Musculoskeletal ultrasonography: Clinical applications
- George AW Bruyn, MD, PhD
George AW Bruyn, MD, PhD
- Department of Rheumatology
- MC IJsselmeerziekenhuizen, Lelystad
- The Netherlands
Ultrasonography (US), sometimes referred to as ultrasound imaging or sonography, is an imaging modality that utilizes reflected pulses of high-frequency (ultrasonic) sound waves to assess soft tissues, cartilage, bone surfaces, and fluid-containing structures. Ultrasonographic imaging, once the sole province of radiologists, is becoming more widely available in rheumatology clinics and other ambulatory and emergency settings. However, the widespread use of US by clinicians who diagnose and treat musculoskeletal disorders has been hampered by questions related to the reliability, validity, standardization, methodology, and the ability to detect changes over time. Technical aspects of musculoskeletal ultrasonography, the validity and reliability of image acquisition, and interpretation in rheumatic disorders, primarily in patients with rheumatoid arthritis, are addressed in detail separately. (See "Musculoskeletal ultrasonography: Nomenclature, technical considerations, validation, and standardization".)
The use of US to assess patients with rheumatic diseases in the clinic was fostered by the development of compact real-time US systems in the 1980s. Synovitis of the knee was the earliest musculoskeletal disorder assessed ultrasonographically in the clinic . Ultrasonographic assessment of synovitis of the small joints of the hands in patients with rheumatoid arthritis followed by a decade , aided by the availability in the 1990s of high-resolution transducers that made detailed assessment of superficial structures feasible.
Selected clinical applications of musculoskeletal US are discussed here. An overview of imaging modalities and guidelines for selecting imaging studies (eg, plain film radiography, computed tomography [CT], magnetic resonance imaging [MRI], and US) for musculoskeletal problems are presented separately. (See "Imaging techniques for evaluation of the painful joint" and "Radiologic evaluation of the painful hip in adults" and "Radiologic evaluation of the painful shoulder".)
Diagnostic imaging is only one element in the assessment of patients with musculoskeletal symptoms. The clinical approach to such patients, including, in most instances, suggestions regarding the role of diagnostic imaging in their assessment, is discussed in the topics that deal with the initial evaluation of patients presenting with pain in various parts of the body. Examples include shoulder pain, hip pain, and knee pain. (See "Evaluation of the patient with shoulder complaints" and "Evaluation of the adult with hip pain" and "General evaluation of the adult with knee pain".)
For the musculoskeletal ultrasonographer, the selection of anatomic structures to image and the planes in which two-dimensional ultrasonography (US) is performed is primarily complaint-driven. Standardized scans and disease-specific protocols for imaging are alternative approaches that are used in certain settings.
- Cooperberg PL, Tsang I, Truelove L, Knickerbocker WJ. Gray scale ultrasound in the evaluation of rheumatoid arthritis of the knee. Radiology 1978; 126:759.
- De Flaviis L, Scaglione P, Nessi R, et al. Ultrasonography of the hand in rheumatoid arthritis. Acta Radiol 1988; 29:457.
- Fenwick SA, Hazleman BL, Riley GP. The vasculature and its role in the damaged and healing tendon. Arthritis Res 2002; 4:252.
- Bruyn GAW, Schmidt WA. Introductory Guide to Musculoskeletal Ultrasound for the Rheumatologist, 2nd, Bohn Stafleu van Loghum, Houten 2011.
- Backhaus M, Burmester GR, Gerber T, et al. Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 2001; 60:641.
- Ling SC, Chen CF, Wan RX. A study on the vascular supply of the supraspinatus tendon. Surg Radiol Anat 1990; 12:161.
- Crass JR, Craig EV, Feinberg SB. The hyperextended internal rotation view in rotator cuff ultrasonography. J Clin Ultrasound 1987; 15:416.
- Middleton WD, Edelstein G, Reinus WR, et al. Ultrasonography of the rotator cuff: technique and normal anatomy. J Ultrasound Med 1984; 3:549.
- Mack LA, Matsen FA 3rd, Kilcoyne RF, et al. US evaluation of the rotator cuff. Radiology 1985; 157:205.
- Breidahl WH, Stafford Johnson DB, Newman JS, Adler RS. Power Doppler sonography in tenosynovitis: significance of the peritendinous hypoechoic rim. J Ultrasound Med 1998; 17:103.
- Grassi W, Tittarelli E, Blasetti P, et al. Finger tendon involvement in rheumatoid arthritis. Evaluation with high-frequency sonography. Arthritis Rheum 1995; 38:786.
- Bakewell CJ, Olivieri I, Aydin SZ, et al. Ultrasound and magnetic resonance imaging in the evaluation of psoriatic dactylitis: status and perspectives. J Rheumatol 2013; 40:1951.
- Alcalde M, D'Agostino MA, Bruyn GA, et al. A systematic literature review of US definitions, scoring systems and validity according to the OMERACT filter for tendon lesion in RA and other inflammatory joint diseases. Rheumatology (Oxford) 2012; 51:1246.
- Bruyn GA, Hanova P, Iagnocco A, et al. Ultrasound definition of tendon damage in patients with rheumatoid arthritis. Results of a OMERACT consensus-based ultrasound score focussing on the diagnostic reliability. Ann Rheum Dis 2014; 73:1929.
- Lillegraven S, Bøyesen P, Hammer HB, et al. Tenosynovitis of the extensor carpi ulnaris tendon predicts erosive progression in early rheumatoid arthritis. Ann Rheum Dis 2011; 70:2049.
- Kovacs P, Behensky H, Lottersberger C, et al. Can the dimensions of artificial tendon lesions be predicted ultrasonographically? A cadaveric study. J Ultrasound Med 2001; 20:459.
- Hartgerink P, Fessell DP, Jacobson JA, van Holsbeeck MT. Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation. Radiology 2001; 220:406.
- Benjamin M, Moriggl B, Brenner E, et al. The "enthesis organ" concept: why enthesopathies may not present as focal insertional disorders. Arthritis Rheum 2004; 50:3306.
- 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.
- Scheel AK, Matteson EL, Dasgupta B, et al. Reliability exercise for the polymyalgia rheumatica classification criteria study: the oranjewoud ultrasound substudy. Int J Rheumatol 2009; 2009:738931.
- Weigand S, Ehrenstein B, Fleck M, Hartung W. Joint involvement in patients with early polymyalgia rheumatica using high-resolution ultrasound and its contribution to the EULAR/ACR 2012 classification criteria for polymyalgia rheumatica. J Rheumatol 2014; 41:730.
- McDonald DG, Leopold GR. Ultrasound B-scanning in the differentiation of Baker's cyst and thrombophlebitis. Br J Radiol 1972; 45:729.
- Guerra J Jr, Newell JD, Resnick D, Danzig LA. Pictorial essay: gastrocnemio-semimembranosus bursal region of the knee. AJR Am J Roentgenol 1981; 136:593.
- Pastershank SP, Mitchell DM. Knee joint bursal abnormalities in rheumatoid arthritis. J Can Assoc Radiol 1977; 28:199.
- Martinoli C, Bianchi S, Derchi LE. Ultrasonography of peripheral nerves. Semin Ultrasound CT MR 2000; 21:205.
- 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.
- Wakefield RJ, Gibbon WW, Conaghan PG, et al. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. Arthritis Rheum 2000; 43:2762.
- Backhaus M, Burmester GR, Sandrock D, et al. Prospective two year follow up study comparing novel and conventional imaging procedures in patients with arthritic finger joints. Ann Rheum Dis 2002; 61:895.
- Hermann KG, Backhaus M, Schneider U, et al. Rheumatoid arthritis of the shoulder joint: comparison of conventional radiography, ultrasound, and dynamic contrast-enhanced magnetic resonance imaging. Arthritis Rheum 2003; 48:3338.
- Szkudlarek M, Court-Payen M, Strandberg C, 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 Rheum 2001; 44:2018.
- Naredo E, Möller I, Cruz A, et al. Power Doppler ultrasonographic monitoring of response to anti-tumor necrosis factor therapy in patients with rheumatoid arthritis. Arthritis Rheum 2008; 58:2248.
- 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.
- Szkudlarek M, Court-Payen M, Jacobsen S, et al. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum 2003; 48:955.
- Walther M, Harms H, Krenn V, 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 Rheum 2001; 44:331.
- Nakagomi D, Ikeda K, Okubo A, et al. Ultrasound can improve the accuracy of the 2010 American College of Rheumatology/European League against rheumatism classification criteria for rheumatoid arthritis to predict the requirement for methotrexate treatment. Arthritis Rheum 2013; 65:890.
- Howard RG, Pillinger MH, Gyftopoulos S, et al. Reproducibility of musculoskeletal ultrasound for determining monosodium urate deposition: concordance between readers. Arthritis Care Res (Hoboken) 2011; 63:1456.
- ACQUIRING IMAGES
- Complaint-driven image selection
- Standardized scanning
- Disease-specific scanning
- ULTRASONOGRAPHY FOR SPECIFIC DISORDERS
- Tendons, ligaments, and muscles
- - Normal tendon and muscle
- - Abnormal tendon and muscle
- - Shoulder tendons
- - Finger tendons
- - Wrist tendons
- - Achilles tendon
- - Enthesitis
- - Subdeltoid-subacromial bursa
- - Olecranon bursa
- - Baker's cyst
- Peripheral nerves
- - Bone erosions
- - Synovitis
- - Cartilage