Clinical and pathogenetic features of damage to the tendon-ligament apparatus in joint diseases of inflammatory and degenerative origin

The dissertation is devoted to the clinical and pathogenetic features of tendon–ligament apparatus involvement of the knee joint in rheumatoid arthritis and osteoarthritis. It analyses the clinical manifestations of tendon, ligament, and entheseal involvement and the potential of ultrasound diagnostics for assessing the severity and character of soft-tissue lesions in inflammatory and degenerative joint diseases. Particular attention is given to the relationship between soft-tissue involvement and the articular and muscular syndromes, as well as to the development of diagnostic markers and clinical and ultrasound criteria of practical value for rheumatology.

Relevance of the Topic

Pathology of the periarticular soft tissues includes localized involvement of tendons, ligaments, muscles, fasciae, and the joint capsule. Patients with disorders of the periarticular tissues account for up to 59% of primary visits in rheumatological practice and up to 15% of consultations in the general network. The main part of the complaints in such cases is related to involvement of the tendon–ligament apparatus. The high rate of chronification and recurrent morbidity leads to a high prevalence and loss of working capacity, representing a serious socio-economic problem (Speed C.A., 2001). Therefore, the attention currently given to this problem is unsurprising. At the same time, the majority of publications deal with periarticular pathology described as separate clinical entities: scapulohumeral periarthritis, medial and lateral epicondylitis of the elbow, and carpal tunnel syndrome (Elkin M.A., Li A.D., 1968; Mironov S.P., Burmakova G.M., 2000; Chiou H., Chou Y., Wu J. et al., 2001), or with the sequelae of traumatic injuries (Zulkarneev R.A., Akhmetov Z.Ya., Zulkarneev R.R., 1997; Kanykin V.Yu., 2000; Yeskin N.A., 2001; Jones M.N., England S.J., Muwanga C.L., Hildreth T., 2000; Lee J.C., Healy J., 2004).

It is well known that changes in the tendon–ligament apparatus (TLA) may be one of the manifestations of rheumatic diseases and may even become their leading syndrome. However, in the literature they have been described in such a context predominantly for seronegative spondyloarthritides. For diseases of this group, TLA involvement is so characteristic that it has been incorporated into diagnostic criteria and activity indices (Dougados M., van der Linden S., Juhlin R. et al., 1991).

A number of authors support the theory that the inflammatory process develops primarily in the soft tissues and affects the synovial membrane of the joint only secondarily. In this connection, the periarticular structures in seronegative spondyloarthritides have been described in considerable detail both clinically and by instrumental methods, and ultrasound indices for the quantitative assessment of enthesopathies have been proposed.

At the same time, only a few isolated works have been devoted to soft-tissue pathology in rheumatoid arthritis (RA), and these mainly describe spontaneous tendon ruptures. In the available literature, no studies have been found whose aim was to evaluate TLA involvement in osteoarthritis (OA). Nevertheless, there is no doubt that the pathological process in OA and RA involves all joint structures, both intra-articular and extra-articular, and that their involvement is determined by the same pathogenetic mechanisms. Nonetheless, no studies have been found that describe the influence of the inflammatory or degenerative processes of the underlying disease on the condition of the periarticular tissues. The area of therapeutic action on the soft-tissue structures of the joint remains insufficiently studied.

The scarcity of data on tendon and ligament pathology in RA, the absence in the literature of information on the involvement of these structures in OA, on their contribution to the clinical picture of these diseases, and on their ultrasound characteristics make a clinical and instrumental investigation of this issue timely.

The aim of the present study was to evaluate the role of tendon–ligament apparatus involvement in the clinical picture of knee joint pathology of inflammatory and degenerative origin.

In accordance with this aim, the following tasks were set:

1. To study the clinical features of tendon and ligament involvement of the knee joint in patients with RA and OA and to compare their manifestations in relation to the factors of the clinical course of the underlying disease;

2. To characterize the changes in tendons, ligaments, and entheses in these groups of patients on the basis of ultrasound examination;

3. To identify, on the basis of clinical and ultrasound investigation, diagnostic markers of tendon–ligament apparatus involvement in patients with osteoarthritis and rheumatoid arthritis;

4. To determine the relationship between tendon–ligament apparatus involvement and the manifestations of the muscular syndrome in rheumatoid arthritis and osteoarthritis.

Scientific Novelty

For the first time, the delineation of a syndrome of tendon–ligament apparatus involvement in the clinical picture of osteoarthritis and rheumatoid arthritis has been scientifically substantiated, and its relationship with the articular and muscular syndromes of these diseases has been established.

For the first time, in rheumatoid arthritis and osteoarthritis, the value of clinical and ultrasound investigation for assessing the course and severity of tendon and ligament involvement has been demonstrated, and a set of signs required for its diagnosis has been proposed.

For the first time, three ultrasound variants of involvement of different zones of the insertional areas and their relationship with the clinical course of enthesitis have been described.

Practical Significance

The use of kinesthetic investigation of the attachment sites of ligaments and tendons, together with the index of knee tendon–ligament apparatus involvement, during routine clinical examination of the musculoskeletal system makes it possible to identify in a timely manner patients with signs of connective-tissue pathology in order to refer them subsequently for in-depth investigation.

Ultrasound examination of tendons, ligaments, and their attachment sites makes it possible to determine accurately the areas of pathological change, which enables local therapeutic methods to be applied directly in the region of involvement and thereby enhances their effectiveness.

Statements Defended

1. The manifestations of the syndrome of tendon–ligament apparatus involvement are comparable in rheumatoid arthritis and osteoarthritis and do not depend on the duration of these diseases or on the age of the patients;

2. In rheumatoid arthritis and osteoarthritis, the severity of tendon–ligament apparatus involvement correlates with the degree of degenerative changes in the knee joint. Disease activity and synovitis exert a significant influence on the condition of tendons and ligaments in rheumatoid arthritis;

3. Tendon–ligament apparatus involvement of the knee joint in these diseases correlates with the manifestations of the muscular syndrome, constituting a single process realized at different levels: for the quadriceps femoris muscle — predominantly within the muscle tissue, and for the semimembranosus, biceps femoris, and pes anserinus muscles — at the sites of tendon attachment.

Approval of the Work

The materials of the dissertation were presented and reported at the XIII Scientific and Practical Conference "Radiologist's Day" (Kazan, 2004), the Annual Scientific and Practical Conference "The Problem of Thromboses in Rheumatology" (Moscow, 2004), the X All-Russian Scientific and Practical Conference "Young Scientists in Medicine" (Kazan, 2005), the IV Congress of Rheumatologists of Russia (Kazan, 2005), and the inter-departmental conference of the staff of the Department of Therapy of KGMA, the Department of Therapy and Family Medicine of KGMA, and the Department of Hospital Therapy of KGMU (Kazan, 2005).

Implementation into Practice

The results of the investigations have been implemented into the practice of the City Rheumatological Center of Kazan, the Department of Radiation Diagnostics of Republican Clinical Hospital No. 2 of the Ministry of Health of the Republic of Tatarstan, and into the teaching process of the Department of Hospital Therapy of the State Educational Institution of Higher Professional Education "Kazan State Medical University" of the Federal Agency for Health Care and Social Development of the Russian Federation.

Publications

On the topic of the dissertation, 14 scientific works have been published. For the patent applications No. 2004123016 "Method for assessing involvement of the tendon–ligament apparatus of the knee joint" and No. 2004123017 "Method for ultrasound assessment of involvement of the tendon–ligament apparatus of the knee joint," priority dates of 29 July 2004 have been established.