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P. Boendermaker (2007)Teach the teachers
T. Spiegel, Spiegel Js, H. Paulus (1987)The joint alignment and motion scale: a simple measure of joint deformity in patients with rheumatoid arthritis.
The Journal of rheumatology, 14 5
A. Scheel, Wolfgang Schmidt, Kay-Geert Hermann, G. Bruyn, M. D'Agostino, Walter Grassi, A. Iagnocco, J. Koski, Klaus Machold, E. Naredo, Horst Sattler, N. Swen, M. Szkudlarek, R. Wakefield, H. Ziswiler, Daniel Pasewaldt, Carola Werner, M. Backhaus, A. Dis, Maria Antonietta, Mark Dagostino (2005)Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR “Train the trainers” course
Annals of the Rheumatic Diseases, 64
Dr. Bouysset, T. Tavernier, J. Tebib, É. Noel, Prof. Tillmann, M. Bonnin, F. Eulry, M. Bouvier (1995)CT and MRI evaluation of tenosynovitis of the rheumatoid hindfoot
Clinical Rheumatology, 14
J. Parker, P. Harrell, G. Alarcón (1988)The value of the joint alignment and motion scale in rheumatoid arthritis.
The Journal of rheumatology, 15 8
A. Goverde, On Gynaecology (2006)Train the trainers!
European Clinics in Obstetrics and Gynaecology, 2
F. McQueen, V. Beckley, J. Crabbe, E. Robinson, S. Yeoman, N. Stewart (2005)Magnetic resonance imaging evidence of tendinopathy in early rheumatoid arthritis predicts tendon rupture at six years.
Arthritis and rheumatism, 52 3
D. Heijde, P. Riel, F. Gribnau, I. Nuver-Zwart, L. Putte (1989)EFFECTS OF HYDROXYCHLOROQUINE AND SULPHASALAZINE ON PROGRESSION OF JOINT DAMAGE IN RHEUMATOID ARTHRITIS
The Lancet, 333
Left medial ankle of a 57-year-old patient with RA, missing the FHL tendon(arrowhead) Figure 2
Jean-Françis Maillefert, Pascal Dardel, A. Cherasse, R. Mistrih, Denis Krause, Christian Tavernier (2003)Magnetic resonance imaging in the assessment of synovial inflammation of the hindfoot in patients with rheumatoid arthritis and other polyarthritis.
European journal of radiology, 47 1
Hilaire Jacob (2001)Forces acting in the forefoot during normal gait--an estimate.
Clinical biomechanics, 16 9
Lawrence Lo, Mark Schweitzer, Jennifer Fan, K. Wapner, P. Hecht (2001)MR imaging findings of entrapment of the flexor hallucis longus tendon.
AJR. American journal of roentgenology, 176 5
E. Naredo, Ingrid Möller, C. Moragues, J. Agustín, A. Scheel, Walter Grassi, E. Miguel, M. Backhaus, P. Bálint, G. Bruyn, M. D'Agostino, E. Filippucci, A. Iagnocco, David Kane, J. Koski, L. Mayordomo, W. Schmidt, W. Swen, M. Szkudlarek, L. Terslev, Søren Torp-Pedersen, J. Uson, R. Wakefield, Carola Werner (2005)Interobserver reliability in musculoskeletal ultrasonography: results from a “Teach the Teachers” rheumatologist course
Annals of the Rheumatic Diseases, 65
E. Jernberg, P. Simkin, M. Kravette, P. Lowe, G. Gardner (1999)The posterior tibial tendon and the tarsal sinus in rheumatoid flat foot: magnetic resonance imaging of 40 feet.
The Journal of rheumatology, 26 2
J. Michelson, Laura Dunn (2005)Tenosynovitis of the Flexor Hallucis Longus: A Clinical Study of the Spectrum of Presentation and Treatment
Foot & Ankle International, 26
J. Koski (1995)Detection of plantar tenosynovitis of the forefoot by ultrasound in patients with early arthritis.
Scandinavian journal of rheumatology, 24 5
N. Reeves (2006)Adaptation of the tendon to mechanical usage.
Journal of musculoskeletal & neuronal interactions, 6 2
J. Koski (1998)Ultrasound detection of plantar bursitis of the forefoot in patients with early rheumatoid arthritis.
The Journal of rheumatology, 25 2
A. Hamel, Seth Donahue, N. Sharkey (2001)Contributions of Active and Passive Toe Flexion to Forefoot Loading
Clinical Orthopaedics and Related Research, 1
Background: To assess the prevalence of and relation between rupture or tenosynovitis of the Flexor Hallucis Longus (FHL) tendon and range of motion, deformities and joint damage of the forefoot in RA patients with foot complaints. Methods: Thirty RA patients with painful feet were analysed, their feet were examined clinically for the presence of pes planus and range of motion (ROM), radiographs were scored looking for the presence of forefoot damage, and ultrasound examination was performed, examining the presence of tenosyovitis or rupture of the FHL at the level of the medial malleolus. The correlation between the presence or absence of the FHL and ROM, forefoot damage and pes planus was calculated. Results: In 11/60(18%) of the feet, a rupture of the FHL was found. This was associated with a limited motion of the MTP1-joint, measured on the JAM (χ = 10.4, p = 0.034), a higher prevalence of pes planus (χ = 5.77, p = 0.016) and a higher prevalence of erosions proximal at the MTP-1 joint 2 2 (χ = 12.3, p = 0.016), and joint space narrowing of the MTP1 joint (χ = 12.7, p = 0.013). Conclusion: Rupture of the flexor hallucis longus tendon in RA-patients is associated with limited range of hallux motion, more erosions and joint space narrowing of the MTP-1-joint, as well as with pes planus. don of the tibialis posterior is considered prevalent and Background In rheumatoid arthritis (RA), synovial inflammation important in the development of foot deformities in the affects the joints as well as periarticular structures such as feet of RA patients [2,3]. Rupture or tenosynovitis of the tendons. It is well recognized that the inflammatory tissue flexor hallucis longus (FHL) is rarely recognized by clini- in rheumatoid arthritis has a local destructive potency. cal examination in RA. This may be due to underestima- Inflammation and the resulting damage both cause func- tion, since in clinical assessment of the painful hind foot, tional limitations . Tenosynovitis or rupture of the ten- swelling is often interpreted as synovitis of the ankle . Page 1 of 5 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:110 http://www.biomedcentral.com/1471-2474/8/110 Imaging has shown to be more sensitive in detecting ten- space narrowing (0–4) per joint according to Sharp/van osynovitis than physical examination [2,4,5]. MRI-studies der Heijde . in RA-patients with hind foot pain showed a FHL-teno- synovitis prevalence of approximately 20% [2,4]. Ultra- Erosion score of the proximal surface of MTP1 (0–5) was sound studies (US) in RA patients showed a higher scored separately, as FHL tendon problems can lead to a prevalence of FHL tenosynovitis then anticipated clini- hallux rigidis with a higher prevalence of dorsal erosions cally [5,6]. To the best of our knowledge, FHL rupture is of the first metatarsal head . never reported in RA-patients. One licensed and qualified rheumatologist, using a Logiq Considering its function, damage of the flexor hallucis 7 General Electrics, 7–13 MHz linear transducer, per- longus (FHL) as a possible consequence of tenosynovitis formed ultrasound investigation. If present, the FHL ten- might be relevant. The FHL not only flexes the great toe don cross section was measured and the tendon assessed but it contributes, together with plantar fascia, to the dis- for signs of tenosynovitis (fluid around the tendon or tribution of forces at the plantar side of the forefoot and presence of Power Doppler signs). This was performed at maintenance of the longitudinal arch of the foot . Loss the level of the medial malleolus and extended 6 cm prox- of the tendon and its loading capability of the longitudi- imal to 6 cm distal of this point. Rupture of the FHL ten- nal arch, esp. at the level of the first ray, can lead to a pes don was defined as absence of this tendon at the level of planus . the medial malleolus. This tendon is difficult to visualise. If it could not be found at first sight, the great toe was Tenosynovitis (or rupture) of this tendon can also result flexed, causing motion of the tendon. If no motion was in a (functional) hallux rigidis and tightening of the FHL detected, the FHL tendon was finally judged to be absent. tendon. The subsequent dorsal compression in the first MTP-joint can in turn lead to the forming of osteophytes, Ultrasound is regarded as a reliable tool for detecting ten- further mechanical impingement, limitation and damage don abnormalities. Naredo et al observed an overall of the MTP1 . agreement of 88.5% in detecting tenosynovitis and 92% in tendon lesions of the ankle and foot, although these The relation between FHL tenosynovitis or rupture and findings were not limited to the tendon of the FHL. Scheel aforementioned abnormalities of the foot in RA patients et al observed an excellent κ value of 1 for the detection of has to be determined. tendon tears and a moderate κ value of 0.49 in detecting tenosynovitis, but this was calculated for tendons in gen- In our study we aim to assess the prevalence of FHL teno- eral and not specified for the tendons of the ankle or the synovitis or rupture and the relation between FHL rupture FHL [13,14]. or tenosynovitis and the range of motion, joint damage and pes planus in symptomatic feet of RA-patients. Differences between groups, regarding the rupture of the FHL, and the correlation with the ROM, Sharp/van der Heijde score and presence of pes planus were tested, using Methods We included 30 consecutive RA patients with at least one Pearson's chi squared test. Ethical approval was obtained painful forefoot and or hind foot who visited the outpa- from the ethics committee from The Medical Spectrum tient rheumatology clinic of the Medisch Spectrum Ensch- Twente; all patients gave their written consent. ede in September 2005. In 60 feet we measured the range of motion of the first metatarsophalangeal joint using the Results joint alignment motion scale (JAM) . A normal range Table 1 shows the demographic characteristics of the stud- of motion (ROM) of MTP is scored 0. A ROM limitation ied RA patients, showing a wide range of age, disease dura- to 65–70 degrees is scored 1, to 55–65 degrees as 2, to 20– tion and damage. 55 degrees as 3 and a range of motion less then 20 degrees is scored as 4. Spiegel et al described the JAM scale and this The median and the range of the JAM score are provided shows good inter reader reliability as well as a good rela- in Table 1. tion with disease activity and function [10,11]. Forty-two feet (70%) were scored as a pes planus. The feet were examined clinically for the presence or absence of a pes planus. Results of the radiograph scores are presented in Table 1. Radiographs were made of all feet. The MTP and IP joints Ultrasonography revealed that the tendon of the FHL was were each scored for joint erosions (range 0–10) and joint ruptured in 11/60(18%) of the feet Figure 2. Page 2 of 5 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:110 http://www.biomedcentral.com/1471-2474/8/110 Table 1: Mean values of the demographic, radiographic and joint mobility characteristics. TOTAL N = 60 FHL TENDON FHL TENDON PEARSON'S χ ABSENT N = 11 PRESENT N = 49 (P VALUE) Age (years) 54 57.6 53.1 NS Disease duration (years) 11.6 11.2 11.7 NS JAM score MTP-1 motion (0–4) 2.1 3.09 1.84 10.4 (0.034) SHS erosion proximal MTP 1 (0–5) 1.0 2.18 0.74 12.3 (0.016) SHS narrowing MTP 1 (0–4) 1.62 2.55 1.4 12.7 (0.013) Total SHS feet (0–84) 29.7 47.1 25.6 NS Pes Planus 42 11/11 31/49 5.77 (0.016) JAM = joint alignment motion scale, SHS = Sharp van der Heijde score, FHL = flexor hallucis longus FHL tendon rupture was associated with a limited range of onum, or overuse of the tendon in runners, dancers and motion of MTP1, measured as a significant higher score of athletes . the JAM motion MTP1 (χ = 10.4, p = 0.034.) Although nothing can be concluded regarding causality, In only one foot, a tenosynovitis was diagnosed, based on we hypothesize that following rheumatoid inflammation, fluid around the tendon. No tendon tears were found. rupture of the FHL tendon takes place. This can occur unnoticed, as the associated pain and swelling of the A pes planus was found in all of the feet with a ruptured ankle are often erroneously contributed to synovitis of the FHL, and only in 31 of the 49 remaining feet (χ = 5.77, p ankle . During tenosynovitis, damage of the MTP-1 = 0.016.) There was a significant relation between rupture of the FHL and erosions proximal at the MTP-1 joint (χ = 12.3, p = 0.016.), and joint space narrowing of the MTP1 joint. (χ = 12.7, p = 0.013.) Discussion This study shows that in RA patients, rupture of the flexor hallucis longus tendon is associated with limited range of hallux motion, erosions and joint space narrowing of the MTP-1 joint and pes planus. The observed prevalence of FHL rupture seems high in this study. We must stress that this is not representative for the RA population since we included only patients with a painful foot. However, the reported prevalence of FHL tenosynovitis in the study of Maillefert et al is also rather high, 3/17 feet (18%) . As far as we know, there are no reports on the prevalence of ruptured FHL in RA patients. FHL rupture (following tenosynovitis) might be provoked by rheumatoid inflammation. As stated earlier, RA can affect tendons as well as joints. This can occur at the level A and C in the Figures 1a and 1b. Early damage of the great toe joint might lead to limited joint motion and sub- sequent chronic underuse of the FHL, contributing to atrophy of its tendon . Mechanical reasons for inflammation or rupture of the a. Medioplantar Figure 1 aspect of the foot tendon are deformity or anatomical variations of the foot a. Medioplantar aspect of the foot. b. Medial aspect of the foot at the level B or C, Figure 1, as can be seen in calcaneus fractures or bony abnormalities like a prominent os trig- Page 3 of 5 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:110 http://www.biomedcentral.com/1471-2474/8/110 Lef Figure 2 t medial ankle of a 57-year-old patient with RA, missing the FHL tendon(arrowhead) Left medial ankle of a 57-year-old patient with RA, missing the FHL tendon(arrowhead). may arise, according to the mechanism described by Competing interests Michelson et al . The author(s) declare that they have no competing inter- ests. The association with a pes planus can be explained by the loss of the FHL in its supporting role of distributing the Authors' contributions forces (together with the fascia plantaris) under the foot HB conceived of the study, carried out the study and and maintenance of the longitudinal arch, as described by drafted the manuscript. Hamel et al . WD and ML conceived of the study, analysed and inter- We hypothesize that early recognition and timely ade- preted the data and drafted the manuscript. quate treatment of tenosynovitis of the FHL (for example by local ultrasound guided steroid injections) might AN, JB and RD analysed and interpreted the data. become important to prevent damage. All authors read and approved the final manuscript. A larger prospective follow-up study however, demon- strating the causal relationship between tenosynovitis or References 1. McQueen F, Beckley V, Crabbe J, Robinson E, Yeoman S, Stewart N: rupture of the FHL and deformities in the rheumatoid Magnetic Resonance Imaging Evidence of Tendinopathy in foot is warranted to draw definite conclusions. early Rheumatoid Arthritis predicts Tendon Rupture at six Years. Arthritis and Rheumatism 2005, 52:744-751. 2. Bouysset M, Tavernier T, Tebib J, Noel E, Tillmann K, Bonnin M, Eulry Conclusion F, Bouvier M: CT and MRI Evaluations of tenosynovitis of the Rupture of the flexor hallucis longus tendon in RA- rheumatoid hind foot. Clinical Rheumatology 1995, 14:303-307. 3. Jernberg ET, Simkin P, Kravette M, Lowe P, Gardner G: The poste- patients is associated with limited range of hallux motion, rior tibial tendon and the tarsal sinus in rheumatoid flat foot: more erosions and joint space narrowing of the MTP-1- magnetic resonance imaging of 40 feet. J Rheumatol 1999, joint, as well as with pes planus. 26(2):289-293. 4. Maillefert JF, Dardel P, Cherasse A, Mistrih R, Krause D, Tavernier C: Magnetic resonance imaging in the assessment of synovial inflammation of the hind foot in patients with rheumatoid arthritis and other polyarthritis. European Journal of Radiology 2003, 47:1-5. Page 4 of 5 (page number not for citation purposes) BMC Musculoskeletal Disorders 2007, 8:110 http://www.biomedcentral.com/1471-2474/8/110 5. Koski JM: Detection of plantar tenosynovitis of the forefoot by ultrasound in patients with early arthritis. Scand J Rheumatol 1995, 24(5):312-313. 6. Koski JM: Ultrasound detection of plantar bursitis of the fore- foot in patients with early rheumatoid arthritis. J Rheumatol 1998, 25:229-230. 7. Hamel AJ, Donahue SW, Sharkey NA: Contributions of Active and Passive Toe Flexion to Forefoot Loading. Clinical Orthopae- dics and Related research 2006, 393:326-334. 8. Jacob HA: Forces acting in the forefoot during normal gait-an estimate. Clinical Biomechanics 2001, 16:783-792. 9. Michelson J, Dunn L: Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treat- ment. Foot Ankle Int 2005, 26(4):291-303. 10. Spiegel TM, Spiegel JS, Paulus HE: The Joint alignment and Motion Scale: a simple Measure of Joint deformity in patients with Rheumatoid Arthritis. J Rheumatol 1987, 14:887-892. 11. Parker JW, Harrell PB, Alarcon GS: The value of the joint align- ment and motion scale in rheumatoid arthritis. J Rheumatol 1988, 15(8):1212-1215. 12. Heijde vd DR, Putte van der LB: Effects of hydroxychloroquine and sulphasalazine on progression of joint damage in rheu- matoid arthritis. Lancet 1989, 333:1036-1038. 13. Naredo E, Moller I, Moragues C, de Agustin JJ, Scheel AK, Grassi W, de Miguel E, Backhaus M, Balint P, Bruyn GA, et al.: Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course. Ann Rheum Dis 2006, 65(1):14-19. 14. Scheel AK, Schmidt WA, Hermann KG, Bruyn GA, D'Agostino MA, Grassi W, Iagnocco A, Koski JM, Machold KP, Naredo E, et al.: Inter- observer reliability of rheumatologists performing muscu- loskeletal ultrasonography: results from a EULAR "Train the trainers" course. Ann Rheum Dis 2005, 64(7):1043-1049. 15. Reeves ND: Adaptation of the tendon to mechanical use. J Musculoskelet neuronal interact 2006, 6:174-180. 16. Lo LD, Schweitzer ME, Fan JK, Wapner KL, Hecht PJ: MR imaging findings of entrapment of the flexor hallucis longus tendon. AJR Am J Roentgenol 2001, 176(5):1145-1148. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2474/8/110/pre pub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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BMC Musculoskeletal Disorders – Springer Journals
Published: Nov 6, 2007
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