Study finds widespread silent entheseal abnormalities in chronic plaque psoriasis patients without clinical arthritis, with higher skin disease severity linked to greater entheseal damage
High-resolution ultrasonography may help identify subclinical enthesopathy in patients with chronic plaque psoriasis before the appearance of clinically evident joint symptoms, according to a prospective study published in the Indian Journal of Dermatology in 2026.
The study found that 85.7% of psoriasis patients without clinical arthritis had ultrasonographic evidence of subclinical enthesitis or enthesopathy. Researchers identified abnormalities across 929 entheseal sites, highlighting the potential role of musculoskeletal ultrasonography in detecting early joint involvement in psoriasis.
Psoriasis is a chronic immune-mediated inflammatory disease affecting approximately 2% to 3% of the global population. Although enthesitis is a recognized feature of psoriatic arthritis (PsA), detecting entheseal inflammation before clinical joint manifestations remains challenging.
To investigate this issue, Dr. Kallolinee Samal and colleagues from the Department of Dermatology, Institute of Medical Sciences (IMS), and SUM Hospital Campus II, Odisha, India, evaluated subclinical enthesitis using high-resolution ultrasonography and the standardized Outcome Measures in Rheumatology (OMERACT) scoring system.
Study Evaluated 91 Patients With Chronic Plaque Psoriasis
The prospective observational study was conducted at an East Indian tertiary-care hospital between January 2024 and January 2025.
Researchers included 91 patients with chronic plaque psoriasis who did not have clinically evident arthritis. Individuals with existing joint disease or systemic comorbidities were excluded.
High-resolution ultrasonography was used to examine 12 entheseal sites. The researchers assessed structural and inflammatory abnormalities and analyzed their relationship with psoriasis severity and disease duration.
Subclinical Enthesopathy Found in 85.7% of Patients
Ultrasonography identified silent entheseal abnormalities in 85.7% of the study participants.
Across the evaluated sites, researchers documented 929 ultrasonographically abnormal entheseal findings, demonstrating that structural and inflammatory changes may occur even when patients do not report active joint symptoms.
The findings suggest that clinical examination alone may not detect all forms of entheseal involvement in patients with psoriasis.
Achilles Tendon Most Frequently Affected
Among the examined entheseal sites, the Achilles tendon showed the highest number of abnormalities, with 263 positive findings.
These included 132 structural abnormalities and 131 inflammatory abnormalities.
The triceps tendon was the second most frequently affected site, with 226 findings, while the proximal patellar ligament showed 85 findings.
The distribution indicates that different entheseal regions may demonstrate varying degrees of involvement in patients with psoriasis.
Structural and Inflammatory Abnormalities Identified
Structural lesions were detected in 75% of the participants. Calcifications were the predominant structural abnormality, accounting for 351 findings.
Inflammatory abnormalities were identified in 79.1% of patients, with tendon thickening being the most frequently observed inflammatory feature, recorded at 480 sites.
The simultaneous presence of structural and inflammatory changes provides evidence of clinically silent entheseal involvement in a substantial proportion of patients with chronic plaque psoriasis.
Higher Psoriasis Severity Linked to Greater Enthesial Damage
The study found a statistically significant association between higher Psoriasis Area and Severity Index (PASI) scores and increased entheseal abnormalities.
Patients with greater skin disease severity showed more extensive entheseal damage, with the association reaching statistical significance at P < 0.05.
However, researchers did not identify a statistically significant relationship between the duration of psoriasis and the presence of subclinical enthesopathy.
Study Highlights Potential Role of Musculoskeletal Ultrasound
The findings indicate that subclinical enthesopathy can be present in psoriasis patients even before clinically detectable arthritis develops.
High-resolution ultrasonography may therefore provide additional information during the assessment of patients with psoriasis, particularly those with more severe skin disease.
The study suggests that identifying entheseal abnormalities at an early stage could help clinicians recognize patients who may require closer musculoskeletal assessment. However, the findings do not establish that ultrasound screening can prevent the development or progression of psoriatic arthritis.
Limitations and Need for Further Research
The researchers noted several limitations, including the single-center design, cross-sectional nature of the assessment, and absence of matched healthy controls.
The study also did not include evaluation of axial entheseal sites, limiting the assessment of the full spectrum of entheseal involvement.
Future longitudinal, multicenter studies incorporating axial entheseal assessments and appropriate control groups may help determine the clinical significance of these subclinical abnormalities and their relationship with subsequent development of psoriatic arthritis.
Important Highlights
- High-resolution ultrasonography detected subclinical entheseal abnormalities in 85.7% of chronic plaque psoriasis patients without clinical arthritis.
- Researchers identified 929 abnormal entheseal sites among 91 study participants.
- The Achilles tendon was the most frequently affected site, with 263 abnormal findings.
- Structural abnormalities were found in 75% of patients, while inflammatory abnormalities were observed in 79.1%.
- Higher PASI scores were significantly associated with increased entheseal abnormalities.
- Subclinical enthesopathy showed no significant association with psoriasis duration in the study.
