Background/Purpose: Despite a crucial role for RA patients’ mobility, the ankle joints are frequently clinically neglected, and omitted in activity scoring systems including DAS 28. In addition, only few studies have assessed pathologies detected by ultrasonography of the ankle in symptomatic RA patients (1). Therefore, the type and degree of involvement of the ankle joints were evaluated in established RA patients regardless of symptomatology utilizing standardized high resolution musculoskeletal ultrasound (MSUS) including power Doppler ultrasonography (PDUS). 

Methods: A total number of 160 ankle joints of 80 consecutive RA patients fulfilling the ACR/EULAR classification criteria 2010 were examined using MSUS (Logic E9, GE Healthcare, Buckinghamshire, GB with a ML6-15 linear probe with 6- 15 MHz) and PDUS according to the EULAR MSUS guidelines (2). In addition, the talonavicular joint, and the flexor and extensor tendons were investigated. Furthermore, ankle pain (VAS score 0-10) was recorded for each patient on joint level. Only VAS = 0 was determined as asymptomatic.

Results: 80 RA patients (52 female, 28 male) with a median age of 60 years (range 28 -81) and a disease duration of 5 years (range 0 – 44) were enrolled in our study. The median DAS28 was 5,0 (range 0,8 -7,8). 97 ankles were painfull (VAS 1-10), whereas 63 ankles were asymptomatic (VAS = 0). Overall, the predominant pathology was arthritis of the tibiotalar and/or talonavicular joint in 124 ankles (77%), followed by tenosynovitis of the flexor tendons in 44 ankles (28%). In symptomatic ankles 59% showed arthritis of the tibiotalar joint (TTJ) and 35% synovitis in the talonavicular joint (TNJ). In 35% of the asymptomatic ankles TTJ synovitis could be detected and 18% TNJ arthritis. PDUS activity was higher in the subgroup of symptomatic ankles (10% of symptomatic ankles (10/97) compared to 2% of asymptomatic patients (3/63). For detailed information see table 1.

Conclusion: Most frequent pathologies detected by MSUS were arthritis of the tibiotalar and talonavicular joint, followed by tenosynovitis of the flexor tendons. Pathologic findings are significantly more frequent in symptomatic ankles but also common in completely asymptomatic ankles of RA patients, whereas overall PDUS activity is low and if present predominately observed in symptomatic patients.

Table 1:

Pathologies	Arthritis tibiotalar (%)	Arthritis talonavicular	Tenosynovitis (M. tibialis posterior +/ or M. flexor digitorum)	PDUS positive Arthritis
All ankles (n = 160)	79 (66%)	45 (28%)	44 (27%)	12 (7,5%)
Symptomatic ankles (n=97)	57 (59%)	34 (35%)	32 (33%)	10 (10%)
Asymptomatic ankles (n=63)	22 (35%)	11 (18%)	12 (19%)	2 (3%)
Chi2	p = 0.003	p = 0.016	n.s.	n.s.

References:

¹Suzuki T, Okamoto A, Clin Exp Rheumatol 2013, 31 (2): 281-284. ²Backhaus M, Burmester G-R, Gerber T et al., Ann Rheum Dis 2001, 60:

641-649

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/asymptomatic-versus-symptomatic-ankle-joints-in-rheumatoid-arthritis-a-high-resolution-b-mode-and-power-doppler-ultrasound-study/