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Volume 15
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This is an early access version, the complete PDF, HTML, and XML versions will be available soon.
Review

From Invisible to Visible: Cutting-Edge Ultrasound Insights into Entheses of the Distal Extremities in Rheumatology

by
Luis Coronel
1,2,*,†,
Chiara Rizzo
2,†,
Juan José de Agustin
1,
David Bong
3,
Maribel Miguel-Pérez
3,
Stefano Alivernini
4,5,
Lene Terslev
6,7,
Maria Antonietta D’Agostino
4,5 and
Ingrid Möller
2,3
1
Rheumatology Unit, Image and Techniques Section, Vall d´Hebron Hospital Universitari, Vall d´Hebron Barcelona Campus, 08035 Barcelona, Spain
2
Instituto Poal de Reumatologia, 08022 Barcelona, Spain
3
Unit of Human Anatomy and Embryology, Department of Pathology and Experimental Therapeutics (Campus of Bellvitge), University of Barcelona, 08907 Barcelona, Spain
4
Division of Rheumatology and Clinical Immunology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
5
Division of Rheumatology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
6
Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, 2600 Glostrup, Denmark
7
Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
J. Clin. Med. 2026, 15(10), 3753; https://doi.org/10.3390/jcm15103753
Submission received: 3 April 2026 / Revised: 3 May 2026 / Accepted: 10 May 2026 / Published: 13 May 2026
(This article belongs to the Special Issue Clinical Updates in Imaging of Musculoskeletal Diseases)
Versions Notes

Abstract

Musculoskeletal ultrasound (MSUS) is a well-established and reliable tool for the evaluation of entheses and enthesitis, particularly at larger and accessible sites. Recent technological advances, including high- and ultra-high-frequency transducers, have expanded its potential, enabling detailed assessment of distal extremity entheses. This narrative review provides a focused and updated perspective on this evolving field, highlighting three key advances. First, the identification and characterization of previously underrecognized entheseal sites in the distal extremities, such as pulley systems, retinacula, novel tendon insertions, and collateral ligaments, broadening the morphological spectrum of entheseal imaging. This is complemented by improved evaluation of vascularization through microvascular imaging and contrast-enhanced US (CEUS). Second, the emergence of interventional approaches, particularly US-guided entheseal biopsy, offers a novel means to investigate entheseal tissue in vivo and may establish a link between imaging and histopathology. Third, the integration of advanced functional imaging modalities, including elastography and multispectral optoacoustic tomography (MSOT), provides preliminary additional insights into the biomechanical and molecular properties of the enthesis beyond conventional structural assessment. Collectively, these developments support new investigational perspectives, positioning MSUS as a dynamic and integrative modality capable of exploring new anatomical territories and biological dimensions, with the potential to reshape the understanding and evaluation of entheseal involvement in rheumatology.
Keywords: enthesis; spondyloarthritis; ultrasound; biopsy; anatomy enthesis; spondyloarthritis; ultrasound; biopsy; anatomy

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MDPI and ACS Style

Coronel, L.; Rizzo, C.; de Agustin, J.J.; Bong, D.; Miguel-Pérez, M.; Alivernini, S.; Terslev, L.; D’Agostino, M.A.; Möller, I. From Invisible to Visible: Cutting-Edge Ultrasound Insights into Entheses of the Distal Extremities in Rheumatology. J. Clin. Med. 2026, 15, 3753. https://doi.org/10.3390/jcm15103753

AMA Style

Coronel L, Rizzo C, de Agustin JJ, Bong D, Miguel-Pérez M, Alivernini S, Terslev L, D’Agostino MA, Möller I. From Invisible to Visible: Cutting-Edge Ultrasound Insights into Entheses of the Distal Extremities in Rheumatology. Journal of Clinical Medicine. 2026; 15(10):3753. https://doi.org/10.3390/jcm15103753

Chicago/Turabian Style

Coronel, Luis, Chiara Rizzo, Juan José de Agustin, David Bong, Maribel Miguel-Pérez, Stefano Alivernini, Lene Terslev, Maria Antonietta D’Agostino, and Ingrid Möller. 2026. "From Invisible to Visible: Cutting-Edge Ultrasound Insights into Entheses of the Distal Extremities in Rheumatology" Journal of Clinical Medicine 15, no. 10: 3753. https://doi.org/10.3390/jcm15103753

APA Style

Coronel, L., Rizzo, C., de Agustin, J. J., Bong, D., Miguel-Pérez, M., Alivernini, S., Terslev, L., D’Agostino, M. A., & Möller, I. (2026). From Invisible to Visible: Cutting-Edge Ultrasound Insights into Entheses of the Distal Extremities in Rheumatology. Journal of Clinical Medicine, 15(10), 3753. https://doi.org/10.3390/jcm15103753

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