Rheumatology Diagnostic Ultrasound. Basics for sonographers and consultant rheumatologist wanted to learn the diagnostic ultrasound, implement and improve musculoskeletal practice as POCUS (point of care ultrasound). Other healthcare professionals can also benefit such as sonographers, physiotherapists, osteopath, chiropractors.

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2.  Musculoskeletal Ultrasound is like a stethoscope for the
musculoskeletal system and for rheumatologists as it is an
extension of clinical examination
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3. ADVANTAGES
 Shows early signs of inflammation
 Dynamic examination (tissue
compressibility – synovium/lumps
and ligament integrity - UCL)
 Rapid contralateral limb
examination for comparison
 Reproducible (image/findings) and
comparable
 Well tolerated and safe
 Lack of radiation
 No known contraindications
 Interventional procedures
 Low cost
 Readily available and real time
imaging
DISADANTAGES
 Incomplete evaluation of bony
and joint anatomy
(osteoarthritis?)
 Small area (can pick up small
erosions and bony lesions –
Hill-Sachs lesion)
 Examiner’s skill level (operator
dependent)
 Time consuming
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 Chronic, progressive auto
immune disease - Primarily
affects synovial joints producing
an inflammatory response
 Common sites: Wrists, MCPjs
2&3, elbows, knees, ankles,
MTPjs
 May be seen earlier on US than
X-ray
 Causes swelling, effusion,
synovial thickening, synovitis
and can lead to bone
destruction

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SYNOVIUM
Anterior Recess of Ankle Joint

6.  Erosions (two planes)
different from osteophytes
and degeneration) –
Doppler for active disease
 Synovial
hypertrophy/thickening
(non-compressible and
not displaceable)
 Effusion (compressible
and displaceable)
 Co-exist synovial
thickening and effusion
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7.  Blood flow (hyperemia)
 New
vessels/Neovasculariz
ation
Surrogate for
inflammation (localised
dilated vessels)
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9.  Synovial hypertrophy –
primary event visible on
imaging
 Grade of
hypertrophy/activity
equates to the level of
disease/activity
 Hyperaemia- sign of
active disease
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10. NICE Guidelines
•Early referral to Rheumatology
•Accurate Diagnosis
•Alternative Diagnosis
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11.  Oral, intramuscular or infusion steroid will temporarily reduce
inflammation and hyperaemia
 Decrease in inflammation is associated with an decrease in
Doppler signal
 Use of steroids prior to a scan may mean that a scan
appears normal when in fact, there is significant inflammatory
arthritis
 NSAID usage may mask the grayscale (GS) and power
Doppler (PD) signal and result in lower scoring despite
continuing disease activity
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13.  Bony Irregularities/osteophytes
 Effusion/inflammatory changes
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14.  Treat to Target (tapering up and down)
 Remission (clinical and US evidence) –
stopping treatment – cost of biologics?
 Early DMARD treatment
 Window of Opportunity
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15.  Ultrasound can be used to improve certainty of RA diagnosis above
clinical criteria alone
 Inflammation seen on ultrasound can be used to correlate with clinical
presentation and predict clinical RA from undifferentiated inflammatory
arthritis
 Ultrasound assessment is more superior to clinical assessment and
should be considered for more accurate assessment of inflammation
(example of clinical remission but subclinical synovitis on next
page)
 Ultrasound should be considered to detect damage at an earlier time
point (especially in early RA) – please request on yellow card
specially if want to detect erosions
 Joint inflammation and damage can be used for prediction of further
joint damage (baseline images and comparison
 Images can be used to predict response to treatment
 Images can be used to monitor disease progression
 Justifying escalating DMARs Biologics
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16.  Inflammation? Specific or non-specific
 Arthralgia/degenerative changes/osteoarthritis.
 Interpret of findings/image – what it means so that
can translate in clinical context
 Grading, operator dependent,
knowledge/management RA and brief patient
history (example radioulnar joint and radiocarpal
joint) – your opinion/questions?
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17.  Demo
 Enthesitis
 Spondyloarthropathies
 Specific regional inflammation related to specific (etc ECU
tenosynovitis relation)
 Fibromyalgia, pain and fibromyalgia in RA
 Intervention – guided injection
 Validity for monitoring therapeutic response in long standing RA
– number of joints and regions (Naredo Arthritis Care Research
2013 and Hammer Arthritis research and therapy 2017)
 NSAID usage masking the grayscale (GS) and power
Doppler (PD) signal and result in lower scoring despite
continuing disease activity – stopping before scan
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18.  Scoring ultrasound synovitis in rheumatoid
arthritis: a EULAR-OMERACT ultrasound
taskforce-Part 2: reliability and application to
multiple joints of a standardised consensus-
based scoring system (2017)
 Rheumatoid arthritis: Final Ultrasound for
diagnosis of rheumatoid arthritis - NICE
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