Objective. The ability to make an early, accurate diagnosis of rheumatoid arthritis (RA) has become increasingly important with the availability of new, expensive, and targeted therapies. However, plain radiography, the traditional method of detecting the characteristic bone erosions and an important adjunct in establishing a diagnosis of RA, is known to be insensitive. This study compared sonography, a modern imaging technique, with conventional radiography for the detection of erosions in the metacarpophalangeal (MCP) joints of patients with RA. Methods. One hundred RA patients (including 40 with early disease) underwent posteroanterior radiography and sonography of the MCP joints of the dominant hand. Twenty asymptomatic control subjects also underwent sonography. Erosion sites were recorded and subsequently compared using each modality. Magnetic resonance imaging (MRI) was performed on the second MCP joint in 25 patients with early RA to confirm the pathologic specificity of sonographic erosions. Intraobserver reliability of sonography readings was assessed using video recordings of 55 MCP joint scans of RA patients, and interobserver reliability was assessed by comparing 160 MCP joint scans performed sequentially by 2 independent observers. Results. Sonography detected 127 definite erosions in 56 of 100 RA patients, compared with radiographic detection of 32 erosions (26 [81%] of which coincided with sonographic erosions) in 17 of 100 patients (P < 0.0001). In early disease, sonography detected 6.5-fold more erosions than did radiography, in 7.5-fold the number of patients. In late disease, these differences were 3.4-fold and 2.7-fold, respectively. On MRI, all sonographic erosions not visible on radiography (n = 12) corresponded by site to MRI abnormalities. The Cohen-kappa values for intra- and interobserver reliability of sonography were 0.75 and 0.76, respectively. Conclusion. Sonography is a reliable technique that detects more erosions than radiography, especially in early RA. Sonographic erosions not seen on radiography corresponded to MRI bone abnormalities. This technology has potential in the management of patients with early RA/inflammatory arthritis and is likely to have major implications for the future practice of rheumatology.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/1529-0131%28200012%2943%3A12%3C2762%3A%3AAID-ANR16%3E3.0.CO%3B2-%23

The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography.

Objective

A prospective study was performed comparing conventional radiography, 3-phase bone scintigraphy, ultrasound, and magnetic resonance imaging (MRI) with precontrast and dynamic postcontrast examinations in 60 patients with various forms of arthritis including rheumatoid arthritis (RA), spondylarthropathy, and arthritis associated with connective tissue disease.



Methods

A total of 840 finger joints were examined clinically and by all 4 imaging methods. Experienced investigators blinded to the clinical findings and diagnoses analyzed all methods independently of each other. The patients were divided into 2 groups. Group 1 included 32 patients (448 finger joints) without radiologic signs of destructive arthritis (Larsen grades 0–1) of the evaluated hand and wrist and group 2 included 28 patients (392 finger joints) with radiographs revealing erosions (Larsen grade 2) of the evaluated hand and/or wrist.



Results

Clinical evaluation, scintigraphy, MRI, and ultrasound were each more sensitive than conventional radiography in detecting inflammatory soft tissue lesions as well as destructive joint processes in arthritis patients in group 1. All differences were statistically significant. We found ultrasound to be even more sensitive than MRI in the detection of synovitis. MRI detected erosions in 92 finger joints (20%; 26 patients) in group 1 that had not been detected by conventional radiography.



Conclusion

Our data indicate that MRI and ultrasound are valuable diagnostic methods in patients with arthritis who have normal findings on radiologic evaluation.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/1529-0131%28199906%2942%3A6%3C1232%3A%3AAID-ANR21%3E3.0.CO%3B2-3

Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging.

Objective: To compare the clinical assessment of overall inflammatory activity in patients with rheumatoid arthritis (RA) with grey scale and power Doppler (PD) ultrasonography (US). Methods: Ninety four consecutive patients with RA were included. Demographic and clinical data, C reactive protein (CRP) level, and erythrocyte sedimentation rate (ESR) were recorded for each patient. The presence of tenderness, swelling, and a subjective swelling score from 1 to 3 were independently assessed by two rheumatologists, who reached a consensus in 60 joints examined in each patient. All patients underwent a US examination by a third blinded rheumatologist, using PD. US joint effusion, synovitis, and PD signal were graded from 1 to 3 in the 60 joints. Joint count and joint index for effusion, synovitis, and PD signal were recorded. A 28 joint count for clinical and US variables was calculated. Interobserver reliability of the US examination was evaluated by a fourth blinded rheumatologist. Results: US showed significantly more joints with effusion (mean 15.2) and synovitis (mean 14.6) than clinical examination (mean 11.5, p Conclusion: US is a sensitive method for assessing joint inflammatory activity in RA, complementary to clinical evaluation.

https://ard.bmj.com/content/annrheumdis/64/3/375.full.pdf

Assessment of inflammatory activity in rheumatoid arthritis: a comparative study of clinical evaluation with grey scale and power Doppler ultrasonography

Compromised shoulder movement due to pain, stiffness, or weakness can cause substantial disability and affect a person's ability to carry out daily activities (eating, dressing, personal hygiene) and work.w1 Self reported prevalence of shoulder pain is estimated to be between 16% and 26%; it is the third most common cause of musculoskeletal consultation in primary care, and approximately 1% of adults consult a general practitioner with new shoulder pain annually.1 Occupations as diverse as construction work and hairdressing are associated with a higher risk of shoulder disorders. Physical factors such as lifting heavy loads, repetitive movements in awkward positions, and vibrations influence the level of symptoms and disability, and psychosocial factors are also important.w1 Recent studies suggest that chronicity and recurrence are common.2 3

Common shoulder disorders exhibit similar clinical features, and the lack of consensus on diagnostic criteria and concordance in clinical assessment complicates treatment choices.3 w2-w5 This review proposes an evidence based approach using a simplified classification of shoulder problems, incorporating diagnostic techniques applicable to a primary care consultation and a “red flag” system to identify potentially serious disease.

We incorporated the latest consensus from systematic reviews and publications identified by a literature search through Medline, CINAHL, AMED, the Cochrane Library (Central, CDSR, HTA, DARE), Clinical Evidence, Best Evidence, Embase, British Nursing Index, PEDro,w6 Web of Science (social science and science citation indexes), and bmj.com. The search strategy included the terms “shoulder pain”, “rotator cuff disorder”, “rotator cuff tear”, “frozen shoulder”, and “primary care”.

We found six published systematic reviews of interventions for shoulder disorders and one health technology assessment systematic review of diagnostic tests for the assessment of shoulder pain.4–10 A topic search within Clinical Evidence identified the section “Shoulder pain.”11 We identified and critically appraised other …

/pdf/shoulder-pain-diagnosis-and-management-in-primary-care-4nw3o698j5.pdf

Shoulder pain: diagnosis and management in primary care

Objective

To simultaneously image bone and synovium in the individual joints characteristically involved in early rheumatoid arthritis (RA).



Methods

Forty patients with early, untreated RA underwent gadolinium-enhanced magnetic resonance imaging (MRI) of the second through fifth metacarpophalangeal joints of the dominant hand at presentation, 3 months, and 12 months. In the first phase (0–3 months), patients were randomized to receive either methotrexate alone (MTX) or MTX and intraarticular corticosteroids (MTX + IAST) into all joints with clinically active RA. The MTX-alone group received no further corticosteroids until the second phase (3–12 months), when both groups received standard therapy.



Results

In the first phase, MTX + IAST reduced synovitis scores more than MTX alone. There were significantly fewer joints with new erosions on MRI in the former group compared with the latter. During the second phase, the synovitis scores were equivalent and a similar number of joints in each group showed new erosions on MRI. In both phases, there was a close correlation between the degree of synovitis and the number of new erosions, with the area under the curve for MRI synovitis the only significant predictor of bone damage progression. In individual joints, there was a threshold effect on new bone damage related to the level of synovitis; no erosions occurred in joints without synovitis.



Conclusion

In early RA, synovitis appears to be the primary abnormality, and bone damage occurs in proportion to the level of synovitis but not in its absence. In the treatment of patients with RA, outcome measures and therapies should focus on synovitis.

Elucidation of the relationship between synovitis and bone damage: A randomized magnetic resonance imaging study of individual joints in patients with early rheumatoid arthritis

Objectives. To evaluate ultrasonography (US) of salivary glands in primary Sjogren's syndrome (SS) and to compare US with parotid magnetic resonance (MR) imaging and MR sialography. Methods. US examination of parotid, submandibular and sublingual glands was performed on 27 patients with primary SS, 27 healthy controls and 27 symptomatic controls without SS. The results were compared with parotid MR imaging and MR sialography and the clinical features of the patients. Results. Salivary gland abnormalities, parenchymal inhomogeneity or adipose degeneration, were visualized in 21 (78%) SS patients, in one healthy control and in two symptomatic controls by US. Eighteen (67%) patients had changes in the parotid and submandibular glands and 8 (30%) changes in the sublingual glands. In the comparison, MR sialography was found to be the most sensitive method (96%), followed by MR imaging (81%) and US (78%), in detecting glandular changes. The specificity of US was 94%. The US and MR results were related to anti-Ro/SSA positivity but not to saliva secretion. The focus scores were related only to parotid MR imaging findings. Conclusions. US, MR imaging and MR sialography with modern technology have reached such a good accuracy in visualizing glandular structural changes that they are promising alternatives to the conventional invasive examinations in the diagnostics of SS.

/pdf/ultrasonography-of-salivary-glands-in-primary-sjogren-s-8wm6w27t0c.pdf

Ultrasonography of salivary glands in primary Sjögren's syndrome. A comparison with magnetic resonance imaging and magnetic resonance sialography of parotid glands

The value of ultrasonography (US), magnetic resonance imaging (MRI), computed tomography (CT) and plain radiography (PR) in detecting bone erosions on the humeral head was evaluated in a study of 26 in-patients (26 shoulders) with rheumatoid arthritis (RA) MRI depicted humeral erosions in 25 (96%), US in 24 (92%), CT in 20 (77%) and PR in 19 (73%) of the 26 shoulders MRI and US were superior to CT in detecting small erosions US was the most sensitive method to show surface erosions on the greater tuberosity US, CT and MRI detected large erosions quite similarly PR frequently missed small erosions In the evaluation of early erosions in the rheumatoid shoulder, US and MRI are more sensitive methods than the traditionally used PR US and MRI are suitable for the evaluation of soft-tissue involvement in the rheumatoid shoulder, but also for the detection of bone erosions of the humeral head

/pdf/evaluation-of-humeral-head-erosions-in-rheumatoid-arthritis-23jmoh1u94.pdf

Evaluation of humeral head erosions in rheumatoid arthritis: a comparison of ultrasonography, magnetic resonance imaging, computed tomography and plain radiography.

OBJECTIVE: To evaluate the value of ultrasonography in assessing arthritic acromioclavicular (AC) joints. METHODS: One hundred twenty-six AC joints of 63 healthy subjects (2 groups) were prospectively examined by ultrasound to determine the-normal limits of capsular distention and the width of the joint space. Thirty-three AC joints of 32 patients with chronic arthritis were evaluated by ultrasound and, for comparison, by radiography, computed tomography (CT), and magnetic resonance imaging (MRI). RESULTS: The mean ultrasonographic distance of the joint capsule from the bone rim was 2.2 mm +/- standard deviation (SD) 0.5 mm in 21-32-year-old control subjects and 2.9 +/- 0.7 mm in 37-81-year-old control subjects. The mean width of the joint space was 4.1 +/- 0.9 mm and 3.5 +/- 0.9 mm in the same control groups, respectively. In detecting soft tissue changes in arthritic AC joints MRI was better than ultrasound. In revealing bony surface changes, CT was the best method and radiography was least sensitive but quite specific. Our most prominent finding was that ultrasound is able to exclude joint inflammation; when the ultrasonographic distance of the joint capsule from the bone rim was < 3 mm, there was no synovial hypertrophy or effusion on MRI scans. CONCLUSION: Ultrasound can detect AC joint changes reliably. It is able to exclude joint inflammation. Effusion in the AC joint may reflect inflammation, but may also be a sign of degeneration.

Ultrasound evaluation of the acromioclavicular joint

We evaluated 31 painful shoulders of 30 patients with chronic arthritis by ultrasonography (US) and compared the results with those of magnetic resonance imaging (MRI). Both US and MRI revealed effusion in the subacromial-subdeltoid (SA-SD) bursa, biceps tendon sheath (BTS) and glenohumeral (GH) joint, but MRI was more accurate in depicting joint inflammation because of its ability to visualize synovial hypertrophy. US visualized biceps tendon ruptures equally well as MRI. MRI was better able to reveal full-thickness tear of the supraspinatus tendon, whereas US showed better other changes of the supraspinatus tendon (degeneration or partial-thickness tear). Both of the imaging methods were able to depict erosions of the humeral head, but the locations occasionally differed. Inexpensive and easily available US can be recommended as the first imaging method for the detection of soft-tissue changes in the arthritic shoulder, but in rotator cuff problems both methods may be needed.

I Suramo

Papers

Ultrasonography of salivary glands in primary Sjögren's syndrome. A comparison with magnetic resonance imaging and magnetic resonance sialography of parotid glands

Evaluation of humeral head erosions in rheumatoid arthritis: a comparison of ultrasonography, magnetic resonance imaging, computed tomography and plain radiography.

Ultrasound evaluation of the acromioclavicular joint

Sonography and MRI in the evaluation of painful arthritic shoulder.