Rheumatology

Rheumatology

Musculoskeletal ultrasound is rapidly emerging as valuable diagnostic tool for Rheumatologists. It improves clinical diagnosis as well as interventional skills. 1 2, 3 Generally, musculoskeletal ultrasound may be used to evaluate inflammatory and crystalline arthropathies as well as regional pain disorders.

Inflammatory Arthritis

Songraphy aids in the confirmation of synovitis in early inflammatory arthritis 2. The sonographic evaluation of inflammatory  arthritis has been aided by consensus definitions of synovitis and erosions by the OMERACT group. 4 Small amounts of fluid can be detected in joints as well as tendon sheaths. Ultraousound is also more sensitive in the detection of enthesitis. 3 Increased vascularization can be demonstrated by  power doppler.

Fig 1: Detection of Effusion in the volar recess of the PIP joint – longitudinal and transverse views.

Ultrasound is more sensitive than plain xrays in the detection of erosions. 5, 6 The earlier detection of erosions may lead to adjustment of remittive therapies especially in the presence of active synovitis. In a patient with established inflammatory arthritis, sonography may be useful in documenting ongoing synovitis.

Fig 2: Active synovitis overlying a large metacarpal head erosion.

Fig 3: Longitudinal view of the wrist revealing active synovitis

Although the traditional view of inflammatory arthritis has been mainly to follow joints, disease activity may also affect the tendon and tendon sheaths. (Please use the pictures I have given you previously – they are on the web site). Similarly, sonography can be readily used at the bedside. to evaluate nerve entrapment at sites such as the carpal or cubital tunnel. The hallmark prestenotic dilation may be demonstrated.

Crystalline Arthropathy

Sonography can differentiate deposition of urate on cartilage from chondrocalcinosis. Urate deposits on the surface of the cartilage (“double contour sign”) while chondrocalcinosis is detected within the cartilage.7 Sonography is more sensitive than plain xrays in detecting erosions. It is also a sensitive tool in the detection of tophii.8

Figure 4: Longitudinal and transverse views of the first MTP revealing tophaceous dorsal deposit as well as double contour sign.

Regional Pain Disorders

Regional pain disorders such as shoulder pain, elbow pain and heel pain may be readily evaluated by ultrasound. Sonography may demonstrate tendinopathy, tendon calcification and vascularization as well as bursitis. Ultrasound visualization of the needle helps in the accurate placement of local injections which may improve outcome. 9, 10

Figure 5: Achilles tendinopathy and retrocalcaneal bursitis.

Figure 6: Common extensor tendinopathy in a patient with lateral elbow pain.

Figure 7: Common extensor origin injection.

  1. Musculoskeletal ultrasound–a state of the art review in rheumatology.
    Part 2: Clinical indications for musculoskeletal ultrasound in rheumatology.
    Kane D, Grassi W, Sturrock R, Balint PV.
    Rheumatology (Oxford) 2004;43(7):829-38.
  2. Ultrasound of the hands and feet for rheumatological disorders: influence on clinical diagnostic confidence and patient management.
    Matsos M, Harish S, Zia P, et al.
    Skeletal Radiol 2009;38(11):1049-54.
  3. Why aren’t we all doing ultrasound?
    Estrach C, Thompson RN.
    Rheumatology 2009;48(9):1019-20.
  4. Musculoskeletal ultrasound including definitions for ultrasonographic pathology.
    Wakefield RJ, Balint PV, Szkudlarek M, et al.
    The Journal of rheumatology 2005;32(12):2485-7.
  5. Prospective two year follow up study comparing novel and conventional imaging procedures in patients with arthritic finger joints.
    Backhaus M, Burmester GR, Sandrock D, et al.
    Annals of the rheumatic diseases 2002;61(10):895-904.
  6. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography.
    Wakefield RJ, Gibbon WW, Conaghan PG, et al.
    Arthritis and rheumatism 2000;43(12):2762-70.
  7. Diagnosis of gout by ultrasound.
    Thiele RG, Schlesinger N.
    Rheumatology (Oxford) 2007;46(7):1116-21.
  8. Gout. Imaging of gout: findings and utility.
    Perez-Ruiz F, Dalbeth N, Urresola A, de Miguel E, Schlesinger N.
    Arthritis research & therapy 2009;11(3):232.
  9. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder.
    Naredo E, Cabero F, Beneyto P, et al.
    The Journal of rheumatology 2004;31(2):308-14.
  10. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis.
    Chen MJ, Lew HL, Hsu TC, et al.
    Am J Phys Med Rehabil 2006;85(1):31-5.