Ultrasound in Rheumatology is cutting edge and can be utilized in the diagnosis of joint disease and evaluation of arthritis, for guidance of needle placement during injections and aspiration of joints, and in treatment of bursitis and tendonitis. Research suggests that patients experience improved outcome in pain and symptoms with ultrasound guided joint injections. Ultrasound of joints for diagnosis has been shown to be as good as radiographs in the detection of bony changes and better in the detection of the early changes of arthritis including joint effusion and proliferation of the synovium (joint lining).
Bone Erosion in Rheumatoid Arthritis
Treatment of the Following Conditions
Rheumatoid Arthritis (RA) is an autoimmune disorder that is characterized by fatigue, morning stiffness, joint pain and joint swelling that typically affects the small joints of the hands and feet. A diagnosis of RA can be made through physical examination, presence of antibodies, and changes in the bones on radiography. Ultrasound and MRI may also be useful to help diagnose RA in its early stages. Treatment consists of medications (pills, injections, or infusions). Best results are achieved with early diagnosis and aggressive treatment.
Osteoarthritis (OA) is a condition characterized by cartilage loss, increased bone density and bone formation around the affected joint. Risk factors include age, family history, female sex, obesity and trauma. Typically with OA, joint pain is worse with prolonged activity and when initiating movement after inactivity. Physical examination of affected joints may reveal joint swelling, pain, bony enlargements, and crepitus (or creaking) of the joint. The diagnosis is confirmed through imaging including x-ray, MRI, and ultrasound in some cases. Treatment includes physical therapy, exercise programs, weight loss if indicated, and pharmacologic treatment.
Tendinitis is a condition characterized by degeneration and possible inflammation of the tendon (the structure which attaches muscle to bone). Involvement of tendons is more common with aging as tendons become less flexible and elastic but may result from a specific injury or repetitive overuse. Tendinitis can affect tendons in all joints but there is a higher frequency in the shoulder, elbow, wrist, hand, knee and ankle joints. Diagnosis can be made with patient history and clinical examination. MRI and ultrasound can help confirm the diagnosis. Tendinitis is managed with oral medication such as non-steroidal anti-inflammatory drugs (NSAIDs), joint injections, and physical therapy.
Bursitis is a condition characterized by inflammation and swelling in the bursa (a protective fluid filled sac that cushions bones, tendons and muscles). Bursitis can occur with injury or trauma to a joint, as a feature of inflammatory arthritis such as gout or rheumatoid arthritis, or from an infection. Symptoms include pain, swelling and warmth around the affected bursa. Treatment involves aspiration of fluid from the bursa, protection from mechanical injury, and if bursitis is not secondary to infection, a steroid injection may relieve symptoms. If bursitis is secondary to infection, aspiration, drainage and treatment with antibiotics are prescribed. If more conservative measures are not effective in the treatment of bursitis, surgical excision of the bursa may be needed.
Carpal Tunnel Syndrome is a condition characterized by compression of the median nerve as it passes under and the flexor retinaculum at the carpal tunnel of the wrist. Carpal tunnel syndrome symptoms include numbness and tingling and pain of the thumb, pointer and middle finger. Symptoms may occur with repetitive motion or abnormal positioning of the wrist. Carpal tunnel syndrome can also occur in the setting of compression of the median nerve by arthritis of the wrist joint, tendon inflammation, and soft tissue masses. It can be diagnosed with ultrasound or by nerve conduction velocities tests which measure the nerve’s response to electrical stimulation. Treatment options include splints to stabilize the wrist, NSAIDs, or corticosteroid injection around the nerve and. If more conservative measures fail, surgery is necessary to decompress the carpal tunnel by removal of the flexor retinaculum.
Osteoporosis is a condition of reduced bone mass and structural changes of the bone which increase the risk of fracture. Osteoporosis is a clinically silent disease unless a fracture has occurred. It is evaluated with Dual-Energy X-ray Absorptiometry (DXA scan) which measures bone mineral density (BMD). Therapy involves improving bone health with weight-bearing exercise, supplementation of calcium and vitamin D, avoidance of cigarette smoking, and treatment with pharmacologic modalities to stabilize bone mineral density. Low BMD that is not severe enough to be classified as osteoporosis is referred to as “osteopenia..” Osteopenia would be managed similarly to osteoporosis with use of pharmacologic therapy on a case by case basis. The FRAX calculator can assess the need for treatment in osteopenia based on personal risk factors and DXA findings.
Gout is a disease characterized by deposits of monosodium urate crystals in the tissue of the joints and the surrounding areas. Gout is usually associated with high levels of blood uric acid. Kidney disease, high blood pressure, obesity, and high cholesterol are risk factors for gout. Gout flares may also be exacerbated by consumption of alcohol and red-meat. Symptoms of gout include fever, pain, swelling, warmth, and redness of affected joints. Chronic gout may present with nodules composed of gout crystals called tophi. The diagnosis of gout is made by aspirating fluid from the affected joint or from a tophus and visualization of gout crystals in the fluid under a microscope. Radiographs may reveal abnormalities in advanced gout as tophus may sometimes erode into bone. Ultrasound may also aid in diagnosis of gout. Treatment consists of anti-inflammatory agents for acute flare-ups and medications that lower serum uric acid levels for long term therapy.
Arthritis may also be caused by deposition of calcium crystals in and around joints. Pseudogout is caused by deposition of calcium pyrophosphate dehydrate (CPPD) crystals in joint fluid, cartilage, and tissues around joints such as tendon and ligaments. Pseudogout is associated with older age, history of joint surgery or trauma, and osteoarthritis. Similar to gout, pseudogout may present with pain, swelling, warmth, and redness of affected joints. Diagnosis is made by aspiration of synovial fluid and identification of calcium pyrophosphate crystals. Symptoms may be relieved with use of anti-inflammatory drugs such as NSAIDs, colchicine, and steroids. Calcific periarthritis and tendonitis is caused by deposits of basic calcium phosphate in tissue around joints. It may occur concurrently with osteoarthritis. Treatment with NSAIDs and intra-articular steroid injection may help symptoms.
Psoriatic Arthritis is an autoimmune arthritis associated with skin psoriasis. Psoriatic arthritis presents with the typical red scaly rash seen in psoriasis, abnormal appearance of the nails, pain, swelling, and stiffness of joints, and dactylitis (“sausage digits”) which appears as swelling of an entire finger/toe. Diagnosis is based on clinical evaluation and x-ray findings showing a combination of new bone formation near the joint and erosions or bone loss. Ultrasound may also be useful in evaluation of bone changes, abnormal tendons, and ligament insertions. Treatment is similar to rheumatoid arthritis and includes management with oral, injectable, and infusible medication which target the immune system.
Ankylosing Spondylitis is a chronic autoimmune disease of the joints in the spine and sacroiliac joints which is characterized with back and buttock pain, stiffness, and fatigue. It may also be associated with eye disease (uveitis), bowel disease (inflammatory bowel disease) and heart involvement (particularly involving the aortic valve). It occurs more commonly in men and is diagnosed in late adolescence or early adulthood. X-rays which show fusion of bones in the spine or abnormality of the sacroiliac joints help confirm the diagnosis. Treatment is with oral, injectable and infusible immunosuppressive medications.
Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by auto-antibodies (Anti-nuclear antibody or ANA), skin rash, arthritis, oral/nasal ulcers, kidney disease, brain and nerve involvement and abnormalities in blood counts. SLE is common in women during reproductive years. Diagnosis is made by identifying ANA with other auto-antibodies and clinical examination that reveals involvement of multiple organ systems. Treatment with immunosuppressive medications including steroids is determined by which organ systems are involved. Lupus can also occur with skin involvement without systemic manifestations as is the case with discoid lupus and subacute cutaneous lupus. Treatment of skin manifestation in all cases involves reduction of sun exposure and possible use of topical and oral medication.
Antiphospholipid Antibody Syndrome is an autoimmune disorder characterized by auto-antibodies that predispose an individual to both arterial and venous blood clot formation. Depending on which systems are involved, the syndrome may cause strokes, kidney problems, skin ulcers, pregnancy loss or morbidity. Antiphospholipid antibody syndrome can occur as a distinct syndrome or be a manifestation of lupus. Treatment involves anticoagulation if a blood clots and may be life long. During pregnancy, anticoagulation with heparin and aspirin can be used to decrease rates of pregnancy loss.
Scleroderma is an autoimmune disorder which presents with skin thickening, Raynaud’s phenomenon, lung, kidney, and gastrointestinal involvement, and tendon sheath inflammation and arthritis. There are two forms: limited cutaneous disease and diffuse cutaneous disease defined by skin involvement. Diagnosis is based on clinical examination, presence of auto-antibody tests, and studies evaluating the organ systems involved in the presentation. Treatment may involve immunosuppressive medications and medications guided by the involved organ systems.
Sjogren’s syndrome is an autoimmune disease characterized by dry eyes and dry mouth symptoms secondary to progressive lacrimal and salivary gland dysfunction. Occasionally, Sjogren’s may have extraglandular manifestations and also involve joint pain, arthritis, thyroid disease, kidney disease, and lung disease. Diagnosis is made by the presence of auto-antibodies including anti-nuclear antibody, anti- RO antibody, or anti-La antibody and documentation of decreased excretion of tears and saliva. Biopsy of a salivary gland may also help in the diagnosis. Sjogren’s syndrome may occur in association with another autoimmune disorder such as rheumatoid arthritis or lupus. Management is symptomatic with the use of agents to stimulate tear production and lubricating eye drops, salivary substitutes, frequent moistening of mouth with sips of water, and use of sugar-free lozenges. Involvement of extraglandular sites may require treatment with immunosuppressive medication.
Vasculitis is a condition involving infiltration of inflammatory cells into the blood vessel walls. Vasculitis is potentially characterized by fatigue, fevers, and weight loss and is further defined by which sized vessels are affected, i.e. large, medium or small. Large vessel vasculitis presents with limb pain, pulselessness, cardiovascular symptoms from involvement of the aortic valve, headaches, and neurologic symptoms. Medium vessel vasculitis may present with nerve involvement, skin ulcers, abdominal pain or bowel perforation, and skin ulcers. Small vessel vasculitis may present involvement of the lung, kidney, skin, and nervous system. Diagnosis is made by clinical examination, elevation of inflammatory markers, presence of antibodies such as anti-nuclear cytoplasmic antibodies (ANCAs) in some disease states, and by imaging and potentially biopsy of the affected tissue. Treatment is dependent on the organ system affected and involves immunosuppressive medication.
Polymyalgia Rheumatica (PMR) is a syndrome of muscle pain and stiffness in the shoulders, neck, and hip muscle groups. PMR presents in older patients and is associated with an elevated erythrocyte sedimentation rate (ESR). It may occur concurrently with a type of vasculitis called Giant Cell Artertis. Treatment is with oral steroids over a prolonged period of time.
Polymyositis (PM) and Dermatomyositis (DM) are autoimmune diseases which are characterized by chronic inflammation of muscle and skin which may be associated with lung, involvement. PM and DM present with non-tender muscle weakness in the proximal muscle groups. DM is characterized by skin involvement. The diagnosis is made by clinical examination and laboratory data showing elevations in muscle enzymes (i.e. creatnine phosphokinase) and abnormalities on electromyography(EMG) and MRI of muscles. The diagnosis is confirmed with muscle biopsy demonstrating muscle degeneration and regeneration and inflammatory cells invading muscle fibers and areas around blood vessels supplying the muscle fibers. Treatment is with immuosuppressive medication including steroids.