Dr Konin offered the following tips on scoring MSUS for tenosynovitis, followed by recommendations for scoring MSUS in patients with rheumatic disease.

General MSUS Tips for Evaluating Joint Disease

  • Evaluate for synovial thickening and proliferative fronds of the joints with or without increased vascularity upon power Doppler interrogation
  • Synovial hyperemia is more suggestive of active disease, and synovial proliferation without hyperemia suggests chronic, inactive disease
  • Proximal distribution in the hands and feet with paucity of joint line osteophytes is more suggestive of an inflammatory arthropathy rather than degenerative arthritis
  • Osseous erosions are difficult to detect as concavities and irregular osteophytes may simulate erosions
  • Suspected erosions should be evaluated in both longitudinal and short axis
  • Thick transmission gel is preferred when evaluating small joints of the hands and wrist and feet so as not to compress possible synovial hyperemia or effusions

Ultrasound Tips for Diagnosis Tenosynovitis

  • Evaluate for synovial thickening and/or fluid distention of the tendon sheath
  • Synovial thickening can be seen with or without increased vascularity upon power Doppler interrogation
  • Tendon sheath thickening without hyperemia is more suggestive of chronic, inactive disease, whereas prominent hyperemia and fluid distention is more indicative of active disease
  • If there is single tendon involvement, the clinician must always consider infection rather than a rheumatologic inflammatory process

Summary and Clinical Applicability

Musculoskeletal ultrasound provides a sensitive tool for identifying and tracking disease activity in rheumatic diseases.


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References

  1. Micu MC, Berghea F, Fodor D. Concepts in diagnosing, scoring, and monitoring tenosynovitis and other tendon abnormalities in patients with rheumatoid arthritis- the role of musculoskeletal ultrasound. Med Ultrason. 2016; 18(3):370-7.
  2. Aletaha D, Neogi T, Silman AJ, et al.  2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology / European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62(9):256.
  3. Cader MZ, Filer A, Hazlehurst J, de Pablo P, Buckley CD, Raza K. Performance of the 2010 ACR/EULAR criteria for rheumatoid arthritis: comparison with 1987 ACR criteria in a very early synovitis cohort. Ann Rheum Dis. 2011;. 70: 949-955.
  4. Lindegaard HM, Vallø J, Hørslev-Petersen K, Junker P, Østergaard M. Low-cost, low-field dedicated extremity magnetic resonance imaging in early rheumatoid arthritis: a 1-year follow-up study. Ann Rheum Dis. 2006; 65: 1208-1212.
  5. 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: 2049-2050. 75.
  6. Janta I, Valor L, De la Torre I, et al. Ultrasound –detected activity in rheumatoid arthritis on methotrexate therapy: Which joints and tendons should be assessed to predict unstable remission? Rheumatol Int. 2016; 36: 387-396.

Figure 1. 82 year-old woman with rheumatoid arthritis. Longitudinal ultrasound image of the left third metacarpophalangeal (MCP) joint demonstrates synovial thickening with power Doppler hyperemia and an osseous erosion at the metacarpal head.

Figure 2. 59 year-old woman with tenosynovial thickening and no associated power Doppler hyperemia of her third flexor tendon sheath seen on the longitudinal gray scale images with power Doppler interrogation.

Figure 3.  59 year-old woman with tenosynovial thickening and no associated power Doppler hyperemia of her third flexor tendon sheath seen on the longitudinal gray scale images without power Doppler interrogation.

Figure 4. 38 year-old woman with tenosynovial thickening and associated power Doppler hyperemia as well as fluid distention of the tendon sheath seen on longitudinal gray scale images with power Doppler interrogation.

Figure 5.  38 year-old woman with tenosynovial thickening and associated power Doppler hyperemia as well as fluid distention of the tendon sheath seen on longitudinal gray scale images without power Doppler interrogation.

Figure 1. 82 year-old woman with rheumatoid arthritis. Longitudinal ultrasound image of the left third metacarpophalangeal (MCP) joint demonstrates synovial thickening with power Doppler hyperemia and an osseous erosion at the metacarpal head.

Figure 2. 59 year-old woman with tenosynovial thickening and no associated power Doppler hyperemia of her third flexor tendon sheath seen on the longitudinal gray scale images with power Doppler interrogation.

Figure 3.  59 year-old woman with tenosynovial thickening and no associated power Doppler hyperemia of her third flexor tendon sheath seen on the longitudinal gray scale images without power Doppler interrogation.

Figure 4. 38 year-old woman with tenosynovial thickening and associated power Doppler hyperemia as well as fluid distention of the tendon sheath seen on longitudinal gray scale images with power Doppler interrogation.

Figure 5.  38 year-old woman with tenosynovial thickening and associated power Doppler hyperemia as well as fluid distention of the tendon sheath seen on longitudinal gray scale images without power Doppler interrogation.