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Guidelines for Musculoskeletal Ultrasound in Rheumatology

1. Introduction Within the past decade, musculoskeletal ultrasound (US) has become an established imaging technique for the diagnosis and follow up of patients with rheumatic diseases.1-5 This has been made possible through technological improvements, resulting in faster computers and higher frequency transducers.

Guidelines for Musculoskeletal Ultrasound in Rheumatology 1

US is most commonly used in the assessment of soft tissue disease or detection of fluid collection and can also be used to visualise other structures, such as cartilage and bone surfaces.6 7 Owing to the better axial and lateral resolution of US, even minute bone surface abnormalities may be depicted. Thus destructive and/or reparative/hypertrophic changes on the bone surface may be seen before they are apparent on plainx rays or even magnetic resonance imaging.

8 However, US wave frequencies cannot penetrate into bone, therefore imaging of intra-articular disease is usually not possible. The real time capability of US allows dynamic assessment of joint and tendon movements, which can often aid the detection of structural abnormalities. Advantages of US include its non-invasiveness, portability, relative inexpensiveness, lack of ionising radiation, and its ability to be repeated as often as necessary, making it particularly useful for the monitoring of treatment.

US can also be used for guidance of aspiration, biopsy, and injection treatment.9 Most musculoskeletal work is performed using grey scale, which means images are produced in a black and white format; each white dot in the image represents a reflected sound wave. Sound waves travel in a similar way to light waves and therefore the denser a material isfor example, bone cortex, the more reflective it is and the whiter it appears on the screen.

Water is the least reflective body material and therefore appears as black as the sound waves travel straight through it. Newer US techniques, which are currently being evaluated, include colour and power Doppler imaging, which provide colour maps of tissues. Here the amount of colour is related to the degree of blood flow, which may be of use in assessment of vascular tissues as may occur in soft tissue inflammation.

Guidelines for Musculoskeletal Ultrasound in Rheumatology 2

10 To increase further the sensitivity of power Doppler intravenous bubble contrast agents are under development. googletag.cmd.

push(function() googletag.display("dfp-ad-mpu"); ); There are few data about which imaging modality is most appropriate in any given situation. Only rarely have the diagnostic values of different imaging techniques in various conditions been compared.

11-13 As US is evolving, its place in patient management is becoming increasingly clear. 2. Technical equipment High quality, high resolution equipment is essential for musculoskeletal work.

The choice of transducer will depend on the type of examinations likely to be undertaken. High frequency (7.520 MHz), linear transducers are generally best for demonstrating superficial structures such as tendons, ligaments, and small joints, whereas low frequency transducers (3.

55 MHz) are sometimes more suited for larger or deeper sited joints such as the shoulder or hip.4 14In US there is a constant compromise between image resolution and depth of penetration of the sound waves. Higher frequency transducers provide better spatial resolution, but these transducers have a shallower depth of penetrance than a lower frequency transducer.

The size of the footprint (the surface area of the transducer in contact with the skin) is also an important factor in examination technique. For example, transducers with a large footprint are often inadequate to visualise fully small joints such as the metacarpophalangeal joints as they cannot be manoeuvred adequately. However, these are only general considerations; the critical issue is the overall image resolution, which has to be analysed and compared carefully before a purchase is made.

For practical reasons it is recommended to test whether with a particular piece of sonographic equipment the fine definition of small structures can be seen, such as the insertion of a small extensor tendon of the finger or the tiny quantity of fluid normally detectable in the pre-Achilles bursa. The practical value of colour Doppler/power Doppler capabilities is still under investigation, especially considering the additional cost. The rationale for colour/power Doppler is the detection of increased soft tissue perfusion.

The potential application of three dimensional US is also currently under evaluation. Finally, consideration needs to be given to methods of image documentation. In general, every examination should be carefully documented.

Images may be recorded on paper, films, video cassettes, laser printed x ray acetates, optical discs, and digital storage systems. All demonstrated structures should be documented in a standardised way to ensure a better reproducibility of these results. Pathological findings should be documented in two perpendicular planes.

Table 1 gives the transducer orientation. View this table:View inline View popup Table 1 Transducer orientation in standardised musculoskeletal examination 3. Teaching and training As US is the most operator dependent imaging modality, the experience and expertise of the examiner will determine the value of the diagnostic information obtained.

Knowledge about the basic principles relevant to sound waves and a detailed knowledge of anatomy is mandatory. Although the procedure itself has no specific side effects, harm may result from incorrect acquisition and interpretation of images owing to operator inexperience. To standardise the quality of musculoskeletal US education, national and international societiesfor example, EULAR, have established training guidelines for US.

Training courses have been organised by experts in US providing hands on experience. However, musculoskeletal US cannot be learnt at a conference over a few days. There is no substitute for proper training under the guidance of an experienced investigator.

Continuous training and education of people performing US is essential. Beginners are therefore encouraged to seek local expertise, where it is available, and the authors of this article are glad to be of help in establishing such contacts in their respective countries. US is most valuable in a clinical setting, in which the clinician can interpret the images in the light of the clinical history and physical examination, enabling ultrasound to become the physician's extended finger.

4 15 However, in some instances, especially for a scientific analysis of the relative values of various imaging modalities, a second view point of an experienced sonographer is necessary to balance the possibility of seeing what one expects to see already from a clinical examination. 4. Standardisation of musculoskeletal US In the following paragraphs a list of detectable diseases, patient positioning, and standard scans are given.

Representative images are provided for a selection of scans. An extensive version with a complete collection of all images of standard scans given can be seen on the internet at the official EULAR web site A link at the bottom of the right side of the screen leads to Imaging in Rheumatology and from there to the Working Group for Musculoskeletal Ultrasound in Rheumatology. 4.

1. SHOULDER JOINT The polyarticular manifestation of rheumatic diseases frequently leads to symptoms earlier in weightbearing joints of the leg. Arthritic joints of the arm may exhibit relatively few symptoms despite marked inflammation.

An early detection of changes of tendons, bursae, rotator cuff, and cartilage is possible by musculoskeletal US, which is essential to establish adequate treatment. To detect inflammatory lesions the anterior, lateral, and posterior, longitudinal and transverse scans with rotation of the shoulder are most helpful. A sensitive technique for finding even very small shoulder effusions is the axillary longitudinal scan, but elevation of the arm may not be possible for patients with advanced disease.


US detectable pathology 1 Rotator cuff: Tear (complete/ partial) Calcific tendinitis 2 Biceps tendon: Tear (complete/partial) Dislocation Tenosynovitis Effusion in the bicipital groove 3 Subcoracoid/subacromial/subdeltoid bursa: Bursitis 4. Axillary recessus: Synovial proliferation Effusion 5 Humeral head: Irregular contour Bone and cartilage lesions (erosions, osteophytes, Hill-Sachs lesion) 6 Joint space: Loose joint bodies Osteochondromatosis 7 Acromioclavicular joint: Dislocation Synovial proliferation/effusion 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 the humerus over the full range of motion with 90 flexed elbow is recommended 4.1.

3. Standard scans 1Anterior transverse scan in neutral position (fig 1)2Anterior transverse scan in maximal internal rotation (fig 2)3Anterior longitudinal scan4Anterior longitudinal scan in maximal internal rotation5Lateral longitudinal scan in neutral position6Lateral longitudinal scan in maximal internal rotation7Posterior transverse scan8Axillary longitudinal scan with raised arm9Acromioclavicular joint scan Download figure Open in new tab Download powerpoint Figure 1 Anterior transverse scan in neutral position at the bicipital groove. h = humerus; t = biceps tendon; d = deltoid muscle.

Download figure Open in new tab Download powerpoint Figure 2 Anterior transverse scan in maximal internal rotation of the shoulder. h = humerus; t = supraspinatus tendon; d = deltoid muscle. 4.

2. ELBOW JOINT Inflammatory lesions in the elbow can most easily be detected early in the disease process in ventral longitudinal scans over the humeroradial and humeroulnar joints. Another common location of synovitis is the olecranon fossa.


US detectable pathology 1 Humeroradial joint: Synovial proliferation Effusion Bony lesion Loose joint body 2 Humeroulnar joint: Synovial proliferation Effusion Bony lesion Loose joint body 3 Olecranon fossa: Synovial proliferation Effusion 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 supination 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 with moderate internal rotation of the humerus 4.2.3.

Standard scans 1Anterior humeroradial longitudinal scan (fig 3)2Anterior humeroulnar longitudinal scan3Anterior transverse scan (fig 4)4Posterior longitudinal scan5Posterior transverse scan (fig 5)6Lateral longitudinal scan in extension7Lateral longitudinal scan in 90 flexion8Medial longitudinal scan Download figure Open in new tab Download powerpoint Figure 3 Anterior humeroradial longitudinal scan at the elbow. h = humerus; r = radius; m = muscles; = articular cartilage Download figure Open in new tab Download powerpoint Figure 4 Anterior transverse scan at the distal humeral epiphysis. h = humerus; = articular cartilage; m = muscles.

Download figure Open in new tab Download powerpoint Figure 5 Posterior transverse scan at the distal humeral epiphysis. h = humerus; = articular cartilage; m = triceps muscle. 4.

3. WRIST In many instances clinical examination of the wrist may be sufficient. With high frequency transducers of 10 MHz and more, even minor synovitic lesions can be detected.

US can also be helpful in differentiating synovial and tenosynovial pathology and examining morphostructural changes of the median nerve in carpal tunnel syndrome. 4.3.

1. US detectable pathology 1 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 Effusion 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 or on an examining table Dynamic examination with active flexion/extension of the fingers 4.3.

3. Standard scans 1 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) Download figure Open in new tab Download powerpoint Figure 6 Volar transverse scan at the carpal tunnel. r = radius; n = median nerve; t = flexor tendons.

4.4. HAND Finger joints are easily accessible to clinical examination.

With high frequency transducers of 10 MHz and more, even minor synovitic lesions can be detected. US can also be helpful in differentiating synovial and tenosynovial pathology. 4.

4.1. US detectable pathology 1Effusion/synovial proliferation2Synovial cysts3Tendinitis/tenosynovitis/tendon tear4Cartilage thinning/lesion5Bony lesion (erosion, change of the bone profile, osteophyte)6Articular dislocation7Ganglion8Periarticular lesions: rheumatoid nodules, crystal deposition, calcinosis 4.

4.2. Positioning of the patient See wrist joint (4.

3.2.) 4.

4.3. Standard scans 1Dorsal longitudinal scan2Dorsal transverse scan (fig 7)3Palmar longitudinal scan (figs 8 and 9)4Palmar transverse scan (fig 10)5Thenar longitudinal scan6Thenar transverse scan7Hypothenar longitudinal scan8Hypothenar transverse scan9Lateral longitudinal scan (proximal interphalangeal (PIP) and metacarpophalangeal I, II, V joints)10 Medial longitudinal scan (PIP joints) Download figure Open in new tab Download powerpoint Figure 7 Dorsal transverse scan at the metacarpal head.

mh = metacarpal head; t = extensor tendon. Download figure Open in new tab Download powerpoint Figure 8 Palmar longitudinal scan at the metacarpophalangeal joint. * = joint cavity; = articular cartilage; pp = proximal phalanx; mh = metacarpal head; t = flexor tendon.

Download figure Open in new tab Download powerpoint Figure 9 Palmar longitudinal scan at the distal interphalangeal joint. * = joint cavity; dp = proximal phalanx; mp = middle phalanx; t = flexor tendon. Download figure Open in new tab Download powerpoint Figure 10 Palmar transverse scan at the metacarpal head.

mh = metacarpal head; = articular cartilage; t = flexor tendon. 4.5.

HIP Only rarely can effusions of the hip joint be detected by clinical examination. Here US is most helpful to detect effusion and synovitis especially before arthrocentesis. The anterior longitudinal scan parallel to the femoral neck is most valuable for the detection of an effusion as well as erosions or osteophytes.

The anterior transverse scan after 90 rotation is necessary before arthrocentesis to define the optimal location and identify vessels which should be avoided. The lateral longitudinal scan is helpful to detect a trochanteric bursitis. 4.

5.1. US detectable pathology 1Joint effusion/synovial proliferation2Cartilage lesion3Bony lesion (erosion, osteophyte, irregular bone surface, slipped capital femoral epiphysis)4(Osteo-)chondromatosis5Loose joint body6Bursa trochanteric/iliopectineal bursitis7Infection or loosening of prosthesis8Calcifications 4.

5.2. Positioning of the patient Supine position Hip joint in neutral position 4.

5.3. Standard scans 1Anterior longitudinal scan (fig 11)2Anterior transverse scan3Lateral longitudinal scan Download figure Open in new tab Download powerpoint Figure 11 Anterior longitudinal scan at the hip.

a = acetabulum; f = femur; * = joint cavity; m = muscles. 4.6.

KNEE In contrast with the hip, the knee joint is easily accessible to clinical examination. However, very small effusions or synovitic proliferations which are missed clinically can often be demonstrated by US. Small amounts of effusion can be detected in the suprapatellar longitudinal and transverse scans in neutral position when pressure is exerted on the suprapatellar and parapatellar pouch by tightening of the quadriceps muscle.

An important indication for musculoskeletal US is the examination of pathological processes of the popliteal region. Popliteal cysts (Baker's cysts) are fluid accumulation in the bursa of the gastrocnemius or semimembranosus muscles. Frequently those cysts communicate with the joint space.

To confirm the diagnosis of a popliteal cyst this comma shaped extension has to be visualised sonographically in the posterior transverse scan between the medial head of gastrocnemius and semimembranosus tendon. Popliteal cysts can extend far into thigh and calf muscles and US allows precise definition of their shape and size. A rupture of a popliteal cyst, which may clinically mimic a deep vein thrombosis, is easily identified by US.

Loose joint bodies in the knee can be detected sonographically in the suprapatellar pouch and in the infrapatellar and popliteal regions. However, the failure to detect a loose body in the knee or any other joint can never rule out its presence. 4.

6.1. US detectable pathology 1 Suprapatellar and parapatellar pouch: Synovial proliferation Synovial folds Effusion 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 signs of 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 intercondylar sulcus Dynamic examination of the suprapatellar pouch with relaxed and contracted quadriceps muscle 4.6.3.

Standard scans 1Suprapatellar longitudinal scan 2Suprapatellar transverse scan in neutral position 3Suprapatellar transverse scan in maximal flexion (fig 12) 4Infrapatellar longitudinal scan 5Infrapatellar transverse scan 6Medial longitudinal scan 7Lateral longitudinal scan 8Posterior medial longitudinal scan 9Posterior lateral longitudinal scan10Posterior transverse scan Download figure Open in new tab Download powerpoint Figure 12 Suprapatellar transverse scan in maximal flexion. f = femur; = articular cartilage. 4.

7. ANKLE AND HEEL Inflammatory changes of the ankle and talocalcaneonavicular joints are easily detectable by US, as are tenosynovitis of tibialis anterior, posterior, and peroneus tendons. The Achilles tendon can by examined by US in its full length, and calcifications, ruptures, and bursitis can be differentiated.

In patients with heel pain, lesions of the plantar fascia, calcaneus spurs, and erosions can be detected sonographically. 4.7.

1. US detectable pathology 1 Ankle and talocalcaneonavicular joint: Synovial proliferation Effusion 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 Tear (partial/complete) Tendinitis/paratendinitis Nodules (tophy, rheumatoid nodules, xanthomas) 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 scans 1 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 Download figure Open in new tab Download powerpoint Figure 13 Anterior longitudinal scan at the ankle. tib = tibia; tal = talus; = articular cartilage. Download figure Open in new tab Download powerpoint Figure 14 Posterior longitudinal scan at the heel.

t = achilles tendon; cal = calcaneus; k = Kager's fat pat. 4.8.

FOOT Toes are easily accessible to clinical examination. With high frequency transducers of 10 MHz and more, even minor synovitic lesions can be detected. US can also be helpful in differentiating synovial and tenosynovial disease.

Lesions of tophaceous gout can be identified by US because of their typical sound shadow. 4.8.

1. US detectable pathology 1 Plantar fascia: Plantar fasciitis 2 Joints: Effusion/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 scans All scans performed moving from proximal to distal.1Plantar longitudinal scan2Plantar transverse scan3Dorsal longitudinal scan (fig 15)4Dorsal transverse scan5Lateral scan (first and fifth toe) Download figure Open in new tab Download powerpoint Figure 15 Dorsal longitudinal scan at the first toe.

mh = metatarsal head; ; pp = proximal phalanx; t = extensor tendon; * = joint cavity; = articular cartilage. References Gibbon WW, Wakefield RJ (1999) Ultrasound in inflammatory disease. Radiol Clin North Am 37:633651, .

OpenUrlCrossRefPubMedWeb of Science Grassi W, Cervini C (1998) Ultrasonography in rheumatology: an evolving technique. Ann Rheum Dis 57:268271, .OpenUrlFREE Full Text Wakefield RJ, Gibbon WW, Emery P (1999) The current status of ultrasonography in rheumatology.

Rheumatology (Oxford) 38:195198, .OpenUrlFREE Full Text Manger B, Kalden JR (1995) Joint and connective tissue ultrasonographya rheumatologic bedside procedure? A German experience.

Arthritis Rheum 38:736742, .OpenUrlPubMedWeb of Science Manger B, Backhaus M (1997) [Ultrasound diagnosis of rheumatic/inflammatory joint diseases.] Z Arztl Fortbild Qualitatssich 91:341345, .

OpenUrlPubMed Grassi W, Tittarelli E, Pirani O, Avaltroni D, Cervini C (1993) Ultrasound examination of metacarpophalangeal joints in rheumatoid arthritis. Scand J Rheumatol 22:243247, .OpenUrlPubMedWeb of Science Grassi W, Lamanna G, Farina A, Cervini C (1999) Sonographic imaging of normal and osteoarthritic cartilage.

Semin Arthritis Rheum 28:398403, .OpenUrlCrossRefPubMedWeb of Science Backhaus M, Kamradt T, Sandrock D, Loreck D, Fritz J, Wolf KJ, et al. (1999) Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging.

Arthritis Rheum 42:12321245, .OpenUrlCrossRefPubMedWeb of Science Grassi W, Lamanna G, Farina A, Cervini C (1999) Synovitis of small joints: sonographic guided diagnostic and therapeutic approach. Ann Rheum Dis 58:595597, .

OpenUrlAbstract/FREE Full Text Hau M, Schultz H, Tony HP, Keberle M, Jahns R, Haerten R, et al. (1999) Evaluation of pannus and vascularization of the metacarpophalangeal and proximal interphalangeal joints in rheumatoid arthritis by high-resolution ultrasound (multidimensional linear array). Arthritis Rheum 42:23032308, .

OpenUrlCrossRefPubMedWeb of Science Swen WA, Jacobs JW, Hubach PC, Klasens JH, Algra PR, Bijlsma JW (2000) Comparison of sonography and magnetic resonance imaging for the diagnosis of partial tears of finger extensor tendons in rheumatoid arthritis. Rheumatology (Oxford) 39:5562, .OpenUrlAbstract/FREE Full Text Swen WA, Jacobs JW, Neve WC, Bal D, Bijlsma JW (1998) Is sonography performed by the rheumatologist as useful as arthrography executed by the radiologist for the assessment of full thickness rotator cuff tears?

J Rheumatol 25:18001806, .OpenUrlPubMedWeb of Science Swen WA, Jacobs JW, Algra PR, Manoliu RA, Rijkmans J, Willems WJ, et al. (1999) Sonography and magnetic resonance imaging equivalent for the assessment of full-thickness rotator cuff tears.

Arthritis Rheum 42:22312238, .OpenUrlCrossRefPubMedWeb of Science Grassi W, Tittarelli E, Blasetti P, Pirani O, Cervini C (1995) Finger tendon involvement in rheumatoid arthritis. Evaluation with high-frequency sonography.

Arthritis Rheum 38:786794, .OpenUrlPubMedWeb of Science Leeb BF, Stenzel I, Czembirek H, Smolen JS (1995) Diagnostic use of office-based ultrasound. Baker's cyst of the right knee joint.

Arthritis Rheum 38:859861, .OpenUrlPubMedWeb of Science Footnotes * The Working Group for Musculoskeletal Ultrasound in the EULAR Standing Committee on International Clinical Studies including Therapeutic Trials

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A 50 year old man presented with an exacerbation of longstanding ankylosing spondylitis affecting cervical and lumbar spine, both hips, and both ankles and heels. He had noted a recent spontaneous increase in left lower calf and heel pain that was beginning to resolve. On clinical examination he was found to have tenderness in both Achilles tendonsleft worse than rightconsistent with a diagnosis of bilateral Achilles tendonitis. A US examination was performed to confirm the diagnosis. The right Achilles tendon was normal. At the middle third of the left Achilles tendon a 2 cm0.25 cm0.36 cm anechoic collection was observed within the Achilles tendon (fig 2). A small area of disruption between the fibres of the deep part of the Achilles tendon was noted adjacent to the collection. The findings were consistent with a left Achilles tendon cystic fluid collection resulting from an atraumatic longitudinal Achilles tendon tear. No evidence of retrocalcaneal bursitis was found, and the Achilles pain was managed conservatively. googletag.cmd.push(function() googletag.display("dfp-ad-mpu"); ); Case 3: Diagnosis and treatment of tennis leg with ultrasound imaging (fig 3)Download figure Open in new tab Download powerpoint Figure 3 Tennis Leg. Serial Longitudinal images of the calf: (1) There is a well localised hypoechoic collection (C) interposed between the medial head of the gastrocnemius (G) and the soleus muscle (S), typical of a tear. (2) About 30 ml of blood stained fluid was drained with a 21G needle (N) under ultrasound guidance. (3) This resulted in the collapse of the central hypoechoic fluid collection with restoration of the normal apposition of the gastrocnemius and soleus muscles. A 51 year old man in good health presented with diffuse swelling and tenderness of the right calf, worse on weight bearing. This had developed acutely during a tennis match, but had worsened over four days. He was due to undertake a long haul flight and wanted a musculoskeletal injury to be confirmed and a DVT excluded. A US study of the calf demonstrated a well localised hypoechoic collection interposed between the medial head of the gastrocnemius and the soleus muscle, typical of a small tear of the medial head of gastrocnemius or of the plantaris tendon. About 30 ml of serosanguinous fluid was drained under US guidance, resulting in collapse of the central hypoechoic fluid collection and restoration of the normal apposition of the gastrocnemius and soleus muscles. The patient noted a marked symptomatic and functional improvement immediately after the procedure. DISCUSSION The differential diagnosis of calf pain and swelling includes DVT, cellulitis, Bakers cyst, muscular injury, tumour or infection, arterial aneurysm, and Achilles tendon inflammation or rupture. Much emphasis in current clinical practice is placed on the diagnosis of DVT owing to the serious risk of pulmonary embolism.1 The sophisticated use of risk stratification models, D-dimer measurement, and Duplex venous studies correctly identifies most DVTs. However, a number of musculoskeletal disorders may present with a similar clinical picture and require careful evaluation in order to avoid inappropriate investigation and management. Dual pathology of a DVT and Bakers cyst has been reported in 3% of DVTs, and the compressive effects of the cyst may predispose to the development of a DVT.2 Additionally, D-dimer levels may be raised in patients with inflammatory arthritis,3 leading to a false positive result and unnecessary investigations and treatment. Although dual pathology or the presentation of a Bakers cyst mimicking a DVT is well described, it is often not considered or diagnosed during the initial venous US study. We suggest that both venous and musculoskeletal US scanning should be performed in cases of acute calf pain and swelling and in all cases of calf pain with a negative venous US examination. In the three cases described, a careful history was the key to the identification of a probable underlying musculoskeletal disorder. In the first case the patient presented to casualty and gave a history of acute calf pain and swelling. D-dimer levels were raised and treatment was started with low molecular weight heparin. Her symptoms subsequently worsened with a further leak of the Bakers cyst. On further questioning, she admitted to a much longer history of calf swelling, and MSUS confirmed a massive Bakers cyst. In the second case the patient clearly identified a recent atraumatic exacerbation of calf pain on a background of longstanding Achilles enthesopathy. MSUS was performed to see if the recent worsening of symptoms was due to the development of retrocalcaneal bursitis that would have been amenable to corticosteroid injection. In the third case the sudden onset of pain while engaged in a non-contact activity suggested a diagnosis of muscular injury. The subsequent development of swelling with a planned long haul flight led to the need to confirm the diagnosis by MSUS. Clinical examination in all three patients allowed localisation of tenderness and swelling, but in all three cases MSUS imaging gave a rapid, anatomical confirmation of the diagnosis. MSUS is increasing in use in rheumatological practice because it allows detailed anatomical evaluation of joints and surrounding soft tissues. It is safe (no ionising radiation), reproducible, portable, inexpensive by comparison with computed tomography (CT) and magnetic resonance imaging (MRI) scanning and may be performed rapidly by the experienced examiner.4,5 The application of MSUS has been clearly shown to be better than the detection on clinical examination of knee effusion and popliteal cyst in rheumatoid arthritis,68 better for the detection of enthesopathy9 in the leg, and better for the localisation of effusions for aspiration.10 Bakers cyst (enlargement of the gastrocnemio-semimembranosus bursa) is a common cause of calf swelling and may be confirmed by orthography, ultrasound, CT scanning or MRI. MSUS is the preferred investigation as it is inexpensive, sensitive, and widely available. Asymptomatic cysts found incidentally do not require treatment. Symptoms usually develop when a cyst enlarges or leaks into the calf, producing swelling and pain. Specific treatment with intra-articular knee injection may relieve symptoms if a knee effusion is present, thus reducing the production of synovial fluid in the knee and subsequent filling into the Bakers cyst. Direct aspiration of a Bakers cyst may be performed when it produces significant local pressure and discomfort. In cases of large or recalcitrant cysts, surgical excision of the cyst and its connection to the joint produces relief of symptoms, but failure to treat associated knee inflammation adequately may lead to a high rate of recurrence.11 In inflammatory arthritis, Achilles tendonitis is often associated with retrocalcaneal bursitis,12,13 which responds to corticosteroid injection of the bursa under MSUS guidance.14 Examination of the Achilles tendon insertion underestimates the presence of retrocalcaneal bursitis as compared with MSUS. In the second case we sought to determine if the recent increase in symptoms related to a bursitis but instead found evidence of a previous minor Achilles tendon rupture with associated fluid collection. As injection of corticosteroid adjacent to the Achilles tendon may be associated with a further softening of the Achilles tendon and possible rupture, we chose not to proceed with bursal injection.15,16 Complete or partial rupture of the fibres of the musculotendinous junction of the medial head of the gastrocnemius muscle, also called tennis leg, is one of the most common muscle injuries in men older than 40 years who participate in racquet sports, alpine skiing, and running.17 It causes acute leg swelling and tenderness with significant functional impairment, but usually resolves after a few weeks with a low recurrence rate. MSUS allows for rapid confirmation of the clinical diagnosis17,18 and exclusion of other disease. Partial muscle tears are seen on US as either small ( US features are similar, though the fluid collection associated with a plantaris tendon tear may be more proximal and the ruptured plantaris tendon may be visualised. US is an inexpensive, safe, and quick diagnostic test in suspected tennis leg. When a haematoma or fluid collection is present, US guided drainage may produce a rapid relief of symptoms and restoration of function. MSUS improves the success rate of joint aspiration in everyday rheumatology practice.10 In the first case, aspiration using real time US imaging was unsuccessful, possibly because the collection was long standing and gelatinous. The hypoechoic nature of the cyst was more typical for an effusion, and further confirmation of a gelatinous cyst at surgery was not possible. In the third case, US guided aspiration of the blood stained collection was successful and produced a prompt symptomatic response. MSUS has the potential to significantly improve clinical diagnosis and management of patients presenting with calf pain. Rheumatologists are increasingly using MSUS in their daily practice to aid diagnosis and therapeutic skills. Initial evidence suggests that the application of MSUS in rheumatology improves diagnostic and therapeutic skills and has a significant impact on patient management.19 THE LESSONS Careful evaluation of the history usually indicates a musculoskeletal cause of calf pain. D-dimers may be raised in patients with inflammatory arthritis in the absence of a DVT. The presentation of a Bakers cyst mimicking a DVT is well described; we recommend musculoskeletal ultrasound in all cases of calf pain and swelling with a negative venous ultrasound study of the lower limbs. Musculoskeletal ultrasound allows differentiation of synovial fluid cysts or collections from muscle haematoma and tears aiding rapid differential diagnosis of a number of causes of musculoskeletal calf pain. Musculoskeletal ultrasound allows guidance of injection therapy in the management of calf pain. REFERENCES Janssen MC, Wollersheim H, Verbruggen B, Novakova IR. Rapid D-dimer assays to exclude deep venous thrombosis and pulmonary embolism: current status and new developments. Semin Thromb Hemost1998;24:393400.OpenUrlPubMedWeb of Science Langsfeld M, Matteson B, Johnson W, Wascher D, Goodnough J, Weinstein E. Bakers cysts mimicking the symptoms of deep vein thrombosis: diagnosis with venous duplex scanning. J Vasc Surg1997;25:65862.OpenUrlCrossRefPubMedWeb of Science McEntegart A, Capell HA, Creran D, Rumley A, Woodward M, Lowe GD. Cardiovascular risk factors, including thrombotic variables, in a population with rheumatoid arthritis. Rheumatology (Oxford)2001;40:6404. Balint PV, Sturrock RD. Intraobserver repeatability and interobserver reproducibility in musculoskeletal ultrasound imaging measurements. Clin Exp Rheumatol2001;19:8992.OpenUrlPubMedWeb of Science Wakefield RJ, Gibbon WW, Emery P. The current status of ultrasonography in rheumatology. Rheumatology (Oxford)1999;38:1958. Fam AG, Wilson SR, Holmberg S. Ultrasound evaluation of popliteal cysts on osteoarthritis of the knee. J Rheumatol1982;9:42834.OpenUrlPubMedWeb of Science Hauzeur JP, Mathy L, De Maertelaer V. Comparison between clinical evaluation and ultrasonography in detecting hydrarthrosis of the knee. J Rheumatol1999;26:26813.OpenUrlPubMedWeb of Science Cellerini M, Salti S, Trapani S, DElia G, Falcini F, Villari N. Correlation between clinical and ultrasound assessment of the knee in children with mono-articular or pauci-articular juvenile rheumatoid arthritis. Pediatr Radiol1999;29:11723.OpenUrlCrossRefPubMedWeb of Science Lehtinen A, Taavitsainen M, Leirisalo-Repo M. Sonographic analysis of enthesopathy in the lower extremities of patients with spondylarthropathy. Clin Exp Rheumatol1994;12:1438.OpenUrlPubMedWeb of Science Balint PV, Kane D, Hunter JA, McInnes IB, Field M, Sturrock RD. A comparison of ultrasound-guided with conventional guided joint aspiration in rheumatology practicea pilot study. J Rheumatol2002;29:220913.OpenUrlAbstract/FREE Full Text Handy JR. Popliteal cysts in adults: a review. Semin Arthritis Rheum2001;31:10818.OpenUrlCrossRefPubMedWeb of Science Balint PV, Sturrock RD. Inflamed retrocalcaneal bursa and Achilles tendonitis in psoriatic arthritis demonstrated by ultrasonography. Ann Rheum Dis2000;59:9313.OpenUrlAbstract/FREE Full Text Cunnane G, Brophy DP, Gibney RG, Fitz Gerald O. Diagnosis and treatment of heel pain in chronic inflammatory arthritis using ultrasound. Semin Arthritis Rheum1996;25:3839.OpenUrlCrossRefPubMedWeb of Science Brophy DP, Cunnane G, Fitzgerald O, Gibney RG. Technical report: ultrasound guidance for injection of soft tissue lesions around the heel in chronic inflammatory arthritis. Clin Radiol1995;50:1202.OpenUrlCrossRefPubMedWeb of Science Shrier I, Matheson GO, Kohl HW 3rd. chilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med1996;6:24550.OpenUrlCrossRefPubMedWeb of Science Waterston SW, Maffulli N, Ewen SW. Subcutaneous rupture of the Achilles tendon: basic science and some aspects of clinical practice. Br J Sports Med1997;31:28598.OpenUrlFREE Full Text Bianchi S, Martinoli C, Abdelwahab IF, Derchi LE, Damiani S. Sonographic evaluation of tears of the gastrocnemius medial head (tennis leg) [see comments]. J Ultrasound Med1998;17:15762.OpenUrlAbstract Gaulrapp H. [Tennis leg: ultrasound differential diagnosis and follow-up.] Sportverletz Sportschaden1999;13:538.OpenUrlCrossRefPubMedWeb of Science Karim Z, Wakefield RJ, Conaghan PG, Lawson CA, Goh E, Quinn MA, et al. The impact of ultrasonography on diagnosis and management of patients with musculoskeletal conditions. Arthritis Rheum2001;44:29323.OpenUrlCrossRefPubMedWeb of Science Footnotes Series editor: Anthony D Woolf
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