Pam Harrison

April 30, 2015

TORONTO — The correlation between radiographic evidence of a displaced enthesophyte and underlying tendon rupture can serve as a "red flag" for potential tendon injury that requires further assessment, new research shows.

"A substantial number of tendon or ligament tears occur at the insertion into the bone site," said Dmitry Golev, MD, from McMaster University Medical Centre in Hamilton, Ontario, Canada. "If a tendon injury involves the insertional fibers in patients with enthesopathy, it commonly results in the displacement of enthesophytes, owing to a retraction of avulsed fibers."

"Because you can readily identify calcification on radiographs, a displaced mineralized fragment in a patient with acute pain should suggest a clinical correlation with a possible tendon injury, and the patient should be further assessed with ultrasound or MRI to ensure timely orthopedic referral," he told Medscape Medical News.

Dr Golev presented the study results here at the American Roentgen Ray Society 2015 Annual Meeting.

The researchers used the radiology database of all MRI and ultrasound examinations done in teaching hospitals in Hamilton from January 2004 to August 2013 for patellar, Achilles, triceps, and quadriceps tendon tears. They identified 128 tears in 121 patients that met their inclusion criteria.

Both MRI and ultrasound studies were reviewed by two radiologists to determine the presence and location of the tendon tear. They paid special attention to the presence of bony fragments separated from the adjacent enthesis.

In the study cohort, 70 tears (54%) in 63 patients had visibly displaced enthesophyte fragments, almost three-quarters of which were confirmed surgically. For another 58 tears in 58 patients, there was no evidence of a visibly displaced bony fragment.

A review of the initial radiographic interpretations revealed that a diagnosis of tendon tear was made or suggested in 41% of patients, but the bony abnormality was missed or misinterpreted in 59% of patients.

Results were similar when the initial radiographic interpretations were reviewed in conjunction with documentation of the clinical exam conducted in emergency department at the time of presentation. A diagnosis of tendon injury was made or suggested in 45% of patients, but the bony abnormality was missed or misinterpreted in 55% of patients.

"You can speculate whether the presence of enthesophytes signifies a tendon abnormality, but that's not what this is about," said Dr Golev.

"It's about identifying the displaced enthesophyte as a marker of tendon injury. If you see it, you need to state this in your report. Then, if the emergency physician is at all concerned, they can do an ultrasound," he explained.

Emergency departments are busy places, so it is quite possible not to notice or think about a tendon tear.

The identification of the displaced enthesophyte could definitely be helpful in flagging previously unsuspected tendon tears, said Brian Le, MD, from Radiology Associates of Regina in Saskatchewan, Canada.

"I already look for these kinds of things on x-rays," he told Medscape Medical News.

"But emergency departments are busy places, so it is quite possible not to notice or think about a tendon tear," Dr Le said.

Both MRI and ultrasound are very good for looking at tendon tears, he added.

However, "ultrasound is a cheaper test for the system and usually has better availability and accessibility than MRI. That's why it's usually suggested that ultrasound be the next test for imaging," he explained.

Dr Golev and Dr Le have disclosed no relevant financial relationships.

American Roentgen Ray Society (ARRS) 2015 Annual Meeting. Abstract 3806. Presented April 22, 2015.


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