Tendon Inflammation in the Hand Predicts Future Arthritis

Pam Harrison

June 15, 2015

ROME — Tenosynovitis detected with a brief ultrasound examination predicts rheumatoid arthritis in patients who present with early undifferentiated disease, and is particularly helpful in seronegative patients, new research shows.

"Patients who are treated in the earliest stage of rheumatoid arthritis progress only minimally, whereas patients who take longer to see their physicians have much more damage in their joints," said Andrew Filer, MD, from the Rheumatology Research Group at the University of Birmingham in the United Kingdom.

"It's easy — all we have to do is treat our patients early," he said during a news conference here at the European League Against Rheumatism (EULAR) Congress 2015.

"But there's a catch because in that first 3-month window of opportunity, the disease really is undifferentiated in a lot of patients," he pointed out, "and you can't tell at baseline who is going to develop rheumatoid arthritis and whose symptoms will resolve."

"What we need is a good tool that helps us predict who is going to need treatment," he explained. "Ultrasound can offer us a real opportunity to look at subclinical disease."

The Birmingham Early Arthritis Cohort (BEACON) study involved 107 patients with clinically apparent synovitis in at least one joint and a symptom duration of 3 months or less.

All patients underwent clinical assessment and ultrasound scanning of 16 different tendons — "not just the hands and wrists, but also the shoulders and the ankles and feet," Dr Filer reported. Outcomes were determined using 1987 American College of Rheumatology criteria.

At baseline, all patients had evidence of tenosynovitis in one or more tendon compartments.

At 18-month follow-up, 43 patients had developed very early rheumatoid arthritis, 20 had nonrheumatoid arthritis persistent disease, and the remaining 44 had resolving disease.

Of the 16 tendons imaged, two were of special interest, Dr Filer noted.

The first was extensor carpi ulnaris tendon in the side of the hand, which is very important for lifting. Patients with early rheumatoid arthritis often notice they have difficulty lifting because of inflammation in this particular tendon, he explained.

The second area of interest was the flexor tendons in the fingers, which allow patients to maintain their grip.

"Synovitis in these two tendons is a very powerful predictor of who is going to go on to develop rheumatoid arthritis over 18 months," said Dr Filer.

In fact, inflammation in these two key tendons is almost as predictive of progression to rheumatoid arthritis as well-established risk factors like having cyclic citrullinated peptide and rheumatoid factor antibodies.

Table. Predictors of Progression to Rheumatoid Arthritis

Variable Odds Ratio P Value
All patients    
   High cyclic citrullinated peptide or rheumatoid factor antibodies 7.1 <.0001
   Involvement of >10 joints 7.9 <.0001
   Finger flexor or extensor carpi ulnaris tenosynovitis 6.6 <.001
Seronegative patients    
   Involvement of >10 joints 7.6 <.001
   Finger flexor or extensor carpi ulnaris tenosynovitis 4.8 .003


"If patients have positive antibodies like cyclic citrullinated peptide or rheumatoid factor, it really helps, but if these antibodies aren't positive, it is very difficult to predict rheumatoid arthritis. Even in this situation, if patients are positive for these tendons, they have almost a five-times odds ratio of evolving into rheumatoid arthritis, so these tendons are particularly helpful in seronegative disease," Dr Filer said.

He pointed out that the data are strong enough to suggest that rheumatologists should be integrating these scans into standard protocols at early arthritis clinics.

The detection of inflammation in the pannus — an early indicator of joint involvement in rheumatoid arthritis — is critical, and it can only be done with the combination of ultrasound and power Doppler, said EULAR President Maurizio Cutolo, MD, from the University of Genoa in Italy.

"With ultrasound and power Doppler, you can detect synovitis and tenosynovitis well before erosion occurs in the joint," Dr Cutolo explained. "And both of these modalities are absolutely safe and can be used noninvasively."

The fact that ultrasound and power Doppler can detect inflammation safely at the very earliest stages of pathology means that rheumatologists can initiate treatment earlier, which is key to staving off disease progression in rheumatoid arthritis.

Dr Filer and Dr Cutolo have disclosed no relevant financial relationships.

European League Against Rheumatism (EULAR) Congress 2015: Abstract OP0015. Presented June 10, 2015.


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