- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
In the last decade, the compelling need of an early diagnosis and careful management of rheumatic diseases has significantly increased the demand of consultations. In particular, regional pain and impaired function are very frequent symptoms influencing patients' quality of life. Today, the physician's role is to rapidly reach an accurate diagnosis and to choose and tailor the best short- and long-term therapeutic strategy for each patient. Therefore, to reduce the cost of patient management and optimize health resources, it is advisable, if possible, to reach the diagnosis and the therapeutic decision in the first medical visit.
The methodologic algorithm includes the clinical and instrumental examination of the symptomatic region. However, the involvement of multiple structures such as joints and periarticular soft tissues (i.e., tendons, bursae, ligaments, and neurovascular bundles) sometimes may hamper the achievement of an accurate clinical diagnosis. Moreover, inflammatory and/or degenerative rheumatic lesions may coexist in the same anatomic structure, and the diagnosis may be even more challenging (1).
Several imaging techniques are currently available for musculoskeletal pathology evaluation, such as conventional radiography, magnetic resonance imaging (MRI), arthroscopy, fluoroscopy, and scintigraphy, with well-known advantages and disadvantages (1). Over the last decades, musculoskeletal ultrasound (MSUS) has become a very useful bedside diagnostic tool in rheumatologic practice because it can be performed easily during consultation and it is cheap, noninvasive, and well accepted by the patients (2). Indeed, MSUS is an objective, detailed, and reliable method for achieving information about multiple structures and types of lesions responsible for regional pain syndromes (3–10). In this way, a more accurate diagnosis can be followed by a rapid therapeutic decision (e.g., conservative or surgical, systemic, and/or local guided injections).
To the best of our knowledge, data on the impact of MSUS in rheumatologic practice have rarely been published (11, 12). The aim of this study was to evaluate the impact of MSUS as a complementary method to clinical assessment on rapid diagnosis and therapeutic decisions in a busy outpatient rheumatology clinic.
Significance & Innovations
Musculoskeletal ultrasound (MSUS) facilitates a quick and accurate diagnosis immediately after clinical examination in the same consultation room.
MSUS spares time for the patient and the doctor as well as prolonged pain for the patient; a supplementary second visit is avoided.
Enhanced information obtained by MSUS evaluation leads to changes, with a significant impact on the initial diagnosis and treatment strategy designed after clinical examination.
- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
Clinical examination was performed in 60 patients (33 women [55%] and 27 men [45%], mean ± SD age 50 ± 17 years [range 44–56 years; 95% CI 42–68%] for women and 57 ± 16 years [range 51–63 years; 95% CI 32–58%] for men, with normal distribution of age inside the group [Kolmogorov-Smirnov P = 0.7563]). Sixty-seven painful anatomic areas were investigated, including 24 shoulders, 5 elbows, 16 hands, 5 hips, 10 knees, 6 ankles and feet, and 1 muscular region, as well as these areas on the contralateral side.
Of 67 painful areas in 60 patients, MSUS was considered necessary after clinical examination for 43 areas (64.17%) in 39 patients (65%) and advisable for 22 areas (32.83%) in 19 patients (31.66%). MSUS was considered not necessary in 2 patients (3.33%), totaling 2 areas (2.98%; 1 hand and 1 knee) by the rheumatologist with no MSUS experience. The other 2 rheumatologists requested MSUS evaluation in all patients after clinical examination.
Table 1 shows the analysis of the data on each anatomic region, the indication of performing MSUS after clinical examination, the change in the initial diagnosis, and the percentage in which a more objective and detailed diagnosis was obtained, as well as the changes in the systemic and local treatment strategy and indications for guided diagnostic and therapeutic procedures.
Table 1. Analysis of the data, overall and on each anatomic area*
|Question||Overall||Shoulder||Elbow||Hand||Hip||Knee||Ankle and foot||Muscle|
|Is MSUS necessary?||64.17||66.7||80||68.8||80||40||67||100|
|Is MSUS advisable?||32.83||33.3||20||24.9||20||50||33||0|
|Is MSUS not needed?||2.98||0||0||6.3||0||10||0||0|
|Did MSUS change the clinical diagnosis?||60 (46–72)†||71||80||53||40||64||50||0|
|Did MSUS provide a more objective and detailed diagnosis?||100||100||100||100||100||100||100||100|
|Did MSUS change the systemic therapy?||25 (15–37)‡||21||0||40||20||33.4||33.3||0|
|Did MSUS change the local therapy?||36 (24–48)§||50||40||13.4||0||66.7||33.3||0|
|Was MSUS used for guided diagnostic injections?||15 (7.5–25.4)¶||13||0||7||0||36||33||0|
|Was MSUS used for guided therapeutic injections?||22 (13.5–34.3)¶||21||40||13||0||45||17||0|
MSUS evaluation after clinical examination led to an overall change of the initial clinical diagnosis in 60% of the anatomic areas (95% CI 46–72%), and showed statistical significance when compared to the percentage of the diagnoses not changed by MSUS assessment (Z = 2.108, P = 0.0175) (Figure 1). In all cases (100%), the new diagnosis was more objective and detailed.
Figure 1. Changes in clinical diagnosis after musculoskeletal ultrasound evaluation, expressed as a percentage on the y-axis. On the x-axis, 1 = shoulder area, 2 = elbow area, 3 = hand area, 4 = hip area, 5 = knee area, 6 = ankle/foot area, 7 = muscle area, and 8 = overall.
Download figure to PowerPoint
In the shoulder, the most frequent clinical diagnosis was an unspecific lesion in the rotator cuff, whereas on MSUS we were able to detect inflammatory and structural damage lesions involving specific tendons (i.e., 1 case of long head biceps tendon tenosynovitis; 11 cases of tendinosis, including 6 of the supraspinatus tendon, 2 of the subscapularis tendon, and 3 of the biceps tendon; 7 cases of full-thickness tears, including 5 of the supraspinatus tendon and 2 of the subscapularis tendon; and 5 cases of partial-thickness tears, including 1 of the supraspinatus tendon, 2 of the subscapularis tendon, and 2 of the infraspinatus tendon), bursae (i.e., 8 cases of subdeltoid bursitis), or joints (i.e., 7 cases of acromioclavicular joint osteoarthritis [OA] and 12 cases of glenohumeral joint OA). Impingement syndrome was clinically diagnosed in 16 cases. The presence of impingement syndrome was certified in 20 cases (versus 1 case not confirmed) while performing dynamic MSUS evaluation maneuvers, including 15 due to supraspinatus tendon acromial encroachment and 5 due to subscapularis tendon subcoracoid encroachment.
The clinical diagnosis suspicion for the 5 painful elbow areas was chronic epicondylitis, whereas MSUS evaluation was able to detect the underlying lesions responsible for the patient's symptoms. We found in all cases enthesopathy of the common extensor tendon, 3 cases with additional partial tears inside the enthesis, and 2 cases with calcific deposits inside the tendon.
After the evaluation of the hands area, clinical suspicion comprised 5 cases of carpal tunnel syndrome, 2 cases of OA, 3 cases of nonspecific arthralgia, 1 case of metacarpophalangeal (MCP) joint oligoarthritis, and 2 cases of isolated finger tendon involvement. Rheumatoid arthritis (RA) onset was suspected in only 3 cases after clinical examination.
Instead, MSUS evaluation (comprising the wrist and finger joints, extensor tendon compartments at the wrist level, extensor tendons at the finger level, and carpal tunnel anatomic structures as well as flexor tendons outside the carpal tunnel) was able to detect polysynovitis in 11 cases, certifying the presence of MCP joint erosions in 2 cases. Tenosynovitis was detected at several tendon compartments in 6 cases (Figure 2A). These findings focused attention on possible RA onset in 8 new cases and confirmed the clinical suspicion in the 3 other cases. Moreover, MSUS examination revealed the underlying pathologic condition for carpal tunnel syndrome development (3 patients with finger flexor compartment tenosynovitis and 2 patients with median nerve compression at the flexor retinaculum level) as well as the structural modifications of the entrapped median nerve.
Figure 2. A, Longitudinal ultrasound (US) scanning position of the volar aspect of the finger showing synovitis (broken white arrow) and flexor tendon tenosynovitis (white arrow) in the second proximal interphalangeal joint. B, Longitudinal US scanning position of the dorsal aspect of the toe showing joint synovial hypertrophy (white arrows) and a double contour sign at the cartilage level characteristic for urate deposition (gout; broken white arrow) in the first metatarsophalangeal joint.
Download figure to PowerPoint
In the hip area, the clinical diagnoses were OA in 4 cases and chronic trochanteritis in 1 case. During the MSUS evaluation, we were able to detect coxofemoral joint synovitis in 2 cases. Confirmation of hip degenerative signs was made in all 4 areas with clinical suspicion. In addition, 3 new areas with calcific peritrochanteric enthesopathy were identified.
Knee OA was the main clinical diagnosis, with Baker's cyst detection only in 1 case. In all cases, MSUS evaluation identified inflammatory lesions (i.e., synovitis in 8 cases, infrapatellar bursitis in 1 case, and presence of Baker's cyst in 6 cases) accompanied by structural damage lesions at femoral cartilage. Calcific enthesopathy was depicted in 6 cases at the level of the quadriceps tendon and in 1 case at the patellar tendon site.
Clinical evaluation of the ankle and foot areas raised the suspicion of arthritis in the first metatarsophalangeal (MTP) joint in 1 case. The rest of the cases were evaluated as having OA (2 cases) and unspecific ankle pain, tarsal tunnel syndrome, and mechanical talalgia (1 case each). MSUS evaluation depicted in 2 cases tibiotarsal joint synovitis, and confirmed synovitis in the first MTP joint together with the presence of juxtaarticular tophus (Figure 2B). A compressive tarsal ganglion was identified as the underlying cause of the tarsal tunnel syndrome. Moreover, during the MSUS evaluation, 2 cases of tenosynovitis of the medial ankle compartment and 1 case of plantar fasciitis at the calcaneal insertion were identified.
Seventeen patients, representing 28.33% of the group and totaling 17 (25%) anatomic areas (95% CI 15–37%), had a statistically significant change in systemic therapy after MSUS evaluation (Z = 2.983 [95% CI 15–37%], P = 0.0014) (Figure 3A). Nine of the patients had an initial indication for systemic therapy after clinical examination. Eight patients received a new indication for systemic therapy after the MSUS examination. The changes in systemic therapy were based on the detection of inflammatory findings in the hand joints (40%), knees (33.4%), ankles (33.3%), and shoulders (21%), and included adjustment of the previous systemic therapy strategy as well as a new indication for treatment with nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, or disease-modifying antirheumatic drugs (DMARDs) (Table 2).
Figure 3. Changes of A, systemic therapy, and B, local therapy, after musculoskeletal ultrasound evaluation, expressed as a percentage on the y-axis. On the x-axis, 1 = shoulder area, 2 = elbow area, 3 = hand area, 4 = hip area, 5 = knee area, 6 = ankle/foot area, 7 = muscle area, and 8 = overall.
Download figure to PowerPoint
Table 2. Initial clinical diagnosis, critical MSUS findings, new diagnosis suspicion, and change of therapy*
|Initial diagnosis||Critical MSUS findings||New diagnosis||Change of therapy|
|Unspecific RCL||LHBT tenosynovitis, total SST rupture, partial SUBT rupture||Specific RCL Rotator cuff interval syndrome LHBT tenosynovitis||NSAID was added to PKT/local therapy|
|Unspecific RCL||Multiple large calcifications inside the SST, SUBTs, also in subclinical shoulder||Search for metabolic disease||Added systemic therapy to local therapy/PKT|
|Shoulder pain (PMR?); high ESR†||Rule out inflammatory findings at rotator cuff level; tendinosis LHBT right, left total rupture of SST||No PMR confirmation Specific RCL||Change of systemic therapy to local only|
|Unspecific RCL||No impingement syndrome on MSUS, probably fracture of the humeral head (very large bone cortex irregularity)||Humeral head fracture suspicion||Analgesic drugs were recommended as well as radiograph/orthopedic consultation|
|Unspecific RCL (PMR relapse?); high ESR||SASD bursitis||PMR confirmation||New recommendation for CS|
|Hand arthralgia without clinical synovitis||PIP joint symmetric synovitis, third flexor tenosynovitis||RA onset?||NSAID|
|PIP joint OA||PIP joint symmetric synovitis||RA onset?||CS|
|PIP joint, wrist arthralgia, RA?||Rotator cuff, MCP joint, PIP joint polysynovitis||RA onset?||CS, DMARD|
|RA? (CS therapy already and positive clinical response)†||MCP joint, PIP joint polysynovitis||RA onset?||DMARD added to CS|
|CTS||Flexor tendon tenosynovitis, MCP and PIP joint polysynovitis||RA onset?||NSAID|
|Rotator cuff oligoarthritis, MCP joint†||Rotator cuff, MCP polysynovitis||RA onset?||NSAID|
|Hip OA†||Coxofemoral synovitis||Hip OA||NSAID|
|Knee OA†||Synovitis (important synovial hypertrophy, popliteal cyst)||Knee OA||NSAID|
|Knee OA†||Synovitis, infrapatellar bursitis, popliteal cyst||Knee OA||NSAID; delay of initial recommended PKT|
|Knee OA†||Bilateral synovitis (important synovial hypertrophy)||Knee OA||NSAID; delay of initial recommended PKT|
|Ankle OA†||Tibiotarsal joint synovitis||Reactive arthritis?||NSAID added to initial PKT, antialgic drug|
|Tarsal tunnel syndrome†||Tibialis posterior tendon tenosynovitis, tarsal tunnel ganglia||Tarsal tunnel syndrome||NSAID added to local therapy, antialgic and neurotrophic drugs|
The overall change of local therapy strategy was present in 36% of areas (95% CI 24–48%, P = 0.09), with the highest percentage identified in the knee area (66.7%) and the lowest percentage identified in the hand area (13.4%). The change was generated by a new decision for performing local guided injections in addition to initial topical NSAID therapy and/or a physiotherapy program prescription (Figure 3B). Therefore, guided aspiration for diagnostic purposes was performed in 15% of areas (95% CI 7.79–25.35%) versus guided therapeutic injections in 22% of areas (95% CI 13.46–34.31%). In 8 anatomic areas (11.94%), guided aspiration was accompanied by guided therapeutic injection.
- Top of page
- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
The economic and financial analysis of the resources of the medical health care system as well as the strategy involved in the management of musculoskeletal pathologies in outpatient clinics can be expressed using the universal statement by Benjamin Franklin, “Time is money.” Today, this phrase is pivotal in the clinical approach to the patient because public and private medical units are confronted with an impressive number of consultations. Therefore, the rational approach to the patient's need and its real-time solution have become mandatory in the outpatient clinics. This implies an organizing effort involving clinical and instrumental procedures that may foster a rapid diagnosis followed by immediate therapeutic decisions. This may avoid additional hospital visits, prolonged patient pain, and persistent absence from work (16, 17).
Our data show the important real-life impact of MSUS assessment on rapid diagnostic and therapeutic decisions in a busy outpatient rheumatology clinic. Painful shoulder, elbow, hand, hip, knee, and/or ankle are frequent rheumatic symptoms. Clinical examination relies on several physical maneuvers testing the range of motion and the generation of pain in different anatomic structures; therefore, clinical diagnosis may be challenging when multiple structures are involved. Within the last decade, MSUS has demonstrated accuracy and reliability in the evaluation of different musculoskeletal areas for a wide range of pathologies (4–10). MSUS has become a valuable tool for improving diagnosis and care of patients with rheumatic diseases (18). MRI is a high-quality imaging technique for soft tissues as well as joints and bones, but important limitations in its use are high cost, low availability immediately after clinical examination, and static image acquisition. Indeed, concomitant examination of more than one anatomic area in the same patient would significantly increase the procedure exposure. The clear advantages of MSUS over MRI are noninvasiveness and dynamic, multiplanar, and contralateral site assessment. If necessary, additional anatomic areas may be examined.
The painful shoulder is the result of periarticular soft tissue involvement of the rotator cuff, subacromial/subdeltoid bursa, and biceps tendon, and more rarely, due to involvement of other structures. It is mandatory to differentiate true shoulder involvement from referred shoulder pain because an optimal treatment strategy is based on accurate diagnosis as the first step.
In our study, the most important informational benefit was obtained following dynamic shoulder assessment, whereas shoulder impingement syndrome could be demonstrated in 20 of 24 areas. Apart from this, identification of inflammatory lesions led to significant local therapy changes. Systemic therapy and/or guided invasive procedures were added to the initial physiotherapy program, representing a quick, accurate, and efficient therapy option applicable in the first patient visit (19).
The suspicion of entheseal involvement in the humeral epicondyles is easy to be raised after clinical examination, but the exact type of involvement is difficult to define unless a soft tissue imaging method is added. MSUS examination is able to detect inflammation and/or structural damage lesions and may help in the choice of different adapted physiotherapeutic strategies and/or corticosteroid injection (20, 21).
Traditional clinical techniques for evaluating hand arthritis rely on inspection, palpation, and dynamic examination of passive and active movements. In recent years, increasing medical data confirm that MSUS has clear superiority to clinical examination in detecting synovitis and erosions (22–24). In comparison to MRI (the gold standard evaluation method), MSUS has the advantage of being applicable to hands both in a multiplanar and dynamic examination in the same consultation room. In our study, when compared to clinical examination, MSUS evaluation detected polyarticular synovitis in a larger number of patients, raising the suspicion for RA onset. This was possible because of detection of subclinical inflammatory lesions at joints and the periarticular structure level. MSUS evaluation of the hands cannot sustain a clear RA diagnosis alone, but it may help in better defining the pattern of articular and periarticular inflammatory involvement. When considered appropriate, systemic therapy (i.e., with NSAIDs, corticosteroids, and DMARDs) was initiated immediately because in early RA, higher treatment efficacy with better outcome is expected when therapy is started promptly (25).
Clinical assessment of the hip area usually encounters difficulties because of the deep joint location. With respect to clinical examination, MSUS evaluation identifies more inflammatory and degenerative lesions at the joint as well as at the periarticular level (8, 26). In particular, when polymyalgia rheumatica onset or relapse is suspected, the detection of hip synovitis may contribute to radical change of the medical approach (27). Instead, detection of asymptomatic trochanteric enthesopathy may focus attention on the possible subclinical onset of spondyloarthritides (28).
Access to the knee area is much easier in clinical practice; however, despite this, MSUS complementary to clinical examination helps in identifying inflammatory and/or structural lesions at multiple structure levels (29–31). In our study, the detection of inflammatory lesions with MSUS determined the revision of the initial therapy strategies in some cases.
The ankle and foot region is well known for its complexity and difficulty of clinical examination assessment. MSUS allows frequent patient evaluation and is more sensitive in detecting tissue modifications than physical examination and radiographs (32, 33). In our patient group, the proportion of inflammatory findings detected by MSUS was higher in comparison to those identified by clinical examination, and the etiology of the tarsal tunnel syndrome was clarified. The knowledge of the MSUS findings led to more guided invasive procedures (aspiration as well as therapeutic injection), and this result is different from a previous study by D'Agostino et al (11). An explanation for the different results may be due to the different number of patients and the type of ankle/foot involvement.
In our study, we have shown that in well-trained hands during the same consultation, MSUS can facilitate a quick, objective, and detailed diagnosis immediately after clinical examination. MSUS assessment in daily practice spares time for the patient and the doctor as well as pain for the patients because it avoids referral to other imaging specialists and the second rheumatology visit. In this context, rheumatologists may recognize in rheumatic diseases characteristic patterns and distribution of the joint/periarticular abnormalities and search for subclinically involved areas, therefore optimizing a rapid therapeutic decision (23, 33, 34). The fact that rheumatologists may have access to more objective and detailed information via MSUS may determine a change in the classic therapeutic approach.
The results of our study are in agreement with previous reports demonstrating once again the poor correlation between MSUS and clinical examination in detecting inflammatory lesions and the danger of underestimating the disease activity and/or extension resulting in a large number of undertreated patients when relying only on clinical examination (12). On the other hand, in case of false clinical suspicion, therapy can be completely reset, avoiding unnecessary patient drug exposure.
Our study has some limitations, since we did not longitudinally assess the impact of MSUS on the outcome and prognosis of the patients. However, we carried out a cross-sectional study focused on the impact of MSUS performance on clinical diagnosis and therapeutic decisions in an outpatient clinic setting. Future studies on the impact of MSUS on the outcome of regional pain syndromes are warranted.
Another limitation is that we did not compare MSUS assessment with MRI examination (considered as a gold standard), a target that was not possible to be reached during the first visit. Moreover, the fact that 2 of the 3 doctors involved in the clinical examination perform MSUS assessment in daily practice (already being aware of the MSUS benefit) may have subconsciously biased the results of the study.
In conclusion, MSUS assessment has a relevant impact over a conventional clinical approach and may drive the therapeutic choice in many rheumatologic conditions, especially when a rapid and efficient medical service is desirable for optimizing health resources. Changes in the therapeutic approach are generated mainly by the MSUS detection of inflammatory and symptomatic as well as subclinical lesions.