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Ultrasound in rheumatology

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Over the last decade, several studies have highlighted the value of ultrasonography for both clinical and research purposes in rheumatology. Ultrasonography is a non-invasive, inexpensive and free-of-radiation-hazards imaging technique providing quick and useful information for the management of rheumatic diseases. Considerable evidence supporting the role of ultrasonography in rheumatological clinical practice has led many rheumatologists to want to become experienced with this imaging technique. The main indications of ultrasonography in rheumatology include the evaluation of patients with regional pain syndromes and chronic arthritis, short-term therapy monitoring and guidance for invasive procedures. Ultrasonography's long learning curve is the main obstacle that hinders its widespread use in rheumatology. Many technical aspects may affect the scanning process and a correct interpretation of sonographic images depends on several elements such as a deep knowledge of ultrasonography anatomy and pathology.

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Equipment and methods

The quality of the US documentation that can be obtained by a skilled operator is directly linked to the quality of the US machine used. Top quality equipment for musculosketal US should include: a set of probes that cover a vast frequency range (ideally from 5 to more than 20 MHz), a very sensitive power and colour Doppler, extended view and three-dimensional US facilities (Figure 1). All these requirements are met by several types of equipment that are now available. Obviously the quality and

Acquisition techniques

Proper US scanning depends on the operator's ability to correctly place the probe and set the equipment. The US beam must be perpendicular with respect to the structures that are to be examined so as to avoid artefacts. Even minimal transducer inclination changes can strongly influence the characteristics of the US images. The best angle of insonation is determined by the operator, with minimal adaptive movements of the probe and/or the anatomical region. Each anatomical structure should be

Sonographic image interpretation

A correct interpretation of US images depends on several elements, such as a detailed knowledge of US anatomy and of the main pathological signs and pitfalls. At present, the US diagnosis is based on the examiner's comments, rather than on an off-line evaluation of the images appended to the report. This is due to the fact that sonographers tend not to print a full and detailed series of images and rheumatologists are not very prone to analysing and understanding them. A rapid and decisive

Indications and limits

There are five main indications for the use of US in rheumatology.

  • 1.

    Initial evaluation of patients with regional pain syndromes. In these patients, information obtained using US can be integrated with clinical data. This leads to a more precise diagnosis based on the identification of the specific anatomical targets of the disease.41, 42

  • 2.

    Identification of the anatomical changes associated with early arthritis. With the introduction of early aggressive therapy, it is advisable to use a very

Who should carry out US examinations?

It is a known fact that most US examinations on the musculoskeletal system are carried out by radiologists. This leads to a series of problems. First and foremost is the considerable time lapse that occurs between the request for an US examination, its execution and the evaluation, by the rheumatologists, of the information acquired. Moreover, many radiologists have a very limited knowledge of rheumatic diseases. This greatly limits the potential utility of the examination, since many important

Training

US is considered to be the most operator-dependent imaging modality. The relatively long learning curve and the lack of standardised training criteria are the main obstacles that hinder its widespread use.

The learning process for most rheumatologists is based on the participation in short (2–3 days) national or international courses and on informal training acquired under the guidance of a tutor.

Sonography courses and workshops are now included in the program of the most important rheumatology

Shoulder

The shoulder is a complex joint and is frequently involved in a wide range of pathological processes. A precise diagnosis and the identification of the anatomical damage to the different structures (joint, tendons, bursae) cannot be solely defined on the basis of history and clinical evaluation. US offers a quick and highly effective assessment of the most frequent pathological changes involving the shoulder.47, 48 These include biceps tenosynovitis, subdeltoid bursitis, rotator cuff pathology

Summary

US can provide a great contribution to the early diagnosis of various rheumatic disorders and offers a clearer view of the anatomical damage induced by inflammatory or degenerative processes. Most of the studies published up until now have been carried out in a relatively small number of pilot centres. Notwithstanding this, one can legitimately affirm that an US revolution has taken place in the field of rheumatology.

The main indications for US in rheumatology include the evaluation of patients

References (51)

  • W. Grassi et al.

    Sonographically guided procedures in rheumatology

    Seminars in Arthritis and Rheumatism

    (2001)
  • W. Grassi et al.

    Imaging modalities for identifying the origin of regional musculoskeletal pain

    Best Practice and Research: Clinical Rheumatology

    (2003)
  • C. Martinoli et al.

    Tendon and nerve sonography

    Radiology Clinics of North America

    (1999)
  • W. Grassi et al.

    Sonographic imaging of normal and osteoarthritic cartilage

    Seminars in Arthritis and Rheumatism

    (1999)
  • P. Balint et al.

    Musculoskeletal ultrasound imaging: a new diagnostic tool for the rheumatologist?

    British Journal of Rheumatology

    (1997)
  • W. Grassi et al.

    Ultrasonography in rheumatology: an evolving technique

    Annals of the Rheumatic Diseases

    (1998)
  • D. Kane et al.

    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

    (2004)
  • D. Kane et al.

    Musculoskeletal ultrasound—a state of the art review in rheumatology. Part 2: clinical indications for musculoskeletal ultrasound in rheumatology

    Rheumatology

    (2004)
  • A. Iagnocco et al.

    Joint sonography in asymptomatic patients with HCV correlated hepatitis

    Clinical and Experimental Rheumatology

    (2004)
  • C.A. Speed et al.

    Musculoskeletal sonography by rheumatologists: the challenges

    Rheumatology

    (2002)
  • M. Backhaus et al.

    Guidelines for musculoskeletal ultrasound in rheumatology

    Annals of Rheumatic Diseases

    (2001)
  • C.A. Speed et al.

    Training in musculoskeletal sonography: report from the first BSR course

    Rheumatology

    (2002)
  • R.J. Wakefield et al.

    Musculoskeletal ultrasonography in Europe: results of a rheumatologist-based survey at a EULAR meeting

    Rheumatology

    (2003)
  • E. Filippucci et al.

    Sonographic training in rheumatology: a self teaching approach

    Annals of Rheumatic Diseases

    (2003)
  • R.J. Wakefield et al.

    Musculoskeletal ultrasonography: what is it and should training be compulsory for rheumatologists?

    Rheumatology

    (2004)
  • R.J. Wakefield et al.

    Power Doppler sonography: improving disease activity assessment in inflammatory musculoskeletal disease

    Arthritis and Rheumatism

    (2003)
  • L. Terslev et al.

    Doppler ultrasound and magnetic resonance imaging of synovial inflammation of the hand in rheumatoid arthritis

    Arthritis and Rheumatism

    (2003)
  • M. Szkudlarek et al.

    Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging

    Arthritis and Rheumatism

    (2001)
  • M. Walther et al.

    Correlation of power Doppler sonography with vascularity of the synovial tissue of the knee joint in patients with osteoarthritis and rheumatoid arthritis

    Arthritis and Rheumatism

    (2001)
  • W.A. Schmidt et al.

    Colour Doppler ultrasonography to detect pannus in knee joint synovitis

    Clinical and Experimental Rheumatology

    (2000)
  • Z. Karim et al.

    Validation and reproducibility of ultrasonography in the detection of synovitis in the knee: a comparison with arthroscopy and clinical examination

    Arthritis and Rheumatism

    (2004)
  • M. Hau et al.

    Evaluation of pannus and vascularization of the metacarpophalangeal and proximal interphalangeal joints in rheumatoid arthritis by high-resolution ultrasound (multidimensional linear array)

    Arthritis and Rheumatism

    (1999)
  • F. Salaffi et al.

    Contrast-enhanced power Doppler sonography of knee synovitis in rheumatoid arthritis: assessment of therapeutic response

    Clinical Rheumatology

    (2004)
  • A. Klauser et al.

    The value of contrast-enhanced color Doppler ultrasound in the detection of vascularization of finger joints in patients with rheumatoid arthritis

    Arthritis and Rheumatism

    (2002)
  • W. Grassi et al.

    Is power Doppler sonography the new frontier in therapy monitoring?

    Clinical and Experimental Rheumatology

    (2003)
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