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‘Deep Koebner’ phenomenon of the flexor tendon-associated accessory pulleys as a novel factor in tenosynovitis and dactylitis in psoriatic arthritis
  1. Ilaria Tinazzi1,
  2. Dennis McGonagle2,
  3. Sibel Zehra Aydin3,
  4. Donatella Chessa4,
  5. Antonio Marchetta1,
  6. Pierluigi Macchioni5
  1. 1 Unit of Rheumatology, Sacro Cuore Don Calabria Hospital, Negrar-Verona, VR, Italy
  2. 2 NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust and The University of Leeds, Leeds, UK
  3. 3 Department of Rheumatology, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  4. 4 Medicina Interna, Ospedale Paolo Dettori, Tempio Pausania, OT, Italy
  5. 5 Rheumatology Department, Ospedale S.Maria Nuova, Reggio Emilia, Italy
  1. Correspondence to Dr Ilaria Tinazzi, Unit of Rheumatology, Ospedale Sacro Cuore Don Calabria, Negrar VR 37024, Italy; ilariatinazzi{at}


Objectives Skin and joint involvement in psoriasis (PsO) and psoriatic arthritis (PsA) are thought to relate to the so-called Koebner response. Given that dactylitis is non-randomly distributed in the digits, this study tested the hypothesis that the accessory pulleys linked to the flexor tendons were thickened in PsA and thus exhibited koebnerisation.

Methods Ninety-six subjects (27 PsA, 27 rheumatoid arthritis (RA), 23 PsO and 19 healthy controls (HCs)) were enrolled. The A1, A2 and A4 pulley thickness was measured using a high-resolution probe (22 MHz). All patients were in remission or low disease activity with current dactylitis being excluded.

Results Within 864 pulleys investigated, patients with PsA had thicker pulleys in every digit compared with both RA (P<0.001 and P=0.003) and HCs (P<0.001). RA and PsO groups had some pulleys in some digits thicker than HCs whereas some others were comparable. The second digit A1 pulley thickness was higher in patients with PsA with previous dactylitis (P=0.020). More pulleys were thickened in the PsA group (165/243, 68%) than RA (41/243, 17%; P<0.001) and HCs (13/171, 7.6%; P<0.001).

Conclusions In established PsA, the accessory pulleys are thickened compared with RA, PsO or HCs and especially in subjects with a history of dactylitis. These findings implicate the involvement of pulleys in PsA-related tenosynovitis and dactylitis supporting the idea of deep koebnerisation in dactylitis and sites of high physical stress.

  • psoriatic arthritis
  • rheumatoid arthritis
  • ultrasonography

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  • Handling editor Josef S Smolen

  • Contributors IT, DMG, SZA and PM gave substantial contributions to study conception and design. IT, DC, AM and PM gave substantial contributions to acquisition of data. IT, DMG, SZA and PM drafted the article and revised it critically for important intellectual content. IT, DMG, SZA, DC, AM and PM gave final approval for the version of the article to be published.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DMG received grants and/or honoraria from Abbvie, Celgene and Janssen. SZA received grants and/or honoraria from Abbvie, Novartis, UCB, Sanofi and Pfizer.

  • Patient consent Obtained.

  • Ethics approval The Ethics Committees of ‘Sacro Cuore’ Hospital Negrar (VR), Italy, and Ospedale S. Maria Nuova, Reggio Emilia, Italy, approved the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.