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Dr Heidi Siddle PhD
FCPM, FFPM RCPS (Glasg)
NIHR Clinical Lecturer
Principal Podiatrist
Leeds Teaching Hospitals NHS Trust
Associate Professor, University of Leeds
Ultrasound imaging to support rheumatology
clinical practice and research
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Imaging in RA
The role of imaging in RA has been firmly
established.
A diagnostic and prognostic tool in clinical
practice and research.
It is particularly important and useful in predicting
the long-term outcome of patients in the early
stages of disease.
Optimally manage the patient’s disease at a time
point where potentially damage is preventable.
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Conventional Radiography versus Ultrasound and MRI
Radiographic images do not identify changes
synonymous with RA e.g. bone erosions until
after irreversible joint damage has occurred.
More sensitive techniques such as ultrasound
imaging and MRI are able to detect synovitis,
effusions and erosions much earlier than CR.
The use of ultrasound has raised questions about
the definition of true remission.
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Ultrasound Imaging
Musculoskeletal ultrasound has evolved into an
important method for:
identifying musculoskeletal abnormalities,
confirming the diagnosis in patients with
suspected inflammatory arthritis,
monitoring therapeutic response,
influencing clinical decision making and
guiding interventions.
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Ultrasound Imaging
Ultrasound techniques can be used to detect the
level of inflammation in the joints and soft tissues
of patients with RA, more sensitive than clinical
examination.
B-mode (grey scale) ultrasound used to detect
thickened synovial membranes in inflamed joints,
bursae and tendon sheaths, and bone erosions.
(Power) Doppler signal to detect increased
synovial blood flow due to inflammation.
Outcome Measure in Rheumatology (OMERACT)
definitions
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Synovitis is abnormal hypoechoic intraarticular tissue that is non displaceable and poorly compressible which may exhibit Doppler signal (Wakefield et al 2005)
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Outcome Measures in Rheumatology Clinical Trials (OMERACT)
Tenosynovitis is hypoechoic or anechoic
thickened tissue with or without fluid within the
tendon sheath, which is seen in two perpendicular
planes and which may exhibit Doppler signal (Wakefield et al 2005)
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Tenosynovitis
SEVERE ECRB TENOSYNOVITIS
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Tenosynovitis (cross-section)
THICKENED SHEATH WITH INFLAMMATION
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EROSION – NO ACTIVE INFLAMMATION EROSION WITH ACTIVE INFLAMMATION
Bone erosion is an intra-articular
discontinuity of the bone surface that is
visible in two perpendicular
planes (Wakefield et al 2005)
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Erosions
Early small erosions are difficult to see with x-ray
because of their typical ‘en face’ anatomical site
Ultrasound is a reliable technique for
– detecting bone erosions in RA
– especially in early disease
– detects more erosions than conventional
radiography
(Wakefield et al 2000, Backhaus et al 2002,
Lopez-Ben et al 2004, Szkudlarek et al 2004)
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Erosions
However…
Dependent upon good technique and perpendicular
positioning of the transducer.
– Forefoot acoustic access is only possible from the
dorsal and plantar aspects
– incomplete coverage of the medial and lateral aspects
of the joint
– erosions may be missed.
Clearly depicts contour defects in the surface of the bone
Less reliable than 3D MRI in demonstrating deeper
erosions with a narrow connection to the joint surface (Backhaus et al 2002)
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Assessment of disease activity and response to treatment
Power Doppler signal predictive value in:
– Diagnosis of very early RA
– Determining disease activity and relapse
– Radiographic damage
– Progression in patients with early disease
– Patients with RA whose disease is in remission
(Szkudlarek et al 2001, Naredo et al 2007, Freeston et al
2010, Dougados et al 2012, Foltz et al 2012)
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Clinical Remission versus Ultrasound Remission
Use of ultrasound has raised questions about the
definition of true remission.
Ultrasound detected synovitis has been reported in the
joints of those patients on DMARDs and anti-TNF
medication who are considered to be in clinical remission
according to remission criteria such as ACR and DAS28
(Brown et al 2006, Wakefield et al 2007)
In early RA, US-driven T2T strategy led to more intensive
treatment, but was not associated with significantly better
clinical or imaging outcomes than a DAS28-driven
strategy (Dale et al 2016)
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Global ultrasound score
Potential to objectively reflect the “real” level of
synovitis (disease activity) compared with
conventional clinical measures.
12-joint score (Naredo et al 2008)
7-joint score (Backhaus et al 2009)
Systematic literature review by the OMERACT
Ultrasound Task Force (Mandl et al 2011)
– difficult to determine a minimal number of joints
to be included in a global ultrasound score and
further validation is required
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Assessment of the foot
Deformity, overlying structures and oedema pose
potential problems when undertaking clinical
examination of the foot
Ultrasound examination has be shown to be more
sensitive than clinical examination for detecting
synovitis, tenosynovitis and bursae in the foot of
patients with RA (Luukkainen et al 2003, Wakefield et al 2003, Ostergaard et al 2005a,
Ostergaard et al 2005b, Wakefield et al 2008, Bowen et al 2010, Riente et al
2011Scire et al 2011)
Development of OMERACT Foot and ankle
Ultrasound Scoring System in RA (FUSS-RA)
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R AT
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Osteoarthritis of midfoot
OA of the midfoot has previously been reported
as being relatively uncommon (prevalence of
3.8%) (Van Saase et al 1989, Wilder et al 2005)
Medial midfoot OA is more prevalent than
previously described (Menz et al. 2007, Roddy et al 2015)
Patients indicate pain to the dorsal midfoot area
with radiographic confirmed OA (Halstead et al. 2015)
– Cuneiform-second metatarsal joint (73 %)
– Navicular-medial cuneiform joint (51 %)
– Cuneiform-first metatarsal joint (46 %)
– Talonavicular joint (24 %)
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Inflammatory disease of midfoot in RA
Midfoot pain reported by 17% of patients with RA
during the course of their disease (Otter et al 2010)
Midfoot synovitis detected on ultrasound 27-55% of
patients (Suzuki et al 2009, Suzuki & Okomoto 2013, Chan et al 2014)
Ultrasound better at detecting midfoot synovitis than
clinical examination (Wakefield et al 2008, Chan et al 2014
DAS28 positively associated with ultrasound
synovitis in the midfoot joints (Sant’ Ana Petetterle et al 2013)
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What does ultrasound offer?
To differentiate between inflammatory and
mechanical disease will enable the clinician to
direct their treatment strategies more
appropriately.
To differentiate between joints that require
treatment with:
– mechanical interventions such as orthoses and
footwear
– local or systemic treatment of inflammatory
disease: ultrasound guided injection,
IM injection or review of disease activity.
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Talo-navicular Joint and Navicular-cuneiform Joint
TAL NAV Medial
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Tarsometatarsal Joint
Cuneiform Metatarsal
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Calcaneo-cuboid Joint
CAL CUB
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5th Tarsometatarsal Joint
Cuboid
Base 5th Met
PB
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Case study
Female, age 56
Diagnosis osteoarthritis
Persistent dorsal midfoot pain
Clinically - bony changes evident
Minimal improvement with footwear modifications
and orthoses provision
Referred for ultrasound +/- injection
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Navicular – Medial Cuneiform Joint
NAV
CUN
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Foot and Ankle corticosteroid injections in RA & SpA D’Agostino et al 2005
Clinician abandoned the planned injections
– Tibiotalar joint (18.6%)
– Tarsometatarsal joints (16.0%)
– Retrocalcaneal bursa (33.3%).
US results in unplanned injections
– Navicular-cuneiform joints (58.3%)
– Calcaneo-cuboid joint (35.8%)
– Subtalar (34.5%) joints
– Tibialis posterior tendon (33.3%).
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Training requirements and qualifications
There is no legal requirement to hold a
recognised ultrasound qualification in order to
practice as a sonographer in the UK
Sonography is not recognised as a profession by
the Health and Care Professions Council (HCPC)
The European Federation of Societies for
Ultrasound in Medicine and Biology (EFSUMB)
Minimum Training Requirements for
Rheumatologists Performing Musculoskeletal
Ultrasound (The rheumatology-COMPASS)
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Training requirements and qualifications
Currently all formal training in the UK for Ultrasound is at
a post graduate level.
CASE (The Consortium for the Accreditation of
Sonographic Education) is a recognised body in the UK
which accredits Ultrasound Courses in UK Universities.
EULAR: Defining the education and training needs of
Health Professionals undertaking Musculoskeletal
Ultrasound for Inflammatory arthritis and osteoarthritis
CoP Ultrasound in Podiatry SAG - Survey
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Acknowledgements
Dr Richard Wakefield
Laura Horton – Sonographer
NIHR
OMERACT FUSS-RA Ultrasound Group
Ultrasound in Podiatry Specialist Advisory Group
Network