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Objective:The objective of this study was to draw up a set of recommendations for the format and content of the musculoskeletal ultrasonography (MSUS) report in rheumatology. METHODS: A panel of rheumatologists, members of the MSUS Study Group of the Italian Society of Rheumatology, met in order to identify the main discrepancies in the MSUS report. A set of 15 recommendations was then defined, aimed at resolving the main discrepancies. They consisted of information about the motivations for the MSUS examination, the equipment, the US modalities and scanning technique, a list of the examined structures and findings, the scoring/grading systems, the number of images and main findings to include and conclusions. Subsequently a Delphi-based procedure was started in order to obtain agreement on a core set of recommendations. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. RESULTS: Three complete rounds were performed. The response rate was 85.2% for the first round, 78.3% for the second and 88.9% for the third. Finally, consensus was obtained for 14 of 15 statements. These 14 statements represent the recommendations of the group for the format and content of the report and documentation in MSUS in rheumatology. CONCLUSION: To the best of our knowledge, our group has produced the first recommendations for the format and content of the report and documentation in MSUS in rheumatology. The report is an integral part of the MSUS examination and its use in a homogeneous form can help in the correct interpretation of the findings.

Objectives: To investigate the prevalence of ultrasound (US) detectable inflammation in hips of patients with ankylosing spondylitis (AS) and the relationship between US and measures of disease activity and severity. Methods: Consecutive patients with AS attending the rheumatology units involved in this study were enrolled. Clinical and demographical data were recorded. US examination of bilateral hips was performed at the same time, evaluating anterior longitudinal scan to search for synovial hypertrophy (SH), joint effusion (JE) or power Doppler (PD) positive synovitis. Results: A total of 56 patients were included, median age (interquartile range, IQR) 49 (39, 59.5), median disease duration 98 (72, 204) months, 80.3% were treated with TNF-α inhibitors, median BASDAI 2.65 (1.96, 3.95), 30.3% had hip tenderness. US JE was found in 26.7% of patients, US SH in 16%, no patient had detectable PD. The concordance between clinical findings and US abnormalities was moderate, with a kappa of 0.44. Patients with detectable US abnormalities had higher median visual analogue scale (VAS) pain and C-reactive protein (CRP), while there was no significant association with other measures of disease activity and disability. In the subgroup of patients with no hip tenderness, US alterations were still significantly related to higher CRP levels, while in patients with hip tenderness and no US abnormalities CRP was not higher than in the asymptomatic patients. Conclusions: US assessment of hip joint in AS patients can be considered of value, as suggested by the correlation with relevant clinical and laboratory measures. In asymptomatic patients, US examination might provide further information on subclinical involvement. © Clinical and Experimental Rheumatology 2012.

Objective: The aims of our study were to investigate the prevalence of ultrasound (US) abnormalities in the foot of patients with rheumatoid arthritis (RA) and to compare them with the clinical findings. Methods: One hundred RA patients were enrolled in the study. Bilateral US examination of metatarsophalangeal (MTP) joints, proximal interphalangeal (PIP) joints, midfoot joints (talonavicular, calcaneo-cuboid, medial, intermediate and lateral navicularcuneiform and cuneiform-metatarsal joints and cuboid-4th and 5th metatarsal joints) were examined for synovitis and erosion. In addition the plantar fascia and the insertion of the anterior and posterior tibialis and peroneous brevis tendons were imaged. Results: Effusion with synovial proliferation was visualised only at MTP joints in 84 out of 200 (42%) feet, at MTP plus at least one joint of the midfoot in other 41 out of 200 (20%) feet (making a total of 125 out of 200 (62%) MTP joints) exclusively in one or more joints of the midfoot in 7 out 200 (3%) feet, in the PIP joint of the 2nd and 3rd toes in 3 (1.5%) and 4 (2%) feet respectively, while no effusion with synovial proliferation was visualised in the PIP joint of the 4th and 5th toes. Synovitis was present most frequently in the 2nd MTP joint whilst erosions were most frequently imaged in the 5th MTP joint. Conclusion: US examination appears to be a useful imaging technique to study joint and tendon involvement of the foot in RA patients. Moreover, US examination of the foot is more sensitive than clinical examination in the detection of joint inflammation and allows for a better understanding of the features and the progression of the disease. © Clinical and Experimental Rheumatology 2011.

Psoriatic arthritis (PsA) is an arthropathy associated with psoriasis, which is part of the spondyloarthropathy family, and which may present with various forms, from mono-oligoarthritis to symmetric polyarthritis mimicking rheumatoid arthritis. In longstanding disease, the symmetric polyarthritis is the most common pattern of PsA, involving the small joints of hands, feet (the involvement of which seems to be very common, ranging from 50 to 100% of patients), wrists, ankles and knees. Other common features are represented by the inflammation of enthesis and tendons. Its exact prevalence, in Italy, should be about 30% in psoriatic subjects or 0.42% when considering the general population. The aims of our study were to investigate, by US examination, the prevalence and the features of foot involvement in PsA and to describe their correlations with clinical findings. Ultrasound (US) examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 14 MHz. One hundred and eighty feet were investigated in a total of 101 patients. Prior to US assessment, all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/absence of pain, tenderness (detected by palpation and/or active or passive mobilisation of the feet) and swelling. US finding indicative of metatarsophalangeal joint inflammation were obtained in 77 (76.2%) patients, while only 34 (33.7%) patients were positive to the clinical examination. This study demonstrates that US detected a higher number of inflamed joints with respect to clinical assessment in PsA patients.

Objectives. To investigate the ability of ultrasonography (US) to detect synovitis in metatarsophalangeal joints (MTP) in patients with suspicion of early arthritis, and to discriminate between diagnoses. Methods. Patients referred to early arthritis clinics for differential diagnosis were enrolled, and clinical and laboratory measures were recorded. Ultrasonography of MTPs was performed searching for synovial hypertrophy (SH), joint effusion (JE) and power Doppler (PD), graded from 0 to 3 on a semi-quantitative scale. Patients were classified according to definite classification criteria, or as undifferentiated arthritis or non-inflammatory pathology. US findings were compared across different diagnoses and diagnostic accuracy was calculated taking clinical diagnosis as reference.Results. Out of 427 patients (71% rheumatoid arthritis (RA), 20% undifferentiated arthritis (UA), 15% spondyloarthritides (SpA), 13% non-inflammatory), 307 (71.9%) showed SH, 120 (25.5%) JE, 77(18.0%) PD. RA patients had median JE, SH and PD scores significantly higher than non-inflammatory and other diseases. Patient with UA and SpA had higher scores of SH and JE compared to non-inflammatory, no significant differences were present among different diagnosis. In RA, SH and JE were more frequently detected in the second MTP, and PD in the fifth. Crystal-related arthritis showed a tendency towards a more frequent involvement of the first MTP. The diagnostic accuracy of single US measures was moderate, but the detection of a PD of 2 or more provided a high specificity for the diagnosis of RA. Conclusions. US can be used as additional information in patients evaluated in an early arthritis setting. High scores of JE, SH and PD, together with the pattern of involvement are suggestive of RA.

The aims of our study were to investigate the prevalence of ultrasound (US) pathologic abnormalities and to compare them with the clinical findings in the knee of rheumatoid arthritis (RA) patients. One hundred RA patients were enrolled in the study. Bilateral US examination of the knee was performed to visualise the presence of effusion, synovial proliferation, bone erosions, femoral cartilage abnormalities, quadricipital and/or patellar enthesopathy. The popliteal fossa and the calf region were also evacuate to detect popliteal cyst. We observed joint effusion in 140 out of 200 (70%) knees. Synovial hypertrophy was present in 115 out of 140 (82%) knees associated with effusion and in 22 out of 115 (19%) knees intra-articular power Doppler (PD) signal was found. Hyperechoic spots within the cartilage layer, suggestive of pyrophosphate crystals deposit, were detected in the knees of 3 patients. US signs of quadricipital and/or patellar enthesopathy were detected in 53 out 200 (26%) knees. Bone erosions were visualised in 16 out 200 (8%) knees. Popliteal cyst was found in 66 out of 200 (33%) joints. US examination of the knee is more sensitive than clinical examination in the detection of joint inflammation and allows for the identification of different patterns of pathologic changes at knee level, including morphostructural changes at both cartilage and tendon level.

Objective: To assess the impact of the knee joint inflammation, detected by ultrasonography (US), on functional disability in patients with recent-onset inflammatory polyarthritis (IP). Methods: We included patients who had IP for less than 12 months and who had more than 5 swollen joints. All patients were assessed clinically at baseline. US was used to identify joint inflammation at multiple joint sites including: hands, wrists, elbows, shoulders, knees, ankles and feet. Joint group involvement was defined when at least one joint showed intra-articular signs of inflammation (synovial fluid abnormalities and/or synovial hypertrophy), according to the OMERACT definitions. Functional disability was measured using the health assessment questionnaire (HAQ) score. All patients with complete clinical and US data were included in the analysis. Results: Patients with US knee involvement showed more active and severe disease at baseline. The mean difference of HAQ between patients with and without US knee inflammation was 0.42 (95%CI 0.22, 0.62; p

Objective. To investigate the prevalence and severity of sonographic-detected abnormalities in knee osteoarthritis (OA) and to correlate ultrasound (US) findings with clinical data. Methods. Outpatients with chronic, painful knee OA according to the ACR criteria were consecutively recruited and underwent clinical and US examinations. An expert rheumatologist recorded the presence of knee joint pain, swelling and tenderness, patient's global assessment of knee pain using visual analogue scale (VAS), and Lequesne Index of severity for knee OA.A second rheumatologist, blinded to the clinical data, performed the knee US examination using a Logiq9 machine equipped with a 12MHz linear probe and registering the presence of joint effusion, synovial proliferation, power Doppler (PD) signal, Baker's cyst, osteophytes and femoral cartilage abnormalities. Results. One hundred and sixty-four knees of 82 patients (53 women, 29 men) were studied; mean age was 63.2 ±8.1 SD years, mean disease duration was 4.3±5.6 SD years. All patients complained of at least one knee joint pain during physical activity. Mean patient's VAS for knee pain was 48.4±19.9 SD mm, mean Lequesne Index was 8.2 ±4.4 SD. Knee swelling was present in 39% of the patients and tenderness was found in 65.8%. US showed: joint effusion in 43.3% of the patients, synovial proliferation in 22.1%, PD signal in 2.9%, Baker's cysts in 6.6%, cartilage abnormalities in 79%, osteophytes in 100%. In all patients US findings were present at least at the level of one knee. Statistically significant correlations were demonstrated between a composite inflammatory score and both VAS (p=0.004) and Lequesne Index (p

Psoriatic arthritis (PsA) is an arthropathy associated to psoriasis, which is part of the spondyloarthropathy family, and which may present with various forms, from mono-oligoarthritis to symmetric polyarthritis mimicking rheumatoid arthritis. In longstanding disease, the symmetric polyarthritis is the most common pattern of PsA, involving small joint of hands, feet, wrists, ankles and, very frequently, knees. Other common features are represented by the inflammation of enthesis and tendons. Ultrasound (US) examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 10-14 MHz. One-hundred and sixty-six knee joints were investigated in a total of 83 patients. Prior to US assessment, all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/absence of pain, tenderness (detected by palpation and/or active or passive mobilisation of the knee), and knee swelling. Sixty-two (74.7%) knee joints were found clinically involved, while at least one US finding indicative of joint inflammation was obtained in 70 (84.3%) knee joints. In the 59% of the patients we noticed synovial hypertrophy. Enthesitis was present in 39.7% of the subjects studied. This study demonstrated that US detected a higher number of inflamed knee joints and enthesis with respect to clinical assessment in PsA patients.

The knee is a frequent target for gout and calcium pyrophosphate dihydrate (CPPD) disease with involvement of both articular and peri-articular structures. The aims of the present study were to investigate the relationship between clinical and ultrasound (US) findings and to describe the prevalence and distribution of crystal deposits in the knee in patients with gout and CPPD disease. Thirty patients with gout and 70 patients with CPPD disease were enrolled in the study. Prior to US assessment all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/ absence of pain, tenderness (evocated by palpation and/or active or passive mobilisation of the knee), and knee swelling. US examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 9 MHz. Two hundred knee joints were investigated in a total of 100 patients. Fifty-one (25.5%) knee joints were found clinically involved, while at least one US finding indicative of joint inflammation was obtained in 73 (36.5%) knee joints. The most frequent US finding indicative of knee joint inflammation was joint effusion, detected in 21 (35%) out of 60 knees and in 52 (37%) out of 140 knees, in gout and CPPD disease, respectively. Ten (17%) out of 60 knees and 21 (15%) out of 140 knees were found positive for synovial hypertrophy with or without intra-articular power Doppler, in gout and CPPD disease respectively. Sonographic evidence of crystal deposition within joint cartilage (hyaline and fibrocartilage) was more frequently seen than in the soft tissue in the knee. This study demonstrated that US detected a higher number of inflamed knee joints than clinical assessment in patients with crystal related arthropathies and that the distribution of crystal deposits at joint cartilage level permitted distinction between gout and CPPD disease. Further studies are required to investigate both sensitivity and specificity of US features indicative of crystal aggregates at both tendon and entheseal level.

Systemic lupus erhthematosus (SLE) is an autoimmune multisystem disorder characterised by frequent musculoskeletal manifestations. Joint involvement in SLE is usually not erosive or destructive but some patients develop hand erosive arthritis or deforming arthropathy of the hand (respectively "rhupus" hand and Jaccoud arthritis). To date, few studies, evaluated joint and tendon involvement in SLE patients by US. We studied wrist and hand structure, using ultrasound, in 50 patients affected by SLE, detecting inflammatory joint involvement in 80% of them at the wrist and in 50% at the hand. Tenosynovitis was visualised in 14 patients, while structural damage was present in 12% of the SLE group. Those results reinforce the importance of including musculoskeletal ultrasound in the patient assessment, especially in those cases in which physical examination is not conclusive.

The field of inflammatory arthritis owes much to the advances in imaging technology which have enlightened not only clinical specialists but also researchers worldwide. The most exciting developments in recent decades have centred upon rheumatoid arthritis (RA) and more specifically the ultrasound (US) and magnetic resonance imaging (MRI) findings at various stages of the natural history of this condition. Investigation of RA using the standard techniques of plain radiography (x-ray) and more sophisticated computerised tomography (CT) have now been superseded by the exponential growth of use of US and MRI and this has been born out by the profusion of scientific papers published on these subjects.This paper aims to review the array of imaging modalities available as investigative tools to the rheumatologist when presented with various clinical scenarios by patients with RA.

Objective. To study the frequency and features of joint and tendon involvement in the hand of patients with primary Sjögren's syndrome (pSS) by musculoskeletal ultrasound (US) examination. Methods. Forty-eight patients with pSS diagnosed according to the preliminary classification criteria proposed by the American-European Classification Criteria Group were enrolled in the study. Bilateral US examination of the 1st-5th metacarpophalangeal (MCP), 2nd-5th proximal interphalangeal (PIP) joints and of flexor tendons were performed. A semi-quantitative grading method (0 to 3) for scoring joint effusion, synovial proliferation and intra-articular power Doppler (PD) signal was used. Results. We observed clear evidence of inflammatory arthritis in 9 (18.7%) patients. Bone erosions at MCP and/or PIP joint were visualized in 6 out of 48 (12.5%) patients. In 10 (20.8%) patients we imaged flexor tenosynovitis which appeared more frequent than in healthy subjects even if no statistically significant difference was detected. Conclusion. US examination appears to be a useful imaging technique to study joint and sofi tissue involvement in connective tissue diseases. The presence of bone erosions in pSS patients is unexpected. Future studies will hopefully concentrate more on defining the erosive capability of connective tissue disorders together with inflammatory involvement of tendons. © Copyright Clinical and Experimental Rheumatology 2009.

Three-dimensional (3D) US is a new sonographic modality which represents a promising tool in the assessment of joint and periarticular tissues abnormalities in rheumatic diseases. The available literature has recently underlined its advantages mainly related to the virtual operator independence due to image acquisition of infinite 3D data sets obtained by transducer automated sweeping. Shortening of the US examination time represents another notable advantage over conventional two-dimensional (2D) US. The aim of the present study was to investigate the validity of 3D US in assessing Achilles tendon enthesitis by comparing it with 2D US. US examinations were performed by using a Logiq 9 (General Electrics Medical Systems, Milwaukee, WI) equipment with a high-frequency (8-15 MHz) volumetric probe. One hundred and eighty-six Achilles tendon enthesis of 93 SpA patients were examined. The analysis of each basic US finding demonstrated from good to excellent agreement rates between 3D and 2D US, both in dichotomous assessment of sonographic lesions and in the use of semi-quantitative grading. Excellent agreement between the two modalities was demonstrated in the assessment of both inflammatory changes and structural lesions. Our study for the first time demonstrated that 3D US is a valid imaging modality for the assessment of Achilles tendon enthesitis.

One of the largest challenges to the field of musculoskeletal ultrasonography is attempting to accurately quantify the changes seen in chronic arthritis. With advances in ultrasound technology, researchers have been increasingly exploring ways of more accurately assessing these changes and attempting to reach consensus with agreed scoring systems. This review presents the main scoring systems developed for quantifying sonographic findings indicative of synovitis and joint damage in patients with rheumatoid arthritis. Further investigation is required to attain international consensus on such scoring systems and to evaluate their impact on therapeutic decision-making.

Enthesitis represents a characteristic features of spondyloarthritis (SpA) and, in the context of the early management of the disease, its reliable assessment has emerged as a central issue. Musculoskeletal ultrasonography (US) has proven to be of value in the assessment of peripheral entheses. Our aim was to systematically review the literature from 2010 to 2013 in order to summarise the evidence on the evaluation of entheses by US in patients with diagnosed or suspected SpA.PubMed and Embase were searched developing a search strategy based on terms related to SpA and US. The target population were patients with SpA or suspected SpA, the intervention was entheseal US, the outcomes were the prevalence of US abnormalities, the reliability, the diagnostic accuracy, the sensitivity to change. The possible comparators were clinical evaluation and other imaging techniques. Cohort studies (cross-sectional or longitudinal), case-control studies, diagnostic accuracy studies, systematic literature reviews and meta-analyses were eligible for inclusion.Out of 3368 retrieved references, 34 papers were finally included. 22 of which reported information on the prevalence of US findings, yielding highly variable results. US was sufficiently reliable, as reported in 6 papers. A minority of studies reported data on sensitivity to change, which was good, and on the application of US for differential diagnosis and diagnosis of SpA, thus demonstrating the value of US also in this context.US confirms its validity and reliability in the assessment of entheseal involvement in patients with SpA. Further application in the help of diagnosis will be provided by future research.

To investigate the prevalence of ultrasonographic (US) shoulder abnormalities in patients with rheumatoid arthritis (RA) and to investigate the relationship between US findings and demographic and clinical features.Consecutive patients attending the rheumatology units involved in this study were enrolled. Clinical and demographical data were recorded. US of bilateral shoulders was performed at the same time, examining tendons, bursae, gleno-humeral and acromion-clavicular joints. The presence of signs of inflammation, bone erosions or rotator cuff pathology was evaluated.A total of one hundred patients were enrolled, mean age (SD) 59.6 (14.7) years, median disease duration (IQR) 56.5 (34.7, 96.5) months, 98% of them were on DMARDs and 22% on biologics. Shoulder tenderness was reported by 44% of patients. 34% of patients showed at least one sign of inflammatory involvement, and 25% of them presented with humeral head erosions. Signs of rotator cuff pathology were seen in 49% of patients. Agreement between the presence of spontaneous pain and US inflammatory abnormalities was moderate (kappa 0.501). Patients with inflammatory involvement of the shoulders had significantly higher DAS28, HAQ, VAS pain, acute phase reactants and disease duration compared to patient with no inflammatory signs, they were more frequently RF positive and reported more frequently spontaneous pain.US assessment of the shoulder in RA patients can be considered of value, especially in patients with relevant indicators of disease activity and severity.

To investigate the prevalence of shoulder ultrasound (US) detectable abnormalities in asymptomatic individuals of various ages and to correlate the US findings with clinical data.97 healthy subjects were enrolled in the present study. They were subgrouped according to their age, as follows: group I (20-29 years); group II (30-39 years); group III (40-49 years); group IV (50-59 years); group V (60 years). A physical examination of both shoulders, based on a series of provocative maneuvers, was carried out. The US assessment was performed by using a Logiq9 machine equipped with a multi-frequency linear probe working at 12MHz and included the study of a number of structures for the evaluation of local abnormalities, as follows: the long head of biceps tendon (synovial effusion (SE), synovial hypertrophy (SH), power Doppler (PD) signal); the subacromion-subdeltoid and sub-scapularis bursae (SE, SH, PD signal); the rotator cuff tendons (tendinosis, calcifications, tears, impingement); the acromionclavicular (ACJ) and gleno-humeral joints (SE, SH, PD signal, osteophytes, erosions, fibrocartilage calcifications, cartilage abnormalities, tophaceous deposits). In addition, deltoid, throchite and throchine enthesopathy were searched for.194 shoulders were studied in total. A low but variable percentage of joints of healthy individuals (3.1-13.4%) showed positive provocative maneuvers. 138 shoulders (71.1%) did not show any US abnormalities. The most frequent changes were SE of ACJ (25.5%), osteophytes of ACJ (23.3%), and supraspinatus tendinosis (20.6%). The prevalence of abnormalities progressively increased with age. Sub-clinical involvement was present in most cases, being provocative maneuvers positive only in a low percentage of joints.The present study demonstrated the presence of a wide set of US-detectable changes in healthy subjects, that were more frequently present in elderly individuals. The absence of any clinical sign of local pathology cannot exclude the presence of local abnormalities.

Musculoskeletal ultrasonography (US) has lately been applied to patients with polymyalgia rheumatica for the examination of shoulders and hip, and included in the 2012 PMR classification criteria. We aimed to perform a comprehensive overview of the literature on this topic with a systematic review.We searched PubMed, Embase, the Cochrane library and the proceedings from EULAR and ACR congresses (2011-2012). We included studies evaluating patients with confirmed or suspected PMR, undergoing US of shoulders and/or hips. The diagnosis of PMR could be based on expert opinion or diagnostic criteria. Cohort, case-control, diagnostic accuracy studies and case-series were eligible for inclusion. The features of the included studies were presented. When available, sensitivities and specificities were calculated for primary studies.Out of 1736 papers identified by our search, 13 articles and 1 abstract were finally included in the review. Eight studies focused on shoulder US, 1 on hip US, 4 on both. Studies were extremely variable in terms of population, US examination, reference standard and control population. In general, at the shoulder, pathological bilateral US findings in most studies were more prevalent in patients with PMR compared to controls. When sensitivity and specificity could be calculated, bilateral findings were more sensitive. Notably, less information was available on hip US.US (especially in shoulder examination) is confirmed to be a potentially useful instrument to integrate clinical information in the management of patients with PMR. Its additional value in conjunction with the new classification criteria should be further tested.

The aims of this study were to investigate the prevalence of ultrasound (US) pathologic abnormalities in the shoulders of psoriatic arthritis (PsA) patients and to compare them with the main clinical findings.Ninety-seven PsA patients were enrolled in the study. The subacromial/subdeltoid bursa, the sheath of the long biceps tendon, the glenohumeral joint and the acromion-clavicular joint were examined for the presence of synovial effusions and synovial hypertrophy. Rotator cuff tendons (supraspinatus, subscapularis, infraspinatus) were imaged for tendinosis, calcifications and total or partial tears, while deltoid enthesis were evaluated for local enthesitis and the lesser and greater tuberosity of the humerus for the presence of enthesophytes.Tendinosis represented the most frequent abnormal finding. Supraspinatus tendinosis was detected more often than subscapularis and infraspinatus tendinosis. When considering tendon tear, supraspinatus was also the most frequently involved anatomical structure. Clinical examination frequently failed to detect abnormalities in patients in whom US examination showed pathological findings. This is particularly true for tendon involvement, i.e. effusion within the sheath of the biceps tendon was imaged in 43 shoulders but clinical assessment reported abnormalities only in 22 shoulders (p0.0001).US examination appears to be a useful and sensitive imaging technique, specifically in identifying joint and tendon involvement of the shoulder.

Fibromyalgia syndrome (FMS) is a common form of non-inflammatory rheumatism within the general population with symptoms often mimicking those of arthritis or muscle disorders. Arthralgic symptoms in the region of the hip are commonly mentioned by patients with FMS and one of the diagnostic trigger points for the condition is found around the greater trochanter. To date, no formal imaging studies using ultrasound (US) have been performed in FMS. This study describes the correlation between clinical and US findings in patients presenting with primary FMS to rheumatology clinics. In the majority of the patients, no significant pathological US abnormalities were detected.

Hip pain is a common complaint in daily practice and the identification of the underlying pathologic condition is the first step for an adequate treatment. In this review, we discuss the available evidence for the application of conventional radiography, computed tomography and magnetic resonance imaging in rheumatologic patients with painful hip, presenting the main imaging findings due to osteoarthritis, inflammatory arthritis (rheumatoid arthritis and spondyloarthritides), osteonecrosis and some other soft tissue involvement (bursitis and synovial cyst) that could be the cause of hip pain. Because different imaging techniques show different sensitivity and specificity, the choice of technique to use depends on the type and stage of the disease itself.

The aims of our study were to investigate the prevalence of ultrasound (US) abnormalities in the foot of patients with osteoarthritis (OA) and to compare them with clinical findings.Consecutive patients with foot OA were investigated by clinical and US examinations. Bilateral US of the midfoot and forefoot joints was performed by using a Logiq9 machine, equipped with a multi-frequency linear probe, operating at 14 MHz; in addition, power Doppler was applied (frequency 7.5 MHz; gain 50%; PRF 750 Hz). Clinical evaluation included the registration of demographic data, disease duration, current treatment undergone, joint swelling and tenderness. US study included the assessment of both inflammatory (joint effusion, synovial hypertrophy, local pathologic vascularisation at PD, big-toe bursitis) and structural (osteophytes, MTP joints subluxation) abnormalities.One hundred patients were studied. At midfoot level, clinical examination demonstrated signs suggestive for joint inflammation (tenderness and/or swelling) in at least one joint in 43/200 feet (21.5%) of 23 patients; US showed inflammatory abnormalities in 87/200 feet (43.5%) of 63 patients and structural lesions in 100/200 feet (50%) of 70 patients. At forefoot level, clinical examination found inflammatory signs in at least one joint in 128 feet (64%) of 64 patients; US showed inflammatory abnormalities in at least one joint in 176 feet (88%) of 88 patients and structural lesions in 189 feet (86%) of 86 patients.US is a useful imaging tool for analysing both inflammatory and structural damage lesions at foot joints level in OA. In addition, it demonstrated to be more sensitive than clinical examination in the detection of inflammatory abnormalities.

Over the last few years, a large number of studies have emphasized the fundamental role of ultrasonography (US) in the clinical evaluation of patients affected by rheumatic disorders. However, not all rheumatic diseases have been studied by US. To date, very few reports exist on the use of US in the assessment of articular, periarticular structures and blood vessels in vasculitis. In this review we provide an overview of the current data regarding the role of US in vasculitis. Sonographic evaluation of cardiac or renal involvement in these disorders will not be covered.

Ultrasound (US) role is becoming more and more relevant in the assessment of rheumatic diseases but there are still some almost unexplored fields and, surely, one of these is represented by the great family of connective tissue diseases (CTD). In this review we provide an update of the available data regarding some applications of US in CTD. Besides an overview of the role of US in their musculoskeletal involvement, we will report data on the use of US in the evaluation of skin and lung in systemic sclerosis and of salivary glands in Sjögren's syndrome. US assessment of heart, kidney or vascular involvement in CTD will not be the subjects of this paper.

Musculoskeletal ultrasound (US) has an increasingly important role in the assessment of spondyloarthritis (SpA) not only for its ability to detect synovial and tendon involvement but also for the accurate imaging of enthesitis, the clinical hallmark feature of SpA. As already known, most cases of enthesitis are subclinical in SpA and US is an effective technique used to detect them. Also, in cases of dactylitis, US can accurately delineate the underlying pathology. US allows clinicians to guide needle positioning within inflamed joints, tendon sheaths and entheses in order to inject steroids or other drugs. This is particularly important for patients with SpA, because of the frequency of mono or oligoarthritis, tendon and entheseal involvement, who may have great benefit from intrarticular or intralesional therapy. The clinical application of US in SpA extends to the monitoring of therapy efficacy, particularly when coupled with power Doppler imaging. Very slight changes in vascularity are easily detected in joints, entheses or tendons, aiding the rheumatologist in the assessment of the effects of local or systemic therapies. The present review provides an update of the available data and discusses research issues of US imaging in SpA.

The present review provides an update of the available data and discusses research issues of ultrasound (US) imaging in rheumatoid arthritis (RA). Currently the principal indications for using US in the assessment of patients with RA include: detection of sub-clinical synovitis, demonstration of bone erosion undetected by conventional radiography, detailed assessment of tendon pathology and guided injection and aspiration of joints and soft tissues. Future potential applications are likely to include short and long term therapy monitoring and early detection of cartilaginous changes in RA. The main priorities requiring the attention of investigators include: addressing validity issues, especially those related to criterion and discriminator validity, development of international consensus on scoring systems, evaluation of the role of power Doppler in the assessment of disease activity, development of a specific training programme for rheumatologists performing US and investigation of the potential of 3D US using a volumetric probe.

The present review provides an update of the available data and discusses research issues relating to ultrasound (US) imaging in osteoarthritis (OA). Currently, the principal indications for using US in OA include: delineation of changes within articular cartilage (AC) and demonstration of synovial and adjacent soft tissue pathology together with injection into OA joints under US guidance. US has been proposed as a possible imaging tool for following the progression of OA. The main priorities requiring the attention of researchers include: addressing difficulties surrounding consensus on definitions of pathology in OA, charting the natural history of AC change in site specific OA, investigation of the link between inflammation and OA and the use of three-dimensional (3D) US in OA.

The hand is one of the anatomical regions most frequently explored by ultrasonography (US) in rheumatology. The last generation US systems equipped with high frequency probes allow for a quick and accurate assessment of even minimal pathological changes in patients with rheumatic conditions affecting the small joints and the soft tissues of the hand and wrist. Several studies have demonstrated the great value of US imaging of the hand and wrist in rheumatology but there are still controversial issues which yet have to be adequately addressed, particularly with regard to US semi-quantitative evaluation of synovitis and bone erosions in patients with chronic arthritis. This paper provides the basic knowledge, reviews the available evidence and discusses the potential of US in the evaluation of the hand and wrist.

Over the last few years, technological advances have resulted in dramatic improvements in quality and resolution of ultrasonography (US), allowing it to become a very powerful tool in rheumatological clinical practice. Despite the fact that the impact of US on final diagnosis or therapeutic options for rheumatic patients has not yet been defined, there is now growing evidence that US improves clinical diagnosis and intervention skills. This review discusses the most important issues connected with the practice of US in rheumatology including: basic requirements, scanning technique, clinical applications, training and future developments. Moreover, it provides a general overview of both US anatomy and pathology relevant for the rheumatologist.

Ultrasonography (US) is a reliable and useful diagnostic tool for the assessment of hip pathology. It depicts changes within the coxo-femoral joint (synovitis, erosions, osteophytes) and in the adjacent peri-articular tissues (calcifications, tendonitis, enthesitis, bursitis) in many rheumatic diseases (rheumatoid arthritis, spondyloarthritis, osteoarthritis, polymyalgia rheumatica ) and in some orthopaedic disorders (septic arthritis, trauma, abscess, painful hip after arthroplasty). It is commonly used both in adults and in children. In the assessment of hip joint pathology, US exerts considerable diagnostic supremacy over physical examination. In fact, by virtue of its size and position, reliable physical examination of the hip is often difficult thus making US particularly useful as a bedside tool for the evaluation of a painful hip. Hip US has also proven to be of great practical benefit when performing aspiration and injection within the joint and in the periarticular soft tissues. The relatively limited acoustic windows available to the US beam is the principal limitation to hip US thereby making detailed examination of some important structures impossible together with the interpretation of power Doppler signal sometimes unreliable. In addition, the deep location of the hip can confer further problems to US scanning in obese or particularly muscular subjects.

Ultrasonography (US) has proved to be a useful diagnostic tool in patients with shoulder pain and/or limited range of motion. It allows careful assessment of a wide range of changes involving many different anatomic structures of the shoulder girdle, such as the rotator cuff tendons (tendonitis, tendon tears and calcific deposits), the long head of the biceps tendon (tenosynovitis, tendonitis, tears, rupture and displacement), the bursae (bursitis), the soft tissues of the gleno-humeral (synovial proliferation, joint effusion) and acromioclavicular joints (synovial proliferation and joint effusion). In addition, it is also a reliable tool in the evaluation of bony profiles detecting the presence of erosions and osteophytes. The use of high quality equipment and the application of a standard scanning protocol are mandatory for reliable US assessment of shoulder pathology.

Ultrasound (US) examination of the elbow and parasternal joints is very useful to detect synovitis, degenerative changes, intrarticular calcification or soft tissue abnormalities. More recently new fields of research involving the sacroiliac and temporomandibular (TM) joints have evolved. Moreover, important information has been obtained about vascularization of the synovial joint in the sacroiliac region and structural modification such as internal derangement in the TM joint.. In this paper, we review and discuss the role of US in the evaluation of elbow, sacroiliac, parasternal and TM joint pathology.