There is unequivocal bilateral disease in the SIJ on the MRI illustrated. All 4 surfaces of the SIJ are involved with different phases of active inflammation (on right only) and structural damage bilaterally.
THe SIJ disease in typical Ank Spond is very frequently asymmetrical or unilateral in early disease before the radiograph becomes abnormal – i.e. at the "non-radiographic axial Spondyloarthritis (nr-axSpA)" stage.
So, if the first abnormal SIJ test was positive 10 years ago, when the patient was aged ~20, she is more likely to have late diagnosis of Juvenile SpA, or early diagnosis of AS, or Reactive Arthritis, than Psoriatic SpA which doesn’t usually present first at such a young age.
Cheers,
Rob
Ok – will stop bothering you all with this case now – but just to show you the sacroiliitis from 2 years ago. The clinician has read through some old journals as well, and actually: in 2013 there was an incident of unilateral sacroiliitis confirmed with MRI. At that time reported as "not likely Bekhterev, because of unilateral distribution".
Oh well. I guess this case proves several points.
Best
Roar
Hi again –
A quick follow up on this case – received several more responses on the images, altogether a very interesting case.
I have investigated further and it turns out that – not mentioned by the clinician – that a MRI of SI-joint performed elsewhere in 2021 showed extensive sacroiliitis. No psoriatic manifestations (yet?). Also, no clinician has done anything with the sacroiliitis diagnosis made 2 years ago, for some odd reason…
I actually believe that radiology is useful – even though the clinicians do not always read our reports 😀
Have a nice day!
Best
Pedersen
NorwayDear Bruno, dear colleagues!
I had a lot of responses – thank you all! Several points in all your responses are very interesting, and actually confirmed some of the thoughts I already had – but that is actually the great advantage with OCAD, some reassurance and some challenging thoughts.
Several of you pointed out that you would like to know more about the patient. So far there seems to be no other relevant anamnestic or clinical findings – and I guess that was part of the reason why this was a puzzling case for me. However, I did not examine the patient myself. Some of your responses/thoughts will be incorporated in my report, as a feedback to the clinician.
In addition to the below response from Bruno, I quote some other responses:
"Pump bump – disuse periarticular osteopenia. Cortex intact, enthesitis leads to cortical erosions and periostitis".
"I think this is mechanical – it looks like Haglund’s disease: prominent posterosuperior calcaneal process + achilles tendinopathy + deep retrocalcaneal bursitis. The edema is more likely related to mechanical enthesitis or reactive osteitis due to the bursitis".
"Looks like a case of inflammatory arthropathy. Enthesitis at the Achilles tendon insertion, retrocalcaneal bursitis, tenosynovitis and tibiotalar joint effusion/synovitis. Should have a rheumatological consultation. Also, patch altered signal intensity of the bone marrow diffusely may be on the basis of osseous demineralization/disuse."
"Haglund’s deformity"
"Enthesopathy is a more safe term, could be enthesitis because there is also ankle synovitis, some in talo-calcaneal, in Chopart, enthesopathy of plantar fascia, some achilles tendon bursitis and diffuse BME, some flexor tenosynovitis, in the bony wall of the bursa. RA? SpA? We need RF, ACPA, HLA-B27."
"This is inflammatory arthropathy. The background achilles tendon is normal and there is marked enthesitis and retrocalcaneal bursitis. Large ankle joint effusion. Tendon sheath effusion flexor ankle tendons. Subcortical marrow signal changes seen in demineralisation related to chronic arthritis. All the above changes point to inflammation and not mechanical changes."
"Here I would prefer to call it insertional tendinopathy as the tendon is thickened as in overuse. It is really hard to tell inflammation in rheumatic conditions (then I would prefer to call it enthesitis) from mechanical reasons without knowing about the patient."
"Hi Roar – I am like you, I do not know how to tell the difference unless she has some other manifestation of an inflammatory enthesitis"
"I would vote enthesitis at achilles and plantar fascial insertions (and a tiny bit of retrocalcaneal bursitis".
"Hi Roar, would have said marrow stress response without fracture line"
Some of you have looked through the entire case at the Collective Minds, others have asked about the functionality – and I really love using it, I think it is perfect for sharing cases, and I also use it in lecturing.
The open link to this case is still: https://www.cmrad.com/cases/1459580672Have a great summer weekend, wherever you are!
Best,
Pedersen
NorwayI always had the same question and I have heard lecturer saying that it was not possible to make the DD between mechanical or inflammatory enthesopathy.
In this case I am intrigued by the regional bone/marrow changes with disseminated dots or linear subcortical marrow edema-like changes that indicate increase bone remodeling. Was she in a plaster for a while ? If not, this finding would indicate a regional process that would best suit the inflammatory hypothesis but this is a very tiny argument.
Any other painful area ? skin changes ?
Bruno
Le 12-07-23 à 19:07, ‘Jlcui’ via OCAD MSK a écrit :
I prefer to think it is Transient bone marrow oedema.
BestCui
Dear friends
Probably a stupid question, but not always obvious for me whether you are dealing with an insertional tendinopathy, enthesitis or stress reaction of bone.
A 30 year old female, no known disease, no trauma, no nothing, just heel pain for several weeks. No fracture line as I can see, just the physeal scar.
Enclosed an image, and the entire case – all sequences – are uploaded to the Collective Minds platform, should be accessible for scrolling without registration, choose "Open Review Mode" on the red button on the right side:
https://www.cmrad.com/cases/1459580672Any good tips on the "enthesitis" problem would be appreciated.
Best
Pedersen
Norway
