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Added value of high-resolution ultrasound and MRI in the evaluation of rheumatologic diseases

Amit Kumar Sahu
Amit Kumar Sahu
, 
Shweta Kataria
Shweta Kataria
 y 
Girish Gandikota
Girish Gandikota
   | 23 nov 2023
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Article Category: Review paper
Publicado en línea: 23 nov 2023
Páginas: e285 - e298
Recibido: 22 sept 2023
Aceptado: 16 oct 2023
DOI: https://doi.org/10.15557/jou.2023.0035
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© 2023 Amit Kumar Sahu et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

Rheumatoid arthritis (RA): AP radiograph of the hand demonstrates periarticular osteopenia (reduced bone density around the joints); reduced radiocarpal and intercarpal joint spaces; erosions (arrows), and subluxation of the metacarpophalangeal joints (white circles). Ankylosis of the intercarpal joints (asterisk) is seen in this case, which can be a feature of chronic untreated rheumatoid arthritis
Rheumatoid arthritis (RA): AP radiograph of the hand demonstrates periarticular osteopenia (reduced bone density around the joints); reduced radiocarpal and intercarpal joint spaces; erosions (arrows), and subluxation of the metacarpophalangeal joints (white circles). Ankylosis of the intercarpal joints (asterisk) is seen in this case, which can be a feature of chronic untreated rheumatoid arthritis

Fig. 2.

Synovitis. Long-axis US image of the suprapatellar knee showing echogenic synovium (asterisk in A) which is partially compressible on probe pressure, as seen in image B. Arrows indicate the quadriceps tendon
Synovitis. Long-axis US image of the suprapatellar knee showing echogenic synovium (asterisk in A) which is partially compressible on probe pressure, as seen in image B. Arrows indicate the quadriceps tendon

Fig. 3.

Joint effusion. Short-axis US image of the shoulder joint with absent rotator cuff. Central compression (arrow) shows complete compression and displacement of the joint fluid (asterisk)
Joint effusion. Short-axis US image of the shoulder joint with absent rotator cuff. Central compression (arrow) shows complete compression and displacement of the joint fluid (asterisk)

Fig. 4.

Greyscale (A) and power Doppler (B) long-axis US images of wrist joint depicting hypoechoic synovial proliferation (arrows in A) distending the joint capsule with diffuse vascularity (arrows in B)
Greyscale (A) and power Doppler (B) long-axis US images of wrist joint depicting hypoechoic synovial proliferation (arrows in A) distending the joint capsule with diffuse vascularity (arrows in B)

Fig. 5.

Power Doppler synovitis grading. Long-axis PDUS of the wrist joint shows grade 0 –no flow (A); grade 1 – single-vessel signal (B); grade 2 – less than half of the area of the synovium-filled with vessels (C); grade 3 – more than half of the area of the synovium filled with vessels (D). Note: the Doppler signal in (A) is from the periarticular vessels and not the synovium
Power Doppler synovitis grading. Long-axis PDUS of the wrist joint shows grade 0 –no flow (A); grade 1 – single-vessel signal (B); grade 2 – less than half of the area of the synovium-filled with vessels (C); grade 3 – more than half of the area of the synovium filled with vessels (D). Note: the Doppler signal in (A) is from the periarticular vessels and not the synovium

Fig. 6.

Axial post-contrast T1-weighted (T1W) fat-suppressed image of the distal radioulnar joint shows enhancing synovium (arrows in A), suggesting synovitis along with enhancement of the flexor and extensor tendon sheaths (arrows in B), consistent with tenosynovitis
Axial post-contrast T1-weighted (T1W) fat-suppressed image of the distal radioulnar joint shows enhancing synovium (arrows in A), suggesting synovitis along with enhancement of the flexor and extensor tendon sheaths (arrows in B), consistent with tenosynovitis

Fig. 7.

Erosions. Grayscale US images of the metacarpophalangeal joint in two orthogonal planes (A and B) show intraarticular discontinuity in the cortical bone surface (arrows)
Erosions. Grayscale US images of the metacarpophalangeal joint in two orthogonal planes (A and B) show intraarticular discontinuity in the cortical bone surface (arrows)

Fig. 8.

Grayscale US images of the 2nd metacarpal head in two orthogonal planes (A and B) show normal anatomical depression of dorsal cortical bone surface (arrows) mimicking erosion
Grayscale US images of the 2nd metacarpal head in two orthogonal planes (A and B) show normal anatomical depression of dorsal cortical bone surface (arrows) mimicking erosion

Fig. 9.

Erosions. Axial T1-W MR image of wrist joint reveals hypointense bony defects in the carpal bones (arrows in A) showing enhancement on post-contrast T1-W fat-suppressed image (arrows in B). Erosions in such locations can be missed on US
Erosions. Axial T1-W MR image of wrist joint reveals hypointense bony defects in the carpal bones (arrows in A) showing enhancement on post-contrast T1-W fat-suppressed image (arrows in B). Erosions in such locations can be missed on US

Fig. 10.

Bone marrow edema (BME). Axial STIR MR image of ankle joint shows patchy areas of hyperintense signal in the distal tibia and fibula (arrows). In this case, extensive BME was due to enthesitis
Bone marrow edema (BME). Axial STIR MR image of ankle joint shows patchy areas of hyperintense signal in the distal tibia and fibula (arrows). In this case, extensive BME was due to enthesitis

Fig. 11.

Tenosynovitis. Long- (A) and short-axis (B,C) US images of the 2nd extensor compartment tendons at wrist joint show circumferential hypoechoicteno-synovial proliferation (arrows in A and B) with significant power Doppler signal (arrow in C) suggestive of active tenosynovitis, in a known case of RA
Tenosynovitis. Long- (A) and short-axis (B,C) US images of the 2nd extensor compartment tendons at wrist joint show circumferential hypoechoicteno-synovial proliferation (arrows in A and B) with significant power Doppler signal (arrow in C) suggestive of active tenosynovitis, in a known case of RA

Fig. 12.

Extensor carpi ulnaris (ECU) tenosynovitis. Short-axis grayscale (A) and power Doppler (B) US of the ECU (asterisks) shows sheath thickening (arrow in A) with power Doppler signal keeping with tenosynovitis, in a patient with RA
Extensor carpi ulnaris (ECU) tenosynovitis. Short-axis grayscale (A) and power Doppler (B) US of the ECU (asterisks) shows sheath thickening (arrow in A) with power Doppler signal keeping with tenosynovitis, in a patient with RA

Fig. 13.

Tenosynovitis. Axial proton density fat-suppressed images of different patients (A and B) show tenosynovial proliferation and edema of flexor (arrow in A) and extensor (arrow in B) tendons
Tenosynovitis. Axial proton density fat-suppressed images of different patients (A and B) show tenosynovial proliferation and edema of flexor (arrow in A) and extensor (arrow in B) tendons

Fig. 14.

Cartilage damage. Short-axis US image of the knee joint at the level of trochlea shows blurring of cartilage margins, loss of clarity of the cartilaginous layer, and loss of its normal homogeneously hypoechoic appearance
Cartilage damage. Short-axis US image of the knee joint at the level of trochlea shows blurring of cartilage margins, loss of clarity of the cartilaginous layer, and loss of its normal homogeneously hypoechoic appearance

Fig. 15.

Enthesitis. Long-axis US images of Achilles tendon show loss of normal fibrillar echotexture and decreased echogenicity of the tendon insertion (asterisks), punctate calcific foci (small arrow in B), erosions of subentheseal bone (large arrows in A and B) and power Doppler signal at enthesis as seen in B
Enthesitis. Long-axis US images of Achilles tendon show loss of normal fibrillar echotexture and decreased echogenicity of the tendon insertion (asterisks), punctate calcific foci (small arrow in B), erosions of subentheseal bone (large arrows in A and B) and power Doppler signal at enthesis as seen in B

Fig. 16.

Enthesitis. Short-axis grayscale (A) and power Doppler (B) US images of tibialis posterior tendon (asterisks) show intra-tendinous and peritendinous thickening and power Doppler signal
Enthesitis. Short-axis grayscale (A) and power Doppler (B) US images of tibialis posterior tendon (asterisks) show intra-tendinous and peritendinous thickening and power Doppler signal

Fig. 17.

Dactylitis. Long-axis US image of flexor tendons (A) and extensor tendon (B) of the fingers of the same patient show tenosynovial proliferation (arrows in A) around flexor tendons (asterisk), representing tenosynovitis. There is thickening of the extensor tendon (arrow in B) at its insertion to the distal phalanx. PIP – proximal interphalangeal joint; DIP – distal interphalangeal joint
Dactylitis. Long-axis US image of flexor tendons (A) and extensor tendon (B) of the fingers of the same patient show tenosynovial proliferation (arrows in A) around flexor tendons (asterisk), representing tenosynovitis. There is thickening of the extensor tendon (arrow in B) at its insertion to the distal phalanx. PIP – proximal interphalangeal joint; DIP – distal interphalangeal joint

Fig. 18.

Sacroiliitis. Coronal oblique T1-W (A) and STIR (B) MR images of sacroiliac joints show bilateral symmetrical periarticular BME (hyperintensity within the circles in B) with areas of sclerosis (hypointensity within circles in A). There is a mild reduction in joint spaces and irregularity of articular marginsv
Sacroiliitis. Coronal oblique T1-W (A) and STIR (B) MR images of sacroiliac joints show bilateral symmetrical periarticular BME (hyperintensity within the circles in B) with areas of sclerosis (hypointensity within circles in A). There is a mild reduction in joint spaces and irregularity of articular marginsv

Fig. 19.

Enthesitis. MR proton density fat-suppressed coronal (A and B) and axial images of the ankle show extensive marrow edema (hyperintensity) at the attachment sites of ligaments (small arrows in A and C); retinaculum (arrows in B) and fascia (long arrow in C)
Enthesitis. MR proton density fat-suppressed coronal (A and B) and axial images of the ankle show extensive marrow edema (hyperintensity) at the attachment sites of ligaments (small arrows in A and C); retinaculum (arrows in B) and fascia (long arrow in C)

Fig. 20.

Severe osteoarthritis (OA). AP radiograph of the right knee shows marginal osteophytes (small arrows), medial joint space narrowing (circle), subchondral sclerosis, and subchondral cysts (long arrow)
Severe osteoarthritis (OA). AP radiograph of the right knee shows marginal osteophytes (small arrows), medial joint space narrowing (circle), subchondral sclerosis, and subchondral cysts (long arrow)

Fig. 21.

Osteoarthritis (OA). Long-axis grayscale (A) and power Doppler (B) US images of the 1st carpometacarpal and joint show osteophytes (long arrow in A) along with synovial and capsular thickening (short arrow in A). There is a power Doppler signal in the thickened synovium as seen in B. The 1st carpometacarpal joint is one of the joints involved early on in OA
Osteoarthritis (OA). Long-axis grayscale (A) and power Doppler (B) US images of the 1st carpometacarpal and joint show osteophytes (long arrow in A) along with synovial and capsular thickening (short arrow in A). There is a power Doppler signal in the thickened synovium as seen in B. The 1st carpometacarpal joint is one of the joints involved early on in OA

Fig. 22.

Osteoarthritis (OA). Long-axis US images of the knee joint show meniscal extrusion (arrow in A), osteophyte (arrowhead in B), and cartilage damage of trochlea (arrows in C), cartilage appears heterogeneous, with uneven thickness and fuzzy contours
Osteoarthritis (OA). Long-axis US images of the knee joint show meniscal extrusion (arrow in A), osteophyte (arrowhead in B), and cartilage damage of trochlea (arrows in C), cartilage appears heterogeneous, with uneven thickness and fuzzy contours

Fig. 23.

Osteoarthritis (OA): MR proton density fat-suppressed coronal image shows cartilage damage with cortical irregularity (long arrow) and osteophyte (small arrow). There is also tear of medial meniscus
Osteoarthritis (OA): MR proton density fat-suppressed coronal image shows cartilage damage with cortical irregularity (long arrow) and osteophyte (small arrow). There is also tear of medial meniscus

Fig. 24.

Cartilage imaging. Sagittal T2 mapping shows different color shades of the cartilage based on the diffusing fluid signal. Color shade towards red indicates cartilage damage(long arrow) and shade towards blue indicates healthy cartilage (small arrow)
Cartilage imaging. Sagittal T2 mapping shows different color shades of the cartilage based on the diffusing fluid signal. Color shade towards red indicates cartilage damage(long arrow) and shade towards blue indicates healthy cartilage (small arrow)

Fig. 25.

Gout. Long-axis grayscale (A) and power Doppler (B) US image at the wrist joint shows large overhanging erosion in the radius (long arrows) adjacent to extensor digitorum tendon (short arrows). There is a large echogenic tophus overlying the erosion (asterisks) with surrounding power Doppler signal (B)
Gout. Long-axis grayscale (A) and power Doppler (B) US image at the wrist joint shows large overhanging erosion in the radius (long arrows) adjacent to extensor digitorum tendon (short arrows). There is a large echogenic tophus overlying the erosion (asterisks) with surrounding power Doppler signal (B)

Fig. 26.

Gout. US intratendinous crystal. A. Deposition of monosodium urate crystals in the patellar tendon (asterisk); B. with Power Doppler signal suggestive of active inflammation. C. Long-axis view of triceps tendon near its insertion, with a tophaceous deposit (asterisk) seen as inhomogeneous echogenicity with loss of normal fibrillar pattern
Gout. US intratendinous crystal. A. Deposition of monosodium urate crystals in the patellar tendon (asterisk); B. with Power Doppler signal suggestive of active inflammation. C. Long-axis view of triceps tendon near its insertion, with a tophaceous deposit (asterisk) seen as inhomogeneous echogenicity with loss of normal fibrillar pattern

Fig. 27.

Gout. A. Transverse US image of the suprapatellar knee joint demonstrates two parallel hyperechoic contours on either side of the hypoechoic hyaline cartilage (asterisk). The deep echogenic contour (long arrows) represents the femoral cortex, while the superficial echogenic contour (arrowheads) represents monosodium urate crystals accumulating on the surface of the hypoechoic hyaline cartilage (asterisk). Long-axis US image of metatarsophalangeal joint (B) and wrist joint (C) with the double contour sign (arrows) around hyaline cartilage. Note the anechoic synovial effusion with hyperechoic crystal deposits (snow-storm appearance) in the first metatarsophalangeal joint without any power Doppler signal (asterisk in B)
Gout. A. Transverse US image of the suprapatellar knee joint demonstrates two parallel hyperechoic contours on either side of the hypoechoic hyaline cartilage (asterisk). The deep echogenic contour (long arrows) represents the femoral cortex, while the superficial echogenic contour (arrowheads) represents monosodium urate crystals accumulating on the surface of the hypoechoic hyaline cartilage (asterisk). Long-axis US image of metatarsophalangeal joint (B) and wrist joint (C) with the double contour sign (arrows) around hyaline cartilage. Note the anechoic synovial effusion with hyperechoic crystal deposits (snow-storm appearance) in the first metatarsophalangeal joint without any power Doppler signal (asterisk in B)

Fig. 28.

Gout: Coronal T1-W MR image of the foot shows large hypointense erosions in the head of the 1st metatarsal (black arrows) with adjacent hypointense tophi. There is also a large hypointense tophus over the base of the 5th metatarsal (white arrow). Note the characteristic clearly demarcated erosion
Gout: Coronal T1-W MR image of the foot shows large hypointense erosions in the head of the 1st metatarsal (black arrows) with adjacent hypointense tophi. There is also a large hypointense tophus over the base of the 5th metatarsal (white arrow). Note the characteristic clearly demarcated erosion

Fig. 29.

Calcium pyrophosphate crystals deposit (CPPD) disease: long-axis US image of medial wrist joint shows nodular hyperechoic deposit in the region of triangular fibrocartilage (arrow in A) which is seen as a calcific opacity in radiograph (arrow in B)
Calcium pyrophosphate crystals deposit (CPPD) disease: long-axis US image of medial wrist joint shows nodular hyperechoic deposit in the region of triangular fibrocartilage (arrow in A) which is seen as a calcific opacity in radiograph (arrow in B)

Fig. 30.

Dual-energy CT (DECT) in gout: 3D reconstructed image of DECT of both feet in a patient with gout shows green color-coded crystal aggregates around the joints (small arrows) and along the tendons (long arrows)
Dual-energy CT (DECT) in gout: 3D reconstructed image of DECT of both feet in a patient with gout shows green color-coded crystal aggregates around the joints (small arrows) and along the tendons (long arrows)

Scoring of bone erosions on US by the OMERACT task force

Grade 0 Intact cortical bone
Grade 1 Single small erosion (diameter: ≤2 mm)
Grade 2 Single large erosion (diameter: >2 mm) or 2 small erosions or 1 large and 1 small erosion
Grade 3 2 large erosions or ≥3 erosions, regardless of size

Features of rheumatologic diseases on HRUS

Disease Joint involvement Key features on HRUS
Degenerative
Osteoarthritis (OA)

Knee

Hand (1st CMC, DIP, PIP)

Hip

Cartilage thinning and irregularity

Intrasubstance echogenicity in cartilage

Marginal Osteophytes

Joint space narrowing

Effusion

Synovitis

Medial meniscal extrusion
Inflammatory
Rheumatoid arthritis (RA)

MCP

PIP

Wrist

MTP

Synovitis

Effusion

Erosions

Tenosynovitis

Bursitis

Enthesitis

Tendinitis

Rheumatoid nodules
Juvenile idiopathic arthritis

Knee

Ankle

Hand

Elbow

Hip

Synovitis

Tenosynovitis

Cartilage loss

Enthesitis

Bursitis

Tendinitis
Lupus arthritis

MCP

PIP

Wrist

Synovitis

Tenosynovitis
Spondyloarthropathies (SpA)

Hand

Knees

Wrist

Enthesitis

Synovitis

Tenosynovitis

Bursitis

Paratenonitis

Dactylitis
Polymyalgia rheumatica (PMR)

Shoulder

Hip

Bursitis

Effusion
Crystal deposition diseases
Gout

1st MTP

Tarsal

Ankle

Knee

Double contour sign

Tophi

Erosions

Synovitis

Effusion
Pseudogout

Knee

Wrist

Ankle

Intracartilaginous echogenic crystal deposits

Synovitis

Effusion

Enthesitis

EULAR-OMERACT combined scoring system for grading synovitis in rheumatoid arthritis

Grade 0 Normal joint No GS-detected SH and no PD signal (within the synovium)
Grade 1 Minimal Synovitis Grade 1 SH and ≤ Grade 1 PD signal
Grade 2 Moderate Synovitis Grade 2 SH and ≤ Grade 2 PD signal or Grade 1 SH and Grade 2 PD signal
Grade 3 Severe Synovitis Grade 3 SH and ≤ Grade 3 PD signal or Grade 1 or 2 SH and Grade 3 PD signal
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