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 Table of Contents  
Year : 2022  |  Volume : 36  |  Issue : 1  |  Page : 22-26

Ultrasonographic evaluation of painful joints in rheumatoid arthritis: Comparison with conventional radiography

1 Department of Radiodiagnosis, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
2 Department of Anaesthesiology, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
3 Department of Pulmonary and Critical Care Medicine, KGMU, Lucknow, Uttar Pradesh, India

Date of Submission08-Jan-2022
Date of Decision04-Mar-2022
Date of Acceptance17-Mar-2022
Date of Web Publication25-Apr-2022

Correspondence Address:
Dr. Sadaf Sultana
Flat No. E1, Sagheera Apartment, Medical Road, Near Fair Price Shopping Mall, Aligarh - 202 001, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_2_22

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Context: High-frequency ultrasound (US) of painful rheumatoid joints allows an increasingly refined analysis of the extent of joint involvement and disease activity. Aims: The aim of this study was to establish the role of the US in the evaluation of painful hand joints in patients with rheumatoid arthritis (RA) and its comparison with Conventional Radiography (CR) changes. Settings and Design: Cross-sectional study. Subjects and Methods: Patients diagnosed with RA were assessed by a thorough clinical examination and relevant laboratory investigations. After X-ray imaging, grayscale, and power Doppler US examination of the wrist, metacarpophalangeal, and proximal interphalangeal joints of both hands were performed using a high-frequency linear transducer. Statistical Analysis Used: SPSS version 20.0 (a statistical package for the social sciences) was used to collect, tabulate, and analyze all data. The results were presented as mean standard deviation or percentage. Differences in categorical data were compared using the Chi-square test and Fisher's exact test. A P < 0.05 was considered statistically significant. Results: Thirty-two of the 51 individuals studied had radiographic abnormalities, whereas 44 had abnormal findings in the US. The US can detect erosions in 37 patients, including all 15 of those who had radiographically visible erosions. A statistically significant difference was noted between the findings of radiography compared with US findings (P < 0.001). Conclusions: US is more sensitive than CR for the detection of erosion and can complement the CR in the evaluation of these patients.

Keywords: Conventional radiography, high-resolution ultrasonography, power Doppler, rheumatoid arthritis

How to cite this article:
Sultana S, Ahmad M, Ahmad I, Usmani H, Arif M. Ultrasonographic evaluation of painful joints in rheumatoid arthritis: Comparison with conventional radiography. Indian J Pain 2022;36:22-6

How to cite this URL:
Sultana S, Ahmad M, Ahmad I, Usmani H, Arif M. Ultrasonographic evaluation of painful joints in rheumatoid arthritis: Comparison with conventional radiography. Indian J Pain [serial online] 2022 [cited 2022 Jul 1];36:22-6. Available from: https://www.indianjpain.org/text.asp?2022/36/1/22/343825

  Introduction Top

Rheumatoid arthritis (RA) is a multisystem chronic inflammatory disease of unknown etiology, characterized by symmetrical polyarthritis. The characteristic disease is synovitis, which damages cartilage, bone, ligaments, and tendons. Small joints of the hands and feet are involved most commonly, causing joint destruction and deformity with extensive morbidity. The role of imaging evaluation of structural damage and disease activity in joints in RA is essential in routine clinical management. We have routine use of conventional radiography (CR) at rheumatology clinics. But does it answer all our questions? Thus, ultrasound (US) comes into our mind and picture.

CR: There is a poor correlation between structural damage as assessed by CR and function, especially in early disease.[1] CR changes are heavily dependent on the radiologic technique and differ appreciably between sets of films, thus questioning their reproducibility. The limitations of CR include projectional superimposition and the use of ionizing radiation. CR detects only late signs of preceding disease activity, resulting in cartilage and bone destruction.[2],[3]

Previous studies evaluating the use of grayscale (B-mode) US for detecting synovial inflammation and joint damage in RA patients showed that clinical examination of the joints and CR are comparatively insensitive.[4],[5],[6],[7] The quantitative assessment of the power Doppler (PD) of vascularized synovium in the metacarpophalangeal (MCP) joints in patients with RA has been shown to correlate with the erythrocyte sedimentation rate (ESR) value.[8],[9] The main advantages of US when compared with other imaging techniques available are its wide availability, low costs, absence of radiation, good visualization of joint space and tendons, multiplanar imaging capability, and comparison with the other side. US can be easily performed at the bedside and is very well accepted by patients. The US is useful in the detection of joint changes and in follow-up of these changes in patients on disease-modifying anti-rheumatoid drugs (DMARD). RA patients require relatively long and frequent follow-ups. High-frequency US, when compared with magnetic resonance imaging (MRI), is significantly better at detecting joint effusion and synovial proliferation.[10] The evaluation of patients in “Clinical Remission:” Over 30% of patients fulfilling remission criteria according to Disease Activity Score/American College of Rheumatology (ACR)/European League against Rheumatism (EULAR) criteria still had progression in joint damage.[11] (outcome measure in RA clinical trial) Consensus Definitions[12] describe the US findings in RA as synovial fluid (effusion), synovial hypertrophy, tenosynovitis, bone erosion, and enthesitis.[13]

The objectives of this study are to establish the role of high-frequency US in the evaluation of painful hand joints in patients with RA and to compare erosion findings between CR and US.

  Subjects and Methods Top

Study design

This was a cross-sectional study being carried out in the Department of Rheumatology and Radiodiagnosis at Jawaharlal Nehru Medical College and Hospital (JNMCH), Aligarh Muslim University (AMU), Aligarh, which is a tertiary care hospital, established in 1962 and catering to the majority of the western UP population. The study period was from August 2017 to August 2019. Fifty-one patients turned to us, met our inclusion criteria, and gave consent. Sample Size: 51 clinically diagnosed RA patients as per ACR/EULAR criteria 2010 were enrolled in this study after giving prior informed consent.

Exclusion criteria

Patients who do not meet the ACR criteria for RA 2010. Alternative diagnoses were discovered after the Ultrasonography (USG) workup, such as gout. Pregnant women and people with severe joint deformities were excluded.

This study included 51 RA patients diagnosed as per ACR/EULAR criteria given in 2010. A score of 6 fulfills the requirements for a definite RA.[14] Initially, patients were assessed by a thorough clinical history (pain, swelling, deformity) and physical examination (swelling, warmth, erythema, deformity). This was followed by blood investigations such as serological tests (RA factor, Anti-cyclic citrullinated peptide [CCP]) and other blood investigations like ESR and (C-reactive protein). Most of the patients were receiving stable treatment with a DMARD in the 4 months before the investigation, and during this period the patients had had no injections of glucocorticoids.

This was followed by CR, i.e., an X-ray of the B/L hands (posterior anterior and lateral projection). Findings are noted as periarticular osteopenia, erosion, loss/reduction of joint space, prominence of soft tissue, or deformity.

The patients were scanned with the US machine (Toshiba Aplio XG-7–18 Mega Hertz [MHz]) using a near-focused transducer with a center frequency of 18 MHz. Scanning was run on the dorsal and volar aspects of all the MCP, proximal interphalangeal (PIP), and wrist of both the hands. Images are assessed in two planes.

Statistical analysis

IBM SPSS version 20. 0 (SPSS Inc., Chicago, IL, USA), was used to collect, tabulate, and analyze all data. The results were presented as mean standard deviation or percentage. Differences in categorical data were compared using the Chi-square test and Fisher's exact test. A P < 0.05 was considered statistically significant.

Ethical approval

The study was approved by the ethical committee of JNMCH, AMU. This research was carried out in accordance with the Helsinki Declaration. Written informed consent was obtained from the participants in this study.

  Results Top

A total of 51 RA patients who met our inclusion criteria were included in this study after giving written informed consent. In our study, the patients had a mean age of 39.5 ± 12.5 years, with a range of 17–65 years. In our study, 43 (84%) were female, and 8 (15.7%) were male. The mean duration of disease in our study was 7.6 years. Patients taking DMARDs were 49, RF (RA factor) positive patients were 43, anti-CCP-positive patients were 19, and seropositive patients were 43. The history of morning stiffness was present in 49 patients, with an average duration of 47 min. The basic demographic data and patient profile is shown in [Table 1].
Table 1: Demographic, clinical, and laboratory data of rheumatoid arthritis patients

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In our study group, the most common findings on CR examination of the B/L hand and wrist were periarticular osteopenia, seen in 15 (29.4%) and erosion, seen in 15 (29.4%) patients out of 51 [Figure 1]. Other findings were joint space loss or reduction seen in 11 (21.6%), mild deformity in 10 (19.6%) and the least common finding was soft tissue prominence seen in 1 (2%) patient out of 51. On radiographic evaluation of B/L hands and wrists, 32 (62.7%) patients had one or more positive findings, whereas it was normal in 19 (37.3%) patients.
Figure 1: B/L hand radiograph (PA view): Erosions on the right 2nd metacarpophalangeal and B/L radio-carpal joints (white arrows) (Image from case study)

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The US findings in the MCP joints of B/L hands (most commonly, findings were noted in the 2nd and 3rd MCP) were seen in 36 (70.6%) patients out of 51. The most common finding was synovial thickening, which was seen in 36 (70.6%), followed by erosion at the metacarpal head near the MCP joint, seen in 28 (54.9%), followed by vascularity detected by PD signal, which was seen in 20 (39.2%). The least common finding was effusion, seen in six (11.8%) patients out of 51.

The US findings in the wrist joints of B/L hands were seen in 39 (76.5%) patients out of 51. The most commonly encountered finding was synovial thickening, seen in 39 (76.5%), followed by erosion at the radio-carpal/ulnocarpal, carpometacarpal, and intercarpal joints, which was seen in 37 (72.5%). Vascularity (detected by PD signals) was seen in 32 (62.7%) [Figure 3]. Other findings were tenosynovitis of the extensor tendon, seen in 20 patients, and effusion, seen in 13 (25.5%) patients out of 51. In our study group, the findings of US examination of the PIP joints of B/L hands revealed synovial thickening only in 5 (9.8%) of the patients.
Figure 2: (a) (Left): shows hypoechoic synovial thickening with lifting of the joint capsule with no vascularity on power Doppler involving the right 3th metacarpophalangeal joint (above and left imaging with white arrow). For comparison, a normal metacarpophalangeal joint is shown (above and below on the right shown by red arrows). The same joint on the grey scale is shown in the left lower image. (Image taken from the case study). (b) (Right): Showing erosion near the articular margin of the head of the 3rd metacarpophalangeal in two planes, longitudinal (left yellow arrow) and axial (right blue arrow)

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Figure 3: Showing synovial thickening on the dorsal aspect of the left wrist joint of a diagnosed rheumatoid arthritis patient on the grey scale (green arrow) with grade 2 vascularity on Power Doppler (red arrow)

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In the US evaluation of B/L hands (all MCP and all PIP) and wrist, 44 (86.3%) patients showed findings (i.e., synovitis), whereas it was negative or normal in 7 (13.7%) patients.

On US evaluation, 44 out of 51 RA patients displayed abnormal findings, such as synovial thickening, joint effusion, bone erosion, tenosynovitis, and increased vascularity on PD, indicating an ongoing disease process [Figure 2]b. This encompassed all 32 participants with radiographic alterations as well as cases with no radiographic changes, reinforcing US's disease detection ability [Table 2] and [Table 3].
Table 2: Comparison of hand and wrist joint involvement detected by conventional radiographic and ultrasound

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Table 3: Comparison between ultrasound and conventional radiographic in detecting erosions

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The CR revealed erosions in 15 patients, while US revealed erosions in 32 patients, indicating that the latter has a higher sensitivity [Table 3] and [Figure 2]a and [Figure 4]b.
Figure 4: (a) (Left): Shows no abnormality in the 2nd metacarpophalangeal joint of the right hand of a seronegative patient with pain in multiple joints. (b) (Right) On colour doppler ultrasound examination, the same patient had synovial thickening and erosion at the head of the 2nd metacarpal in longitudinal (black arrow) and its perpendicular plane (red arrow) with adjacent synovial thickening with no vascularity in the 2nd metacarpophalangeal joint of the right hand

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  Discussion Top

High-frequency US, when compared with MRI, is significantly better at detecting joint effusion and synovial proliferation.[10] Using modern, high-quality sonographic equipment, PD can very well determine the flow even in small blood vessels, giving an estimate of the presence and extent of inflammation.[8] US is gradually establishing itself as an essential tool in the rheumatology clinical setting.[15] High-frequency US has made detection of joint effusion, synovial thickening, and superficial erosion easy.

US has arisen as a reliable means to detect subclinical synovitis and to quantify or grade inflammation and thus has a definite role in therapeutic choices in RA patients. Early detection of an ongoing destructive process in the joint remains crucial for initiating early treatment and heralding it before irreversible damage sets in, which affects the overall prognosis and morbidity of the RA patient. CR fails to pick up early signs of subclinical synovitis and inflammation in and around the joint.[16]

On radiographic evaluation of B/L hands, 62.74% of patients showed findings on X-ray, whereas 86.27% of patients showed findings on US. This difference was found to be statistically significant on the application of the Fisher's exact test (P < 0.001). On comparison of erosions, 72.45% of patients had erosions on the US as compared to only 29.41% of patients showed erosion on the CR. The US could detect erosions in 37 patients, including all of the 15 patients who had radiographically noticeable erosions [Figure 4]. The correlation of erosion between the CR and the US examination of the B/L hand and wrist was analyzed by applying the Chi-square test. A statistically significant difference was noted between the abnormal finding of erosion in radiography compared with US findings (P < 0.001).

Similar results were obtained by the study done by Szkudlarek et al. in the year 2006.[9] They wanted to look into the role of US in detecting inflammation and the extent of destruction in RA patient's finger joints, which CR and clinical examination cannot do. A systematic literature review done by Takase-Minegishi et al. in 2018 included fourteen articles. They estimated the sensitivity and specificity of US for wrist, MCP, PIP, and knee joints, and they concluded that US is a reliable diagnostic method for detecting synovial inflammation in the wrist and finger joints. They recommended the routine use of US as part of the standard diagnostic method in RA patients.[17]

The US was found to be more sensitive and informative than the CR of the B/L hand and wrist examination. Although clinicians mainly prefer radiography for the diagnosis and follow-up of RA patients, many studies, including mine, have proven the upcoming role of US as a more sensitive modality than CR in the detection of early changes in RA. If there are no active signs of inflammation detected on the US examination, then the current treatment should be continued or tapered. If the US examination reveals active inflammation, change or optimization of the current treatment should be considered.[18] There is a higher risk of relapse when stopping or tapering biological therapy in patients with a high US score on the grayscale and PD than in patients with a low score.[18],[19] Rheumatologists commonly recommend baseline radiography at the initiation of treatment for assessment of the severity of disease. Because RA patients require a long-term follow-up, repeated radiographs expose them to radiation exposure while not revealing details of synovial and bony changes or inflammatory activity that US can detect. Once the diagnosis of RA is made, patients may be followed by US for disease activity. As US is now widely available, the structural changes can be assessed with greater sensitivity as compared to CR. The result of this study suggests that high-resolution US of joints in patients with RA is a relatively simple technique that is quite easy to learn and has a high diagnostic yield. Therefore, US should be considered in all RA patients for making a diagnosis in equivocal cases, confirmation of diagnosis, treatment response, and follow-up for better control of disease progression and prevention of erosions and subsequent deformity.

My research limitations

No diagnostic method other than US, like MRI, was used in all the patients in our study. Therefore, no comparison was made with the gold standard imaging modality.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Scott DL, Pugner K, Kaarela K, Doyle DV, Woolf A, Holmes J, et al. The links between joint damage and disability in rheumatoid arthritis. Rheumatology (Oxford) 2000;39:122-32.  Back to cited text no. 1
Taylor PC. The value of sensitive imaging modalities in rheumatoid arthritis. Arthritis Res Ther 2003;5:210-3.  Back to cited text no. 2
van der Heijde D, van der Helm-van Mil AH, Aletaha D, Bingham CO, Burmester GR, Dougados M, et al. EULAR definition of erosive disease in light of the 2010 ACR/EULAR rheumatoid arthritis classification criteria. Ann Rheum Dis 2013;72:479-81.  Back to cited text no. 3
Hau M, Schultz H, Tony HP, Keberle M, Jahns R, Haerten R, et al. Evaluation of pannus and vascularization of the metacarpophalangeal and proximal interphalangeal joints in rheumatoid arthritis by high-resolution ultrasound (multidimensional linear array). Arthritis Rheum 1999;42:2303-8.  Back to cited text no. 4
Grassi W, Filippucci E, Farina A, Salaffi F, Cervini C. Ultrasonography in the evaluation of bone erosions. Ann Rheum Dis 2001;60:98-103.  Back to cited text no. 5
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Qvistgaard E, Røgind H, Torp-Pedersen S, Terslev L, Danneskiold-Samsøe B, Bliddal H. Quantitative ultrasonography in rheumatoid arthritis: Evaluation of inflammation by Doppler technique. Ann Rheum Dis 2001;60:690-3.  Back to cited text no. 8
Szkudlarek M, Court-Payen M, Strandberg C, Klarlund M, Klausen T, Ostergaard M. Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: A comparison with dynamic magnetic resonance imaging. Arthritis Rheum 2001;44:2018-23.  Back to cited text no. 9
Wang MY, Wang XB, Sun XH, Liu FL, Huang SC. Diagnostic value of high-frequency ultrasound and magnetic resonance imaging in early rheumatoid arthritis. Exp Ther Med 2016;12:3035-40.  Back to cited text no. 10
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Terslev L, Naredo E, Aegerter P, Wakefield RJ, Backhaus M, Balint P, et al. Scoring ultrasound synovitis in rheumatoid arthritis: A EULAR-OMERACT ultrasound taskforce-Part 2: Reliability and application to multiple joints of a standardised consensus-based scoring system. RMD Open 2017;3:e000427.  Back to cited text no. 13
Kay J, Upchurch KS. ACR/EULAR 2010 rheumatoid arthritis classification criteria. Rheumatology (Oxford) 2012;51 Suppl 6:i5-9.  Back to cited text no. 14
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Saigal R. Ultrasonographic Evaluation of Joint Involvement in Rheumatoid Arthritis: Comparison with Conventional Radiography and Correlation with Disease Activity Parameters. Availablefrom: https://www.indianjrheumatol.com/article.asp?issn=0973-3698;year=2017;volume=12;issue=1;spage=6;epage=11;aulast=Saigal. [Last accessed on 2021 Nov 21].  Back to cited text no. 16
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3]


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