Skip to main content

Advertisement

Log in

The role of ultrasound in the diagnosis and management of psoriatic arthritis

  • Published:
Current Rheumatology Reports Aims and scope Submit manuscript

Abstract

Psoriatic arthritis (PsA) presents many diagnostic, management and research challenges for rheumatologists who wish to obtain early diagnosis, differentiate synovitis and enthesitis, monitor disease activity accurately and objectively, prevent the development of structural damage, deliver local therapy accurately, and obtain PsA tissue for research purposes. Musculoskeletal ultrasound (MSUS) is widely used by European rheumatologists in their clinical practice to meet these challenges and has the potential to become the rheumatologist’s stethoscope in Europe and North America. This paper examines the evidence that MSUS can improve clinical evaluation of patients with PsA for synovitis and enthesitis, that MSUS is more sensitive than plain radiography in detecting structural damage in joints, that MSUS can improve the success of joint aspiration and guide biopsy of PsA tissues. Recent exciting developments in the management of PsA are detailed including the role of power Doppler in the diagnosis of enthesitis in PsA, the role of MSUS in objective monitoring of disease activity, the evaluation of MSUS in the diagnosis of sacroiliitis, and the use of MSUS to guide therapeutic injection of the sacroiliac joints.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Grassi W, Cervini C: Ultrasonography in rheumatology: an evolving technique. Ann Rheum Dis 1998, 57:268–271.

    Article  PubMed  CAS  Google Scholar 

  2. Kane D, Balint PV, Sturrock R, Grassi W: Musculoskeletal ultrasound—a state of the art review in rheumatology. Part 1: current controversies and issues in the development of musculoskeletal ultrasound in rheumatology. Rheumatology (Oxford) 2004, 43:823–828.

    Article  CAS  Google Scholar 

  3. Kane D, Grassi W, Sturrock R, Balint PV: Musculoskeletal ultrasound—a state of the art review in rheumatology. Part 2: clinical indications for musculoskeletal ultrasound in rheumatology. Rheumatology (Oxford) 2004, 43:829–838. This article is a thorough review of the current clinical indications for MSUS in rheumatology.

    Article  CAS  Google Scholar 

  4. Koski JM: Ultrasound guided injections in rheumatology. J Rheumatol 2000, 27:2131–2138.

    PubMed  CAS  Google Scholar 

  5. Grassi W, Filippucci E: Is power Doppler sonography the new frontier in therapy monitoring? Clin Exp Rheumatol 2003, 21:424–428.

    PubMed  CAS  Google Scholar 

  6. Blomley MJ, Cooke JC, Unger EC, et al.: Microbubble contrast agents: a new era in ultrasound. BMJ 2001, 322:1222–1225.

    Article  PubMed  CAS  Google Scholar 

  7. Nazarian LN, Rawool NM, Martin CE, Schweitzer ME: Synovial fluid in the hindfoot and ankle: detection of amount and distribution with US. Radiology 1995, 197:275–278.

    PubMed  CAS  Google Scholar 

  8. Moss SG, Schweitzer ME, Jacobson JA, et al.: Hip joint fluid: detection and distribution at MR imaging and US with cadaveric correlation. Radiology 1998, 208:43–48.

    PubMed  CAS  Google Scholar 

  9. Marchal GJ, Van Holsbeeck MT, Raes M, et al.: Transient synovitis of the hip in children: role of US. Radiology 1987, 162:825–828.

    PubMed  CAS  Google Scholar 

  10. Jacobson JA, Andresen R, Jaovisidha S, et al.: Detection of ankle effusions: comparison study in cadavers using radiography, sonography, and MR imaging. AJR Am J Roentgenol 1998, 170:1231–1238.

    PubMed  CAS  Google Scholar 

  11. Schmidt WA, Schmidt H, Schicke B, Gromnica-Ihle E: Standard reference values for musculoskeletal ultrasonography. Ann Rheum Dis 2004, 63:988–994. Clinical rheumatologists using MSUS will find this article detailing the normal measurement values of articular structures to be invaluable when applying MSUS to their patients.

    Article  PubMed  CAS  Google Scholar 

  12. Hauzeur JP, Mathy L, De Maertelaer V: Comparison between clinical evaluation and ultrasonography in detecting hydrarthrosis of the knee. J Rheumatol 1999, 26:2681–2683.

    PubMed  CAS  Google Scholar 

  13. Kane D, Balint PV, Sturrock R: Ultrasonography is superior to clinical examination in the detection and localisation of knee joint effusion in rheumatoid arthritis. J Rheumatol 2003, 30:966–971.

    PubMed  Google Scholar 

  14. Raza K, Lee CY, Pilling D, et al.: Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis. Rheumatology (Oxford) 2003, 42:976–979.

    Article  CAS  Google Scholar 

  15. Fraser AD, van Kuijk AW, Westhovens R, et al.: A randomised, double-blind, placebo controlled, multi-centre trial of combination therapy with methotrexate plus cyclosporin in patients with active psoriatic arthritis. Ann Rheum Dis 2004 (Epub ahead of print) This placebo-controlled study of methotrexate in combination with cyclosporin in PsA demonstrates a modest benefit of combination therapy but also is the first study to suggest that MSUS may be a more objective measure of disease activity than traditional measures in clinical trials of PsA.

  16. Fiocco U, Cozzi L, Rubaltelli L, et al.: Long-term sonographic follow-up of rheumatoid and psoriatic proliferative knee joint synovitis. Br J Rheumatol 1996, 35:155–163.

    Article  PubMed  CAS  Google Scholar 

  17. Karim Z, Wakefield RJ, Quinn M, et al.: Validation and reproducibility of ultrasonography in the detection of synovitis in the knee: a comparison with arthroscopy and clinical examination. Arthritis Rheum 2004, 50:387–394. MSUS detection of synovitis of the knee is validated with arthroscopy.

    Article  PubMed  CAS  Google Scholar 

  18. Backhaus M, Kamradt T, Sandrock D, et al.: Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis Rheum 1999, 42:1232–1245.

    Article  PubMed  CAS  Google Scholar 

  19. Szkudlarek M, Court-Payen M, Strandberg C, et al.: Contrastenhanced power Doppler ultrasonography of the metacarpophalangeal joints in rheumatoid arthritis. Eur Radiol 2003, 13:163–168.

    PubMed  Google Scholar 

  20. Grassi W: Clinical evaluation versus ultrasonography: who is the winner? J Rheumatol 2003, 30:908–909.

    PubMed  Google Scholar 

  21. Moll JMH, Wright V: Psoriatic arthritis. Semin Arthritis Rheum 1973, 3:55–78.

    Article  PubMed  CAS  Google Scholar 

  22. Veale D, FitzGerald O: Psoriatic arthritis—"DIP or not DIP? That is the question". Br J Rheumatol 1992, 31:430–431.

    Article  PubMed  CAS  Google Scholar 

  23. Vasey FB, Espinoza LR: Psoriatic arthropathy. In Spondyloarthropathies. Edited by Calin A. New York: Grune and Stratton. 1984: 151–185.

    Google Scholar 

  24. Wakefield RJ, Brown AK, O’Connor PJ, Emery P: Power Doppler sonography: improving disease activity assessment in inflammatory musculoskeletal disease. Arthritis Rheum 2003, 48:285–288.

    Article  PubMed  Google Scholar 

  25. Balint PV, Sturrock RD: Inflamed retrocalcaneal bursa and achilles tendonitis in psoriatic arthritis demonstrated by ultrasonography. Ann Rheum Dis 2000, 59:931–933.

    Article  PubMed  CAS  Google Scholar 

  26. D’Agostino MA, Said-Nahal R, Hacquard-Bouder C, et al.: Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross-sectional study. Arthritis Rheum 2003, 48:523–533. Power Doppler is of increasing interest to rheumatologists performing MSUS. This study noted that power Doppler changes at entheses in SpA were of a higher magnitude and frequency than in other arthritides.

    Article  PubMed  Google Scholar 

  27. Taylor PC, Steuer A, Gruber J, et al.: Comparison of ultrasonographic assessment of synovitis and joint vascularity with radiographic evaluation in a randomized, placebo-controlled study of infliximab therapy in early rheumatoid arthritis. Arthritis Rheum 2004, 50:1107–1116.

    Article  PubMed  CAS  Google Scholar 

  28. Balint PV, Kane D, Wilson H, et al.: Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy. Ann Rheum Dis 2002, 61:905–910.

    Article  PubMed  CAS  Google Scholar 

  29. Falsetti P, Frediani B, Fioravanti A, et al.: Sonographic study of calcaneal entheses in erosive osteoarthritis, nodal osteoarthritis, rheumatoid arthritis and psoriatic arthritis. Scand J Rheumatol 2003, 32:229–234.

    Article  PubMed  CAS  Google Scholar 

  30. Galluzzo E, Lischi DM, Taglione E, et al.: Sonographic analysis of the ankle in patients with psoriatic arthritis. Scand J Rheumatol 2000, 29:52–55.

    Article  PubMed  CAS  Google Scholar 

  31. Frediani B, Falsetti P, Storri L, et al.: Ultrasound and clinical evaluation of quadricipital tendon enthesitis in patients with psoriatic arthritis and rheumatoid arthritis. Clin Rheumatol 2002, 21:294–298.

    Article  PubMed  CAS  Google Scholar 

  32. Falsetti P, Frediani B, Filippou G, et al.: Enthesitis of proximal insertion of the deltoid in the course of seronegative spondyloarthritis. An atypical enthesitis that can mime impingement syndrome. Scand J Rheumatol 2002, 31:158–162.

    PubMed  Google Scholar 

  33. McGonagle D, Marzo-Ortega H, O’Connor P, et al.: Histological assessment of the early enthesitis lesion in spondyloarthropathy. Ann Rheum Dis 2002, 61:534–537. To understand enthesitis we need to develop techniques that allow the sampling of enthesitis tissues. MSUS guided biopsy of the enthesis was well tolerated with no serious side effects.

    Article  PubMed  CAS  Google Scholar 

  34. Kane D, FitzGerald O: Tumor necrosis factor-alpha in psoriasis and psoriatic arthritis: a clinical, genetic, and histopathologic perspective. Curr Rheumatol Rep 2004, 6:292–298.

    Article  PubMed  Google Scholar 

  35. Kane D, Stafford L, Bresnihan B, FitzGerald O: A prospective, clinical and radiological study of early psoriatic arthritis: an early synovitis clinic experience. Rheumatology (Oxford) 2003, 42:1460–1468.

    Article  CAS  Google Scholar 

  36. Salvarani C, Cantini F, Olivieri I, et al.: Isolated peripheral enthesitis and/or dactylitis: a subset of psoriatic arthritis. J Rheumatol 1997, 24:1106–1110.

    PubMed  CAS  Google Scholar 

  37. Kane D, Greaney T, Bresnihan B, et al.: Ultrasonography in the diagnosis and management of psoriatic dactylitis. J Rheumatol 1999, 26:1746–1751.

    PubMed  CAS  Google Scholar 

  38. Olivieri I, Barozzi L, Favaro L, et al.: Dactylitis in patients with seronegative spondylarthropathy. Assessment by ultrasonography and magnetic resonance imaging. Arthritis Rheum 1996, 39:1524–1528.

    Article  PubMed  CAS  Google Scholar 

  39. Olivieri I, Barozzi L, Pierro A, et al.: Toe dactylitis in patients with spondyloarthropathy: assessment by magnetic resonance imaging. J Rheumatol 1997, 24:926–930.

    PubMed  CAS  Google Scholar 

  40. Williams C, Kane D, Duffy G: Psoriatic dactylitis: bone scintigraphic appearances. Clin Nucl Med 1997, 22:853–854.

    Article  PubMed  CAS  Google Scholar 

  41. Grassi W, Filippucci E, Farina A, Cervini C: Sonographic imaging of the distal phalanx. Semin Arthritis Rheum 2000, 29:379–384.

    Article  PubMed  CAS  Google Scholar 

  42. Klauser A, Springer P, Frauscher F, et al.: Comparison between magnetic resonance imaging, unenhanced and contrast enhanced ultrasound in the diagnosis of active sacroiliitis. Arthritis Rheum 2002, 46:S426. Though MRI is the established technique for spinal imaging, this study suggests that MSUS may be used to image the sacro-iliac joints and possibly other para-spinal strutures.

    Article  Google Scholar 

  43. Pekkafahli MZ, Kiralp MZ, Basekim CC, et al.: Sacroiliac joint injections performed with sonographic guidance. J Ultrasound Med 2003, 22:553–559. MSUS offers an alternative to MRI and computed tomography for guiding sacro-iliac joint injection.

    PubMed  Google Scholar 

  44. Schmidt WA: Value of sonography in diagnosis of rheumatoid arthritis. Lancet 2001, 357:1056–1057.

    Article  PubMed  CAS  Google Scholar 

  45. Mease PJ, Kivitz AJ, Burch FX, et al.: Etanercept treatment of psoriatic arthritis: safety, efficacy and effect on disease progression. Arthritis Rheum 2004, 50:2264–2272.

    Article  PubMed  CAS  Google Scholar 

  46. Balint PV, Kane D, Hunter J, et al.: Ultrasound guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study. J Rheumatol 2002, 29:2209–2213. MSUS improves the success of joint and soft tissue aspiration in routine clinical practice.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kane, D. The role of ultrasound in the diagnosis and management of psoriatic arthritis. Curr Rheumatol Rep 7, 319–324 (2005). https://doi.org/10.1007/s11926-005-0043-6

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11926-005-0043-6

Keywords

Navigation