Open Access Highly Accessed Open Badges Research article

Ultrasound in the evaluation of enthesitis: status and perspectives

Frédérique Gandjbakhch1, Lene Terslev2, Fredrick Joshua3, Richard J Wakefield4, Esperanza Naredo5, Maria Antonietta D'Agostino6* and OMERACT Ultrasound Task Force

Author Affiliations

1 Rheumatology Department, Université Paris 6-Pierre et Marie Curie, Hôpital La Pitié Salpetrière, APHP, 83 Boulevard de l'hôpital 75013 Paris, France

2 Rheumatology Department, Copenhagen University Hospital at Glostrup, Nordre Ringvej 57 2600 Glostrup, Denmark

3 Rheumatology Department, Prince of Wales Hospital, Barker St Randwick NSW 2031 Australia

4 Section of Musculoskeletal Disease, LIMM, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research, Chapeltown Road Leeds LS7 4SA,UK

5 Rheumatology Department, Hospital Universitario Severo Ochoa; Doctor Alvarez Sierra 4, 4° A, 28033 Madrid, Spain

6 Rheumatology Department, Université Paris Ouest-Versailles-Saint Quentin en Yvelines, Hôpital Ambroise Paré, APHP, UPRES EA 2506, 9 avenue Charles De Gaulle 92100 Boulogne-Billancourt, France

For all author emails, please log on.

Arthritis Research & Therapy 2011, 13:R188  doi:10.1186/ar3516

Published: 17 November 2011



An increasing number of studies have applied ultrasound to the evaluation of entheses in spondyloarthritis patients. However, no clear agreement exists on the definition of enthesitis, on the number and choice of entheses to examine and on ultrasound technique, which may all affect the results of the examination. The objectives of this study were to first determine the level of homogeneity in the ultrasound definitions for the principal lesions of enthesitis in the published literature and second, to evaluate the metric properties of ultrasound for detecting enthesitis according to the OMERACT filter.


Search was performed in PUBMED and EMBASE. Both grey-scale and Doppler definitions of enthesitis, including describing features of enthesitis, were collected and metrological qualities of studies were assessed.


After selection, 48 articles were analyzed. The definition of ultrasound enthesitis and elementary features varied among authors. Grey-scale enthesitis was characterized by increasing thickness (94% of studies), hypoechogenicity (83%), enthesophytes (69%), erosions (67%), calcifications (52%), associated bursitis (46%) and cortical irregularities (29%). Only 46% of studies reported the use of Doppler. High discrepancies were observed on frequency, type of probe and Doppler mode used. Face and content validity were the most frequently evaluated criteria (43%) followed by reliability (29%) and responsiveness (19%).


Ultrasound has evidence to support face, content validity and reliability for the evaluation of enthesitis, though there is a lack of well-reported methodology in most of the studies. Consensus on elementary lesions and standardization of exam is needed to determine the ultrasound definition of enthesitis in grey-scale and in Doppler for future applications.

Systematic literature review; scoring system; ultrasound; power Doppler; enthesitis; enthesopathy; spondyloarthritis; ankylosing spondylitis; OMERACT filter