Ultrasound in Rheumatology Alison Hall Consultant MSK Sonographer Research Institute for Primary Care & Health Sciences, Keele University Department of Rheumatology, Cannock Hospital, Royal Wolverhampton Trust Delivering high quality multidisciplinary research in primary care.
Objectives Introducing arthritis Diagnosis Role of Ultrasound Technique Ultrasound appearances Pitfalls Managing IA Take home messages
Introducing arthritis Acute or chronic inflammation of one or more joints, usually accompanied by pain and stiffness, resulting from infection, trauma, degenerative changes, autoimmune disease, or other cause The American Heritage Science Dictionary
Osteoarthritis ( OA) 2 million people/year in UK seek treatment from GP Cartilage thins, extra bone forms Hips, knees, hands most affected
Inflammatory Arthritis (IA) Presentations to GP/year Rheumatoid arthritis 350,000 Gout 250,000 Ankylosing spondylitis 115,000 Juvenile Idiopathic arthritis 12,000 Rarer inflammatory disorders Lupus, temporal arteritis, polymyalgia rheumatica
Diagnosis of IA Clinical history Imaging Family history Diagnosis Blood tests Clinical examination
Role of ultrasound Aid diagnosis Refine diagnosis Exclude concurrent pathology (?) Monitor treatment Educate patients and clinicians Guide therapeutic injections
Ultrasound service to confirm or exclude inflammatory arthritis Synovitis Erosion Tenosynovitis/enthesitis NOT necessarily To determine cause of hand/foot pain
So who should be scanning these patients? Radiology Huge ultrasound experience Less clinical rheumatology knowledge Best equipment/setup Less accessible waiting times, other commitments Rheumatology Variable ultrasound experience Huge clinical rheumatology knowledge Variable equipment/difficult setup Immediately accessible one stop shops
US appearances: Synovial Hypertrophy and Synovitis Synovial proliferation and resulting hypertrophy is the primary event in RA that is visible on imaging Abnormal hypoechoic (relative to subdermal fat, but sometimes may be isoechoic or hyperechoic) intraarticular tissue that is nondisplaceable and poorly compressible OMERACT SIG When inflamed, synovial hypertrophy becomes active synovitis and is a sign of active IA Synovial hypertrophy which may exhibit Doppler signal The level of synovial hypertrophy and synovitis is related to the grade of activity of disease
Grading of synovitis Grey scale Grade 0: no synovial thickening Grade 1: minimal synovial thickening without bulging over the line linking tops of the bones Grade 2: synovial thickening bulging over the line linking tops of the periarticular bones Grade 3: synovial thickening bulging over the line linking tops of the periarticular bones with extension Power Doppler signal Grade 0: no flow in the synovium Grade 1: single vessel signals Grade 2: confluent vessel signals in less than half of the area of the synovium Grade 3: vessel signals in more than half of the area of the synovium. BERNER HAMMER 2011
US appearances Erosions An intraarticular discontinuity of the bone surface that is visible in 2 perpendicular planes. OMERACT 7 SIG
US appearances Tenosynovitis Hypoechoic or anechoic thickened tissue with or without fluid within the tendon sheath, which is seen in 2 perpendicular planes and which may exhibit Doppler signal. OMERACT 7 SIG
Patient position Comfort Stability Ergonomics
Technique : Hand Patient/Sonographer comfort Systematic approach Flexible and dynamic capability, specific for each individual Each joint and tendon should be scanned in longitudinal and transverse planes, from one aspect to the other
Technique : Foot Ankle joint assessed from anterior aspect Transducer moved from medial to lateral in order to assess the whole width of the joint. Medial and lateral tendons assessed in both longitudinal and transverse planes. MTP and IP joints assessed in both longitudinal and transverse planes.
Grey scale synovial hypertrophy Identifies suspicious areas But don t be fooled It is not specific It is not always obvious
Doppler flow Find active synovitis in longitudinal Grade it in transverse
Inflammatory arthritis/rheumatic disease Many different types!
Rheumatoid Arthritis Chronic, progressive autoimmune disease affecting around 600,000 people in the UK Commonly starts between the ages of 40 and 60 Three times more women are affected than men. Produces an inflammatory response of the joint capsule or tendon sheath Causes swelling, effusion and synovitis Leads to destruction of the articular cartilage and erosion of the bone surface www.nras.org.uk
Common sites Wrists Metacarpophalangeal joints MCPjs Index and middle fingers Elbows Knees Ankles Metatarsophalangeal joints MTPjs www.nras.org.uk
Other inflammatory arthritides
Psoriatic arthritis - PsA Psoriasis sufferers or family history of psoriasis Common presentation of enthesopathy Abnormally hypoechoic (loss of normal fibrillar architecture and/or thickened tendon or ligament at its bony attachment seen in 2 perpendicular planes that may exhibit Doppler signal and/or bony changes including enthesophytes, erosions, or irregularity. OMERACT 7 SIG
Psoriatic arthritis common sites Joint synovitis - wrists Tenosynovitis hands/wrists Extensor enthesitis proximal interphalangeal joints ( PIPjs) Achilles enthesitis Plantar fasciitis Interdigital bursitis
Interdigital foot pain Is it a Morton s neuroma? Or is it an interdigital bursitis Is it unilateral or bilateral? Is there a good reason for it?
Gout Elevated levels of uric acid in the blood Synovitis Erosions Double contour Deposition of uric acid crystals on the surface of cartilage Tophus/tophi Deposition of uric acid crystals in joint capsules or soft tissues
Gout - common sites 1 st MTPj/knees synovitis, erosions, DC sign Dorsum of foot - tophi in/around tendons Achilles/patellar tendons tophi Elbows - bursitis
Pseudogout Causes attacks of IA similar to gout Caused by the collection of salt called calcium pyrophosphate dihydrate (CPPD) within the cartilage Among older adults, a common cause acute arthritis in a single joint. Mainly affects the elderly. Can be difficult to diagnose on ultrasound
Pseudogout common sites TFCC of the wrist Menisci of the knees
Pitfalls - Equipment settings Doppler sensitivity PRF/wall filter, colour frequency and gain Light transducer pressure with plenty of coupling gel Slow methodical transducer movements to avoid compression of tiny vessels and obliteration of Doppler signal Maximise and intra-articular Doppler flow
Pitfalls - Steroids Steroids will temporarily reduce inflammation and hyperaemia Decrease in inflammation associated with an decrease in Doppler signal. Scan may appear normal when in fact, there is significant inflammatory arthritis Image A shows the joint before steroid treatment, B, 4 weeks after steroids and C, 12 weeks after treatment when the symptoms and Doppler signal are returning A B C A B C
Role of US in early diagnosis Nice Guidelines Early referral to rheumatology Early synovitis clinics Accurate diagnosis - US Alternative diagnoses
Questions to ask the undiagnosed patient Are you taking any steroids or have had any steroid injections within the last 6 weeks? Where does it hurt? Is the pain bilateral? When does it hurt the most? Is it worse at any specific time of day or the more you do? Do you have psoriasis?
Clinical question Patients without a diagnosis: Are there any inflammatory joint or soft tissue features? If so, where are they? Are there any features specific to a particular arthritis? RA, PsA, Crystal arthropathy If not, is there any other obvious cause for their symptoms? CTS, tumour, fracture
Role of US in disease management Aggressive treatment to prevent bony damage DMARDS Anti TNF Biologic therapy Clinical monitoring - DAS score Appropriate drug use? remission
Clinical question Patients with a diagnosis Is this patient active? Are there features of ongoing synovitis/tenosynovitis despite treatment? Do I need to increase/change drugs? Can I reduce drugs? Are they in remission Is the original diagnosis correct?
Reports State the question Answer it Use the correct anatomical names index, middle etc rather than 2,3 etc Don t assume no need to conclude Suggest onward referral if appropriate
Reports No evidence of active synovitis seen arising from the wrists or within the MCP or PIPjs. No tenosynovitis. No erosions seen. There is grade 2 active joint synovitis in the index and middle finger MCPjs bilaterally and arising from the right wrist. There is flexor tenosynovitis of the index and middle fingers on the left. No erosions seen. Ultrasound appearances would support a diagnosis of inflammatory arthritis and an urgent rheumatology opinion is suggested.
Guided injections/aspirations To relieve pain Steroid Local anaesthetic To enable mobility As above Hyaluronic acid For diagnosis gout, infection
Take home messages GP requests NICE guidelines Discuss with Rheumatology - grading Revise anatomy bone and soft tissue, bursae and tendon sheaths Ask questions about drugs Suggest Rheumatology referral Use your wide MSK experience
And remember to think outside the box. Patient with Psoriatic arthritis. Pain lateral ankle. Is there evidence of peroneal tenosynovitis?
Any questions?
Thank you Research Institute for Primary Care and Health Sciences David Wetherall Building Keele University Newcaslte-under-Lyme ST5 5BG Tel: 01782 733905 Fax: 01782 734719 www.keele.ac.uk/pchs
Useful references Wakefield R J, Balint PV, Szkudlarek M, et al. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 2005 ; 32 : 2485 7 Szkudlarek M, Court-Payen M, Jacobsen S, e t al. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum 2003 ; 48 : 955 62 Naredo E, Bonilla G, Gamero F, et al. Assessment of inflammatory activity in rheumatoid arthritis: a comparative study of clinical evaluation with with grey scale and power Doppler ultrasonography. Ann Rheum Dis 2005 ; 64 : 375 81 Berner Hammer H et al. Examination of intra and interrater reliability with a new ultrasonographic reference atlas for scoring of synovitis in patients with rheumatoid arthritis. Ann Rheum Dis 2011;70:1995 1998 Wakefield RJ et al Musculoskeletal Ultrasound Including Definitions for Ultrasonographic Pathology OMERACT SIG. Journal of Rheumatology 2005