control participants supporting the notion that this lesion is not exclusive to gout.

Despite the high tophus burden observed in the participants with gout, intratendinous structural damage was not a major feature. Further, we observed only minimal erosive damage at the enthesis, suggesting that the calcaneal enthesis is not a common site of bone erosion in tophaceous gout. Additionally, entheseal thickening was not a significant feature, with no differences being found between participants with tophaceous gout and controls. Calcaneal enthesophyte formation was also observed at a similar rate in both groups. Enthesophytes are commonly found in healthy individuals and therefore do not necessarily indicate disease. The presence of minimal damage together with no significant alteration in fibrillar echotexture provides further evidence that the AT may not be structurally altered in participants with tophaceous gout.

Some limitations of our present study should be taken into account. Despite the study demonstrating crystal deposition and vascularization, the scoring and definitions of elemental tendinous features in tophaceous gout are yet to be standardized and validated. Future research would benefit from validation of these features through comparison with other advanced forms of musculoskeletal imaging including dual-energy CT and magnetic resonance imaging. The cross-sectional study design did not enable the investigation of a temporal sequence of lesion development, which would have allowed differentiation between disease-specific and age-related characteristics. Finally, the control participants were not screened for hyperuricemia, which may have influenced the US findings10.

US features of urate deposition and vascularization are present throughout the AT in patients with tophaceous gout. Despite crystal deposition, intratendinous structural changes are infrequent. Many characteristics observed in the AT, particularly at the calcaneal enthesis, are not disease-specific to people with tophaceous gout.

Footnotes

  • This study was funded by Arthritis New Zealand.

  • Accepted for publication June 9, 2017.

REFERENCES

  1. 1.↵
    1. Martinon F,
    2. Pétrilli V,
    3. Mayor A,
    4. Tardivel A,
    5. Tschopp J
    . Gout-associated uric acid crystals activate the NALP3 inflammasome. Nature 2006;440:237–41.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Dalbeth N,
    2. Merriman TR,
    3. Stamp LK
    . Gout. Lancet 2016;388:2039–52.
    OpenUrlPubMed
  3. 3.↵
    1. Khanna PP,
    2. Nuki G,
    3. Bardin T,
    4. Tausche AK,
    5. Forsythe A,
    6. Goren A,
    7. et al.
    Tophi and frequent gout flares are associated with impairments to quality of life, productivity, and increased healthcare resource use: Results from a cross-sectional survey. Health Qual Life Outcomes 2012;10:117.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Dalbeth N,
    2. Collis J,
    3. Gregory K,
    4. Clark B,
    5. Robinson E,
    6. McQueen FM
    . Tophaceous joint disease strongly predicts hand function in patients with gout. Rheumatology 2007;46:1804–7.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Ventura-Ríos L,
    2. Sánchez-Bringas G,
    3. Pineda C,
    4. Hernández-Díaz C,
    5. Reginato A,
    6. Alva M,
    7. et al.
    Tendon involvement in patients with gout: an ultrasound study of prevalence. Clin Rheumatol 2016;35:2039–44.
    OpenUrl
  6. 6.↵
    1. Dalbeth N,
    2. Kalluru R,
    3. Aati O,
    4. Horne A,
    5. Doyle AJ,
    6. McQueen FM
    . Tendon involvement in the feet of patients with gout: a dual-energy CT study. Ann Rheum Dis 2013;72:1545–8.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    1. Naredo E,
    2. Uson J,
    3. Jiménez-Palop M,
    4. Martínez A,
    5. Vicente E,
    6. Brito E,
    7. et al.
    Ultrasound-detected musculoskeletal urate crystal deposition: which joints and what findings should be assessed for diagnosing gout? Ann Rheum Dis 2014;73:1522–8.
    OpenUrlAbstract/FREE Full Text
  8. 8.↵
    1. de Ávila Fernandes E,
    2. Sandim GB,
    3. Mitraud SA,
    4. Kubota ES,
    5. Ferrari AJ,
    6. Fernandes AR
    . Sonographic description and classification of tendinous involvement in relation to tophi in chronic tophaceous gout. Insights Imaging 2010;1:143–8.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Terslev L,
    2. Gutierrez M,
    3. Christensen R,
    4. Balint PV,
    5. Bruyn GA,
    6. Delle Sedie A,
    7. et al;
    8. OMERACT US Gout Task Force
    . Assessing elementary lesions in gout by ultrasound: results of an OMERACT patient-based agreement and reliability exercise. J Rheumatol 2015;42:2149–54.
    OpenUrlAbstract/FREE Full Text
  10. 10.↵
    1. Stewart S,
    2. Dalbeth N,
    3. Vandal AC,
    4. Allen B,
    5. Miranda R,
    6. Rome K
    . Ultrasound features of the first metatarsophalangeal joint in gout and asymptomatic hyperuricemia: comparison with normouricemic individuals. Arthritis Care Res 2017;69:875–83.
    OpenUrl
  11. 11.↵
    1. Wallace SL,
    2. Robinson H,
    3. Masi AT,
    4. Decker JL,
    5. McCarty DJ,
    6. Yü TF
    . Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 1977;20:895–900.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Lagergren C,
    2. Lindholm A
    . Vascular distribution in the Achilles tendon; an angiographic and microangiographic study. Acta Chir Scand 1959;116:491–5.
    OpenUrlPubMed
  13. 13.↵
    1. Chen TM,
    2. Rozen WM,
    3. Pan WR,
    4. Ashton MW,
    5. Richardson MD,
    6. Taylor GI
    . The arterial anatomy of the Achilles tendon: anatomical study and clinical implications. Clin Anat 2009;22:377–85.
    OpenUrlCrossRefPubMed
  14. 14.↵
    1. de Ávila Fernandes E,
    2. Kubota ES,
    3. Sandim GB,
    4. Mitraud SA,
    5. Ferrari AJ,
    6. Fernandes AR
    . Ultrasound features of tophi in chronic tophaceous gout. Skeletal Radiol 2011;40:309–15.
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. Terslev L,
    2. Naredo E,
    3. Iagnocco A,
    4. Balint PV,
    5. Wakefield RJ,
    6. Aegerter P,
    7. et al;
    8. Outcome Measures in Rheumatology Ultrasound Task Force
    . Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise. Arthritis Care Res 2014;66:741–8.
    OpenUrl
  16. 16.↵
    1. Grassi W,
    2. Meenagh G,
    3. Pascual E,
    4. Filippucci E
    . “Crystal clear”-sonographic assessment of gout and calcium pyrophosphate deposition disease. Sem Arthritis Rheum 2006;36:197–202.
    OpenUrlCrossRefPubMed
  17. 17.↵
    1. Filippucci E,
    2. Aydin SZ,
    3. Karadag O,
    4. Salaffi F,
    5. Gutierrez M,
    6. Direskeneli H,
    7. et al.
    Reliability of high-resolution ultrasonography in the assessment of Achilles tendon enthesopathy in seronegative spondyloarthropathies. Ann Rheum Dis 2009;68:1850–5.
    OpenUrlAbstract/FREE Full Text
  18. 18.↵
    1. Olivieri I,
    2. Barozzi L,
    3. Padula A,
    4. De Matteis M,
    5. Pierro A,
    6. Cantini F,
    7. et al.
    Retrocalcaneal bursitis in spondyloarthropathy: assessment by ultrasonography and magnetic resonance imaging. J Rheumatol 1998;25:1352–7.
    OpenUrlPubMed
  19. 19.↵
    1. Balint PV,
    2. Kane D,
    3. Wilson H,
    4. McInnes IB,
    5. Sturrock RD
    . Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy. Ann Rheum Dis 2002;61:905–10.
    OpenUrlAbstract/FREE Full Text
  20. 20.↵
    1. Zhao H,
    2. Ren Y,
    3. Wu YN,
    4. Liu SQ,
    5. Zhang LQ
    . Ultrasonic evaluations of Achilles tendon mechanical properties poststroke. J Appl Physiol 2009;106:843–9.
    OpenUrlAbstract/FREE Full Text
  21. 21.↵
    1. Grassi W,
    2. Filippucci E,
    3. Farina A,
    4. Cervini C
    . Sonographic imaging of tendons. Arthritis Rheum 2000;43:969–76.
    OpenUrlCrossRefPubMed
  22. 22.↵
    1. Schmidt WA
    . Value of sonography in diagnosis of rheumatoid arthritis. Lancet 2001;357:1056–7.
    OpenUrlCrossRefPubMed
  23. 23.↵
    1. Wakefield RJ,
    2. Balint PV,
    3. Szkudlarek M,
    4. Filippucci E,
    5. Backhaus M,
    6. D’Agostino MA,
    7. et al;
    8. OMERACT 7 Special Interest Group
    . Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 2005;32:2485–7.
    OpenUrlAbstract/FREE Full Text
  24. 24.↵
    1. Landis JR,
    2. Koch GG
    . The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74.
    OpenUrlCrossRefPubMed
  25. 25.↵
    1. Chhana A,
    2. Callon KE,
    3. Dray M,
    4. Pool B,
    5. Naot D,
    6. Gamble GD,
    7. et al.
    Interactions between tenocytes and monosodium urate monohydrate crystals: implications for tendon involvement in gout. Ann Rheum Dis 2014;73:1737–41.
    OpenUrlAbstract/FREE Full Text
  26. 26.↵
    1. Oliva F,
    2. Via AG,
    3. Maffulli N
    . Physiopathology of intratendinous calcific deposition. BMC Med 2012;10:95.
    OpenUrlCrossRefPubMed
View Abstract
PreviousNext
Back to top

In this issue

The Journal of Rheumatology
Vol. 44, Issue 10
1 Oct 2017
  • Table of Contents
  • Table of Contents (PDF)
  • Index by Author
  • Editorial Board (PDF)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about The Journal of Rheumatology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Ultrasound Characteristics of the Achilles Tendon in Tophaceous Gout: A Comparison with Age- and Sex-matched Controls
(Your Name) has forwarded a page to you from The Journal of Rheumatology
(Your Name) thought you would like to see this page from the The Journal of Rheumatology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Ultrasound Characteristics of the Achilles Tendon in Tophaceous Gout: A Comparison with Age- and Sex-matched Controls
Matthew Carroll, Nicola Dalbeth, Bruce Allen, Sarah Stewart, Tony House, Mark Boocock, Christopher Frampton, Keith Rome
The Journal of Rheumatology Oct 2017, 44 (10) 1487-1492; DOI: 10.3899/jrheum.170203

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

 Request Permissions

Share
Ultrasound Characteristics of the Achilles Tendon in Tophaceous Gout: A Comparison with Age- and Sex-matched Controls
Matthew Carroll, Nicola Dalbeth, Bruce Allen, Sarah Stewart, Tony House, Mark Boocock, Christopher Frampton, Keith Rome
The Journal of Rheumatology Oct 2017, 44 (10) 1487-1492; DOI: 10.3899/jrheum.170203
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
Save to my folders

Jump to section

  • Article
    • Abstract
    • MATERIALS AND METHODS
    • RESULTS
    • DISCUSSION
    • Footnotes
    • REFERENCES
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
  • eLetters

Keywords

GOUT
ACHILLES TENDON
TOPHI
ULTRASOUND

Related Articles

Cited By...

More in this TOC Section

  • Flare Rate Thresholds for Patient Assessment of Disease Activity States in Gout
  • Sex Differences in the Clinical Profile Among Patients With Gout: Cross-sectional Analyses of an Observational Study
  • Epidemiology of Depression and Anxiety in Gout: A Systematic Review and Metaanalysis
Show more Gout

Similar Articles

Keywords

  • gout
  • ACHILLES TENDON
  • TOPHI
  • ultrasound

Content

  • First Release
  • Current
  • Archives
  • Collections
  • Audiovisual Rheum
  • COVID-19 and Rheumatology

Resources

  • Guide for Authors
  • Submit Manuscript
  • Author Payment
  • Reviewers
  • Advertisers
  • Classified Ads
  • Reprints and Translations
  • Permissions
  • Meetings
  • FAQ
  • Policies

Subscribers

  • Subscription Information
  • Purchase Subscription
  • Your Account
  • Terms and Conditions

More

  • About Us
  • Contact Us
  • My Alerts
  • My Folders
  • RSS Feeds
The Journal of Rheumatology
The content of this site is intended for health care professionals.
Copyright © 2016 by The Journal of Rheumatology Publishing Co. Ltd.
Print ISSN: 0315-162X; Online ISSN: 1499-2752
Powered by HighWire