doi:10.1136/ard.60.7.641 2001;60;641-649 Ann Rheum Dis

  Wakefield and B Manger M Backhaus, G-R Burmester, T Gerber, W Grassi, K P Machold, W A Swen, R J 

rheumatologyGuidelines for musculoskeletal ultrasound in

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REVIEW

Guidelines for musculoskeletal ultrasound inrheumatology

M Backhaus, G-R Burmester, T Gerber, W Grassi, K P Machold, W A Swen,R J Wakefield, B Manger*

1. IntroductionWithin the past decade, musculoskeletal ultra-sound (US) has become an established imag-ing technique for the diagnosis and follow up ofpatients with rheumatic diseases.1–5 This hasbeen made possible through technologicalimprovements, resulting in faster computersand higher frequency transducers. US is mostcommonly used in the assessment of soft tissuedisease or detection of fluid collection and canalso be used to visualise other structures, suchas cartilage and bone surfaces.6 7 Owing to thebetter axial and lateral resolution of US, evenminute bone surface abnormalities may bedepicted. Thus destructive and/or reparative/hypertrophic changes on the bone surface maybe seen before they are apparent on plain x raysor even magnetic resonance imaging.8 How-ever, US wave frequencies cannot penetrateinto bone, therefore imaging of intra-articulardisease is usually not possible. The “real time”capability of US allows dynamic assessment ofjoint and tendon movements, which can oftenaid the detection of structural abnormalities.Advantages of US include its non-invasiveness,portability, relative inexpensiveness, lack ofionising radiation, and its ability to be repeatedas often as necessary, making it particularlyuseful for the monitoring of treatment. US canalso be used for guidance of aspiration, biopsy,and injection treatment.9 Most musculoskeletalwork is performed using “grey scale”, whichmeans images are produced in a black andwhite format; each white dot in the image rep-resents a reflected sound wave. Sound wavestravel in a similar way to light waves and there-fore the denser a material is—for example,bone cortex, the more reflective it is and thewhiter it appears on the screen. Water is theleast reflective body material and thereforeappears as black as the sound waves travelstraight through it.

Newer US techniques, which are currentlybeing evaluated, include colour and powerDoppler imaging, which provide colour mapsof tissues. Here the amount of colour is relatedto the degree of blood flow, which may be ofuse in assessment of vascular tissues as mayoccur in soft tissue inflammation.10 To increasefurther the sensitivity of power Dopplerintravenous bubble contrast agents are underdevelopment.

There are few data about which imagingmodality is most appropriate in any given situ-ation. Only rarely have the diagnostic values ofdiVerent imaging techniques in various condi-tions been compared.11–13 As US is evolving, itsplace in patient management is becomingincreasingly clear.

2. Technical equipmentHigh quality, high resolution equipment isessential for musculoskeletal work. The choiceof transducer will depend on the type ofexaminations likely to be undertaken. Highfrequency (7.5–20 MHz), linear transducersare generally best for demonstrating superficialstructures such as tendons, ligaments, andsmall joints, whereas low frequency transduc-ers (3.5–5 MHz) are sometimes more suitedfor larger or deeper sited joints such as theshoulder or hip.4 14 In US there is a constantcompromise between image resolution anddepth of penetration of the sound waves.Higher frequency transducers provide betterspatial resolution, but these transducers have ashallower depth of penetrance than a lower fre-quency transducer. The size of the footprint(the surface area of the transducer in contactwith the skin) is also an important factor inexamination technique. For example, transduc-ers with a large footprint are often inadequateto visualise fully small joints such as the meta-carpophalangeal joints as they cannot bemanoeuvred adequately. However, these areonly general considerations; the critical issue isthe overall image resolution, which has to beanalysed and compared carefully before a pur-chase is made. For practical reasons it isrecommended to test whether with a particularpiece of sonographic equipment the finedefinition of small structures can be seen, suchas the insertion of a small extensor tendon ofthe finger or the tiny quantity of fluid normallydetectable in the pre-Achilles bursa.

The practical value of colour Doppler/powerDoppler capabilities is still under investigation,especially considering the additional cost. Therationale for colour/power Doppler is thedetection of increased soft tissue perfusion.The potential application of three dimensionalUS is also currently under evaluation. Finally,consideration needs to be given to methods of

Ann Rheum Dis 2001;60:641–649 641

Department ofRheumatology andClinical Immunology,Charité UniversityHospital, HumboldtUniversity, Berlin,GermanyM BackhausG-R Burmester

Department ofRheumatology andPhysical Medicine,University Hospital,Zurich, SwitzerlandT Gerber

Department ofRheumatology,University of Ancona,Jesi, ItalyW Grassi

Division ofRheumatology,Department ofInternal Medicine III,University of Vienna,AustriaK P Machold

Department ofRheumatology,Medisch CentrumAlkmaar, TheNetherlandsW A Swen

Department ofRheumatology,University of Leeds,United KingdomR J Wakefield

Department ofInternal Medicine III,Institute for ClinicalImmunology andRheumatology,University Erlangen,GermanyB Manger

Correspondence to:Dr B Manger, Departmentof Internal Medicine III,University ErlangenKrankenhausstr 12, D-91054Erlangen, Germany

Accepted 19 March 2001

*The Working Group forMusculoskeletal Ultrasoundin the EULAR StandingCommittee on InternationalClinical Studies includingTherapeutic Trials

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image documentation. In general, every exami-nation should be carefully documented. Im-ages may be recorded on paper, films, videocassettes, laser printed ‘x ray’ acetates, opticaldiscs, and digital storage systems. All demon-strated structures should be documented in astandardised way to ensure a better reproduc-ibility of these results. Pathological findingsshould be documented in two perpendicularplanes. Table 1 gives the transducer orienta-tion.

3. Teaching and trainingAs US is the most operator dependent imagingmodality, the experience and expertise of theexaminer will determine the value of the diag-nostic information obtained. Knowledge aboutthe basic principles relevant to sound wavesand a detailed knowledge of anatomy ismandatory. Although the procedure itself hasno specific side eVects, harm may result fromincorrect acquisition and interpretation ofimages owing to operator inexperience. Tostandardise the quality of musculoskeletal USeducation, national and internationalsocieties—for example, EULAR, have estab-lished training guidelines for US. Trainingcourses have been organised by experts in USproviding “hands on” experience. However,musculoskeletal US cannot be learnt at a con-ference over a few days. There is no substitutefor proper training under the guidance of anexperienced investigator. Continuous trainingand education of people performing US isessential. Beginners are therefore encouragedto seek local expertise, where it is available, andthe authors of this article are glad to be of helpin establishing such contacts in their respectivecountries.

US is most valuable in a clinical setting, inwhich the clinician can interpret the images inthe light of the clinical history and physicalexamination, enabling ultrasound to becomethe physician’s extended finger.4 15 However, insome instances, especially for a scientific analy-sis of the relative values of various imagingmodalities, a second view point of an experi-enced sonographer is necessary to balance thepossibility of “seeing” what one expects to seealready from a clinical examination.

4. Standardisation of musculoskeletal USIn the following paragraphs a list of detectablediseases, patient positioning, and standardscans are given. Representative images are pro-vided for a selection of scans. An extensive ver-sion with a complete collection of all images ofstandard scans given can be seen on the inter-net at the oYcial EULAR web site (www.eu-lar.org). A link at the bottom of the right side ofthe screen leads to “Imaging in Rheumatology”(www.sameint.it/eular) and from there to the“Working Group for Musculoskeletal Ultra-sound in Rheumatology”.

4.1. SHOULDER JOINTThe polyarticular manifestation of rheumaticdiseases frequently leads to symptoms earlier inweightbearing joints of the leg. Arthritic jointsof the arm may exhibit relatively few symptomsdespite marked inflammation. An early detec-tion of changes of tendons, bursae, rotator cuV,and cartilage is possible by musculoskeletalUS, which is essential to establish adequatetreatment. To detect inflammatory lesions theanterior, lateral, and posterior, longitudinaland transverse scans with rotation of the shoul-der are most helpful. A sensitive technique forfinding even very small shoulder eVusions isthe axillary longitudinal scan, but elevation ofthe arm may not be possible for patients withadvanced disease.

4.1.1. US detectable pathology1 Rotator cuV:

• Tear (complete/ partial)• Calcific tendinitis

2 Biceps tendon:• Tear (complete/partial)• Dislocation• Tenosynovitis• EVusion in the bicipital groove

3 Subcoracoid/subacromial/subdeltoid bursa:• Bursitis

4. Axillary recessus:• Synovial proliferation• EVusion

5 Humeral head:• Irregular contour• Bone and cartilage lesions (erosions, osteo-

phytes, Hill-Sachs lesion)6 Joint space:

• Loose joint bodies• Osteochondromatosis

7 Acromioclavicular joint:• Dislocation• Synovial proliferation/eVusion• Irregular bone profile

8 Deltoid muscle• Haematoma• Tear

4.1.2. Positioning of the patient• Sitting position• 90° flexion of the elbow joint• The hand should be positioned in supination

on top of the patient’s thigh• For a dynamic examination, active and/or

passive external and internal rotation of thehumerus over the full range of motion with90° flexed elbow is recommended

4.1.3. Standard scans1 Anterior transverse scan in neutral position

(fig 1)2 Anterior transverse scan in maximal internal

rotation (fig 2)3 Anterior longitudinal scan4 Anterior longitudinal scan in maximal inter-

nal rotation5 Lateral longitudinal scan in neutral position6 Lateral longitudinal scan in maximal internal

rotation7 Posterior transverse scan8 Axillary longitudinal scan with raised arm9 Acromioclavicular joint scan

Table 1 Transducer orientation in standardised musculoskeletal examination

Longitudinal scan Transverse scan

Left side of the screen Proximal, cranial, upper Medial, ulnar, tibialRight side of the screen Distal, caudal, lower Lateral, radial, fibular

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4.2. ELBOW JOINTInflammatory lesions in the elbow can most eas-ily be detected early in the disease process inventral longitudinal scans over the humero-radial and humeroulnar joints. Another com-mon location of synovitis is the olecranon fossa.

4.2.1. US detectable pathology1 Humeroradial joint:

• Synovial proliferation• EVusion• Bony lesion• Loose joint body

2 Humeroulnar joint:• Synovial proliferation• EVusion• Bony lesion• Loose joint body

3 Olecranon fossa:• Synovial proliferation• EVusion

4 Olecranon bursa:• Bursitis

5 Lateral/medial humeral epicondylus:• Epicondylitis (lateral and medial)

6 Ulnar nerve:• Compression• Morphostructural changes

7 Subcutaneous tissue:• Rheumatoid nodule• Tophi

4.2.2. Positioning of the patient• Sitting position• Full extension of the elbow joint and supina-

tion of the lower arm (ventral scans)• Flexion of the elbow joint in a 90° angle

(dorsal scans)• For the dorsal scans the hand can be placed

on the hip or on the thigh of the patient withmoderate internal rotation of the humerus

4.2.3. Standard scans1 Anterior humeroradial longitudinal scan

(fig 3)2 Anterior humeroulnar longitudinal scan3 Anterior transverse scan (fig 4)4 Posterior longitudinal scan5 Posterior transverse scan (fig 5)6 Lateral longitudinal scan in extension7 Lateral longitudinal scan in 90° flexion8 Medial longitudinal scan

4.3. WRISTIn many instances clinical examination of thewrist may be suYcient. With high frequencytransducers of 10 MHz and more, even minorsynovitic lesions can be detected. US can alsobe helpful in diVerentiating synovial and teno-synovial pathology and examining morpho-structural changes of the median nerve in car-pal tunnel syndrome.

Figure 1 Anterior transverse scan in neutral position at the bicipital groove. h = humerus; t = biceps tendon; d = deltoidmuscle.

Figure 2 Anterior transverse scan in maximal internal rotation ofthe shoulder. h = humerus; t = supraspinatus tendon; d = deltoidmuscle.

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4.3.1. US detectable pathology1 Carpal tunnel:

• Tenosynovitis• Morphostructural changes of median nerve• Ganglion

2 Extensor tendons:• Tenosynovitis• Alterations of extensor tendons• Rheumatoid nodules• Ganglion

3 Radio-ulno-carpal joint:• Synovial proliferation• EVusion• Ganglion• Lesions of triangular fibrocartilage complex• Calcification• Bony lesions (erosions, osteophytes)

4.3.2. Positioning of the patient• Sitting position

• Positioning of the hand on top of the thigh oron an examining table

• Dynamic examination with active flexion/extension of the fingers

4.3.3. Standard scans1 Volar transverse scan (fig 6)2 Volar longitudinal scan3 Dorsal transverse scan (radial)4 Dorsal transverse scan (ulnar)5 Dorsal longitudinal scan (radial)6 Dorsal longitudinal scan (median)7 Dorsal longitudinal scan (ulnar)

4.4. HANDFinger joints are easily accessible to clinicalexamination. With high frequency transducersof 10 MHz and more, even minor synoviticlesions can be detected. US can also be helpful

Figure 3 Anterior humeroradial longitudinal scan at theelbow. h = humerus; r = radius; m = muscles; ° =articular cartilage

Figure 4 Anterior transverse scan at the distal humeralepiphysis. h = humerus; ° = articular cartilage; m =muscles.

Figure 5 Posterior transverse scan at the distalhumeral epiphysis. h = humerus; ° = articularcartilage; m = triceps muscle.

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in diVerentiating synovial and tenosynovialpathology.

4.4.1. US detectable pathology1 EVusion/synovial proliferation2 Synovial cysts3 Tendinitis/tenosynovitis/tendon tear4 Cartilage thinning/lesion5 Bony lesion (erosion, change of the bone

profile, osteophyte)6 Articular dislocation7 Ganglion8 Periarticular lesions: rheumatoid nodules,

crystal deposition, calcinosis

4.4.2. Positioning of the patient• See wrist joint (4.3.2.)

4.4.3. Standard scans1 Dorsal longitudinal scan2 Dorsal transverse scan (fig 7)

3 Palmar longitudinal scan (figs 8 and 9)4 Palmar transverse scan (fig 10)5 Thenar longitudinal scan6 Thenar transverse scan7 Hypothenar longitudinal scan8 Hypothenar transverse scan9 Lateral longitudinal scan (proximal inter-

phalangeal (PIP) and metacarpophalangealI, II, V joints)

10 Medial longitudinal scan (PIP joints)

4.5. HIPOnly rarely can eVusions of the hip joint bedetected by clinical examination. Here US ismost helpful to detect eVusion and synovitisespecially before arthrocentesis. The anteriorlongitudinal scan parallel to the femoral neck ismost valuable for the detection of an eVusionas well as erosions or osteophytes. The anteriortransverse scan after 90° rotation is necessary

Figure 6 Volar transverse scan at the carpal tunnel. r = radius; n = median nerve; t = flexor tendons.

Figure 7 Dorsal transverse scan at the metacarpal head.mh = metacarpal head; t = extensor tendon.

Figure 8 Palmar longitudinal scan at the metacarpophalangeal joint. * = joint cavity; ° = articular cartilage; pp =proximal phalanx; mh = metacarpal head; t = flexor tendon.

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before arthrocentesis to define the optimallocation and identify vessels which should beavoided. The lateral longitudinal scan is helpfulto detect a trochanteric bursitis.

4.5.1. US detectable pathology1 Joint eVusion/synovial proliferation2 Cartilage lesion3 Bony lesion (erosion, osteophyte, irregular

bone surface, slipped capital femoral epiphy-sis)

4 (Osteo-)chondromatosis5 Loose joint body6 Bursa trochanteric/iliopectineal bursitis7 Infection or loosening of prosthesis8 Calcifications

4.5.2. Positioning of the patient• Supine position• Hip joint in neutral position

4.5.3. Standard scans1 Anterior longitudinal scan (fig 11)2 Anterior transverse scan3 Lateral longitudinal scan

4.6. KNEEIn contrast with the hip, the knee joint is easilyaccessible to clinical examination. However,very small eVusions or synovitic proliferationswhich are missed clinically can often bedemonstrated by US. Small amounts ofeVusion can be detected in the suprapatellar

Figure 9 Palmar longitudinal scan at the distal interphalangeal joint. * = joint cavity; dp = proximal phalanx; mp =middle phalanx; t = flexor tendon.

Figure 10 Palmar transverse scan at the metacarpalhead. mh = metacarpal head; ° = articular cartilage; t =flexor tendon.

Figure 11 Anterior longitudinal scan atthe hip. a = acetabulum; f = femur; * =joint cavity; m = muscles.

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longitudinal and transverse scans in neutralposition when pressure is exerted on the supra-patellar and parapatellar pouch by tightening ofthe quadriceps muscle.

An important indication for musculoskeletalUS is the examination of pathological proc-esses of the popliteal region. Popliteal cysts(Baker’s cysts) are fluid accumulation in thebursa of the gastrocnemius or semimembrano-sus muscles. Frequently those cysts communi-cate with the joint space. To confirm the diag-nosis of a popliteal cyst this comma shapedextension has to be visualised sonographicallyin the posterior transverse scan between themedial head of gastrocnemius and semimem-branosus tendon. Popliteal cysts can extend farinto thigh and calf muscles and US allows pre-cise definition of their shape and size. Arupture of a popliteal cyst, which may clinicallymimic a deep vein thrombosis, is easily identi-fied by US.

Loose joint bodies in the knee can bedetected sonographically in the suprapatellarpouch and in the infrapatellar and poplitealregions. However, the failure to detect a loosebody in the knee or any other joint can neverrule out its presence.

4.6.1. US detectable pathology1 Suprapatellar and parapatellar pouch:

• Synovial proliferation• Synovial folds• EVusion

2 Quadriceps tendon:• Tear (partial or complete)

3 Femoropatellar joint:• Irregular contours• Bony lesions (erosions, osteophytes)

4 Popliteal sulcus:• Bursitis• Synovial proliferation

5 Patellar ligament:• Tear (partial/complete)

6 Deep infrapatellar bursa:• Bursitis

7 Subcutaneous prepatellar bursa:• Bursitis

8 Tuberosity of tibia:• Irregular bony contour (Mb. Osgood-

Schlatter)• Infrapatellar bursitis

9 Ligaments:• Tear/lesion

10 Meniscus (lateral/medial):• Lesion• Cyst

11 Popliteal fossa:

• Popliteal cyst (volume, echogenicity signsof leakage)

• Compression of vessels

4.6.2. Positioning of the patient• Supine position for ventral and lateral scans• Prone position for dorsal scans• Knee joint in neutral position and/or 30°

flexion• Maximal flexion for imaging of the inter-

condylar sulcus• Dynamic examination of the suprapatellar

pouch with relaxed and contracted quadri-ceps muscle

4.6.3. Standard scans1 Suprapatellar longitudinal scan2 Suprapatellar transverse scan in neutral

position3 Suprapatellar transverse scan in maximal

flexion (fig 12)4 Infrapatellar longitudinal scan5 Infrapatellar transverse scan6 Medial longitudinal scan7 Lateral longitudinal scan8 Posterior medial longitudinal scan9 Posterior lateral longitudinal scan

10 Posterior transverse scan

4.7. ANKLE AND HEELInflammatory changes of the ankle and talocal-caneonavicular joints are easily detectable byUS, as are tenosynovitis of tibialis anterior,posterior, and peroneus tendons.

The Achilles tendon can by examined by USin its full length, and calcifications, ruptures,and bursitis can be diVerentiated. In patientswith heel pain, lesions of the plantar fascia, cal-caneus spurs, and erosions can be detectedsonographically.

4.7.1. US detectable pathology1 Ankle and talocalcaneonavicular joint:

• Synovial proliferation• EVusion• Cartilage lesions• Bony lesions• Loose joint body• (Osteo-)chondromatosis

2 Tibial anterior muscle:• Tenosynovitis/tear

3 Tibial posterior muscle:• Tenosynovitis/tear

4 Peroneus long./brev. muscles:• Tenosynovitis/tear

5 Achilles tendon:• Calcification

Figure 12 Suprapatellar transverse scan in maximal flexion. f = femur; ° = articular cartilage.

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• Tear (partial/complete)• Tendinitis/paratendinitis• Nodules (tophy, rheumatoid nodules, xan-

thomas)• Bursitis (retrocalcaneal or superficial)

6 Calcaneus:• Calcification of plantar fascia• Ossification (calcanaeus spur)• Bony lesions (erosion)

4.7.2. Positioning of the patient• Supine position for ventral and lateral scans• Prone position for dorsal scan• Hip and knee joints in neutral position

4.7.3. Standard scans1 Anterior longitudinal scan (fig 13)2 Anterior transverse scan3 Perimalleolar medial longitudinal scan4 Perimalleolar medial transverse scan5 Perimalleolar lateral longitudinal scan6 Perimalleolar lateral transverse scan7 Posterior longitudinal scan (fig 14)8 Posterior transverse scan

4.8. FOOTToes are easily accessible to clinical examina-tion. With high frequency transducers of 10MHz and more, even minor synovitic lesions

can be detected. US can also be helpful in dif-ferentiating synovial and tenosynovial disease.Lesions of tophaceous gout can be identified byUS because of their typical sound shadow.

4.8.1. US detectable pathology1 Plantar fascia:

• Plantar fasciitis2 Joints:

• EVusion/synovial proliferation• Cartilage lesions• Bone lesions (erosions, osteophytes)

3 Tendons:• Tenosynovitis/tear

4 Subcutaneous tissue:• Gout tophi

4.8.2. Positioning of the patient• Supine position for the dorsal scans• Prone position for plantar scans

4.8.3. Standard scansAll scans performed moving from proximal todistal.1 Plantar longitudinal scan2 Plantar transverse scan3 Dorsal longitudinal scan (fig 15)4 Dorsal transverse scan5 Lateral scan (first and fifth toe)

Figure 13 Anterior longitudinal scan at theankle. tib = tibia; tal = talus; ° = articularcartilage.

Figure 14 Posterior longitudinal scan at the heel. t = achilles tendon; cal = calcaneus; k = Kager’s fat pat.

Figure 15 Dorsal longitudinal scan at the first toe. mh = metatarsal head; ; pp = proximal phalanx; t = extensor tendon;* = joint cavity; ° = articular cartilage.

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