Musculoskeletal ultrasonography: Nomenclature, technical considerations, validation, and standardization
- George AW Bruyn, MD, PhD
George AW Bruyn, MD, PhD
- Department of Rheumatology
- MC Groep hospitals, Lelystad, the Netherlands
Ultrasonography (US), also 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. US imaging, at one time the sole province of radiologists, has become now widely available in rheumatology clinics and other ambulatory and emergency settings.
The nomenclature, technical considerations, validity, and reliability of musculoskeletal US are discussed here. Imaging modalities generally used to diagnose disorders of the musculoskeletal system and guidelines for selecting imaging studies (eg, plain film radiography, computed tomography [CT scan], magnetic resonance imaging [MRI], and US) for selected 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" and "Musculoskeletal ultrasonography: Clinical applications".)
The use of US to screen for, diagnose, and monitor the response of osteoporosis to treatment requires dedicated, special-purpose devices rather than US imaging systems to assess bone mineral content. (See "Screening for osteoporosis", section on 'Ultrasound'.)
NOMENCLATURE AND CONVENTIONS
Various terms are used to describe ultrasonographic (US) equipment, transducer and image orientation, normal and abnormal features in acquired images, and artifacts.
Types of ultrasonography
B-mode US — Brightness (B)-mode US or Grayscale US are terms indicating the same technique. They are used interchangeably.
- Torp-Pedersen S, Christensen R, Szkudlarek M, et al. Power and color Doppler ultrasound settings for inflammatory flow: impact on scoring of disease activity in patients with rheumatoid arthritis. Arthritis Rheumatol 2015; 67:386.
- 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.
- Torp-Pedersen ST, Terslev L. Settings and artefacts relevant in colour/power Doppler ultrasound in rheumatology. Ann Rheum Dis 2008; 67:143.
- Wakefield RJ, Balint PV, Szkudlarek M, et al. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 2005; 32:2485.
- Haavardsholm EA, Aga AB, Olsen IC, et al. Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial. BMJ 2016; 354:i4205.
- Dale J, Stirling A, Zhang R, et al. Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial. Ann Rheum Dis 2016; 75:1043.
- Joshua F, Lassere M, Bruyn GA, et al. Summary findings of a systematic review of the ultrasound assessment of synovitis. J Rheumatol 2007; 34:839.
- 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.
- Scheel AK, Schmidt WA, Hermann KG, et al. Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR "Train the trainers" course. Ann Rheum Dis 2005; 64:1043.
- Naredo E, Möller I, Moragues C, et al. Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course. Ann Rheum Dis 2006; 65:14.
- Wakefield RJ, D'Agostino MA, Iagnocco A, et al. The OMERACT Ultrasound Group: status of current activities and research directions. J Rheumatol 2007; 34:848.
- 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.
- Bruyn GA, Naredo E, Damjanov N, et al. An OMERACT reliability exercise of inflammatory and structural abnormalities in patients with knee osteoarthritis using ultrasound assessment. Ann Rheum Dis 2016; 75:842.
- Bruyn GA, Naredo E, Möller I, et al. Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis. Ann Rheum Dis 2009; 68:357.
- Bruyn GA, Möller I, Garrido J, et al. Reliability testing of tendon disease using two different scanning methods in patients with rheumatoid arthritis. Rheumatology (Oxford) 2012; 51:1655.
- Bruyn GA, Naredo E, Iagnocco A, et al. The OMERACT Ultrasound Working Group 10 Years On: Update at OMERACT 12. J Rheumatol 2015; 42:2172.
- Terslev L, Gutierrez M, Christensen R, et al. Assessing Elementary Lesions in Gout by Ultrasound: Results of an OMERACT Patient-based Agreement and Reliability Exercise. J Rheumatol 2015; 42:2149.
- Filippou G, Scirè CA, Damjanov N, et al. Definition and Reliability Assessment of Elementary Ultrasonographic Findings in Calcium Pyrophosphate Deposition Disease: A Study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force. J Rheumatol 2017.
- NOMENCLATURE AND CONVENTIONS
- Types of ultrasonography
- - B-mode US
- - Grayscale US
- - Doppler US
- - Color Doppler US
- - Duplex US
- - Power Doppler US
- Transducer orientation and image presentation
- - Bone surface
- - Cartilage
- - Synovium
- - Synovial fluid
- - Joint capsule
- - Tendons
- - Nerves
- - Muscles
- - Bursae
- - Ligaments
- - Axial resolution
- - Lateral resolution
- Time or B gain correction
- Edge shadows
- Comet tail
- Acoustic shadowing
- TECHNICAL CONSIDERATIONS
- VALIDATION, RELIABILITY, AND STANDARDIZATION