Dr Heidi Siddle PhD

FCPM, FFPM RCPS (Glasg)

NIHR Clinical Lecturer

Principal Podiatrist

Leeds Teaching Hospitals NHS Trust

Associate Professor, University of Leeds

Ultrasound imaging to support rheumatology

clinical practice and research

Imaging in RA

The role of imaging in RA has been firmly

established.

A diagnostic and prognostic tool in clinical

practice and research.

It is particularly important and useful in predicting

the long-term outcome of patients in the early

stages of disease.

Optimally manage the patient’s disease at a time

point where potentially damage is preventable.

Conventional Radiography versus Ultrasound and MRI

Radiographic images do not identify changes

synonymous with RA e.g. bone erosions until

after irreversible joint damage has occurred.

More sensitive techniques such as ultrasound

imaging and MRI are able to detect synovitis,

effusions and erosions much earlier than CR.

The use of ultrasound has raised questions about

the definition of true remission.

Ultrasound Imaging

Musculoskeletal ultrasound has evolved into an

important method for:

identifying musculoskeletal abnormalities,

confirming the diagnosis in patients with

suspected inflammatory arthritis,

monitoring therapeutic response,

influencing clinical decision making and

guiding interventions.

Ultrasound Imaging

Ultrasound techniques can be used to detect the

level of inflammation in the joints and soft tissues

of patients with RA, more sensitive than clinical

examination.

B-mode (grey scale) ultrasound used to detect

thickened synovial membranes in inflamed joints,

bursae and tendon sheaths, and bone erosions.

(Power) Doppler signal to detect increased

synovial blood flow due to inflammation.

Outcome Measure in Rheumatology (OMERACT)

definitions

Synovitis is abnormal hypoechoic intraarticular tissue that is non displaceable and poorly compressible which may exhibit Doppler signal (Wakefield et al 2005)

Outcome Measures in Rheumatology Clinical Trials (OMERACT)

Tenosynovitis is hypoechoic or anechoic

thickened tissue with or without fluid within the

tendon sheath, which is seen in two perpendicular

planes and which may exhibit Doppler signal (Wakefield et al 2005)

Tenosynovitis

SEVERE ECRB TENOSYNOVITIS

Tenosynovitis (cross-section)

THICKENED SHEATH WITH INFLAMMATION

EROSION – NO ACTIVE INFLAMMATION EROSION WITH ACTIVE INFLAMMATION

Bone erosion is an intra-articular

discontinuity of the bone surface that is

visible in two perpendicular

planes (Wakefield et al 2005)

Erosions

Early small erosions are difficult to see with x-ray

because of their typical ‘en face’ anatomical site

Ultrasound is a reliable technique for

– detecting bone erosions in RA

– especially in early disease

– detects more erosions than conventional

radiography

(Wakefield et al 2000, Backhaus et al 2002,

Lopez-Ben et al 2004, Szkudlarek et al 2004)

Erosions

However…

Dependent upon good technique and perpendicular

positioning of the transducer.

– Forefoot acoustic access is only possible from the

dorsal and plantar aspects

– incomplete coverage of the medial and lateral aspects

of the joint

– erosions may be missed.

Clearly depicts contour defects in the surface of the bone

Less reliable than 3D MRI in demonstrating deeper

erosions with a narrow connection to the joint surface (Backhaus et al 2002)

Assessment of disease activity and response to treatment

Power Doppler signal predictive value in:

– Diagnosis of very early RA

– Determining disease activity and relapse

– Radiographic damage

– Progression in patients with early disease

– Patients with RA whose disease is in remission

(Szkudlarek et al 2001, Naredo et al 2007, Freeston et al

2010, Dougados et al 2012, Foltz et al 2012)

Clinical Remission versus Ultrasound Remission

Use of ultrasound has raised questions about the

definition of true remission.

Ultrasound detected synovitis has been reported in the

joints of those patients on DMARDs and anti-TNF

medication who are considered to be in clinical remission

according to remission criteria such as ACR and DAS28

(Brown et al 2006, Wakefield et al 2007)

In early RA, US-driven T2T strategy led to more intensive

treatment, but was not associated with significantly better

clinical or imaging outcomes than a DAS28-driven

strategy (Dale et al 2016)

Global ultrasound score

Potential to objectively reflect the “real” level of

synovitis (disease activity) compared with

conventional clinical measures.

12-joint score (Naredo et al 2008)

7-joint score (Backhaus et al 2009)

Systematic literature review by the OMERACT

Ultrasound Task Force (Mandl et al 2011)

– difficult to determine a minimal number of joints

to be included in a global ultrasound score and

further validation is required

Assessment of the foot

Deformity, overlying structures and oedema pose

potential problems when undertaking clinical

examination of the foot

Ultrasound examination has be shown to be more

sensitive than clinical examination for detecting

synovitis, tenosynovitis and bursae in the foot of

patients with RA (Luukkainen et al 2003, Wakefield et al 2003, Ostergaard et al 2005a,

Ostergaard et al 2005b, Wakefield et al 2008, Bowen et al 2010, Riente et al

2011Scire et al 2011)

Development of OMERACT Foot and ankle

Ultrasound Scoring System in RA (FUSS-RA)

R AT

Osteoarthritis of midfoot

OA of the midfoot has previously been reported

as being relatively uncommon (prevalence of

3.8%) (Van Saase et al 1989, Wilder et al 2005)

Medial midfoot OA is more prevalent than

previously described (Menz et al. 2007, Roddy et al 2015)

Patients indicate pain to the dorsal midfoot area

with radiographic confirmed OA (Halstead et al. 2015)

– Cuneiform-second metatarsal joint (73 %)

– Navicular-medial cuneiform joint (51 %)

– Cuneiform-first metatarsal joint (46 %)

– Talonavicular joint (24 %)

Inflammatory disease of midfoot in RA

Midfoot pain reported by 17% of patients with RA

during the course of their disease (Otter et al 2010)

Midfoot synovitis detected on ultrasound 27-55% of

patients (Suzuki et al 2009, Suzuki & Okomoto 2013, Chan et al 2014)

Ultrasound better at detecting midfoot synovitis than

clinical examination (Wakefield et al 2008, Chan et al 2014

DAS28 positively associated with ultrasound

synovitis in the midfoot joints (Sant’ Ana Petetterle et al 2013)

What does ultrasound offer?

To differentiate between inflammatory and

mechanical disease will enable the clinician to

direct their treatment strategies more

appropriately.

To differentiate between joints that require

treatment with:

– mechanical interventions such as orthoses and

footwear

– local or systemic treatment of inflammatory

disease: ultrasound guided injection,

IM injection or review of disease activity.

Talo-navicular Joint and Navicular-cuneiform Joint

TAL NAV Medial

Tarsometatarsal Joint

Cuneiform Metatarsal

Calcaneo-cuboid Joint

CAL CUB

5th Tarsometatarsal Joint

Cuboid

Base 5th Met

PB

Case study

Female, age 56

Diagnosis osteoarthritis

Persistent dorsal midfoot pain

Clinically - bony changes evident

Minimal improvement with footwear modifications

and orthoses provision

Referred for ultrasound +/- injection

Navicular – Medial Cuneiform Joint

NAV

CUN

Foot and Ankle corticosteroid injections in RA & SpA D’Agostino et al 2005

Clinician abandoned the planned injections

– Tibiotalar joint (18.6%)

– Tarsometatarsal joints (16.0%)

– Retrocalcaneal bursa (33.3%).

US results in unplanned injections

– Navicular-cuneiform joints (58.3%)

– Calcaneo-cuboid joint (35.8%)

– Subtalar (34.5%) joints

– Tibialis posterior tendon (33.3%).

Training requirements and qualifications

There is no legal requirement to hold a

recognised ultrasound qualification in order to

practice as a sonographer in the UK

Sonography is not recognised as a profession by

the Health and Care Professions Council (HCPC)

The European Federation of Societies for

Ultrasound in Medicine and Biology (EFSUMB)

Minimum Training Requirements for

Rheumatologists Performing Musculoskeletal

Ultrasound (The rheumatology-COMPASS)

Training requirements and qualifications

Currently all formal training in the UK for Ultrasound is at

a post graduate level.

CASE (The Consortium for the Accreditation of

Sonographic Education) is a recognised body in the UK

which accredits Ultrasound Courses in UK Universities.

EULAR: Defining the education and training needs of

Health Professionals undertaking Musculoskeletal

Ultrasound for Inflammatory arthritis and osteoarthritis

CoP Ultrasound in Podiatry SAG - Survey

Acknowledgements

Dr Richard Wakefield

Laura Horton – Sonographer

NIHR

OMERACT FUSS-RA Ultrasound Group

Ultrasound in Podiatry Specialist Advisory Group

Network

h.siddle@leeds.ac.uk