GUIDELINES for ULTRASOUND USE in RHEUMATOLOGY PRACTICE

The MSUS Committee presented recommendations for "reasonable" rather than "appropriate" use because the RAND analysis method used excludes cost consideration. The authors write, "Where risks of the procedure are minimal...and because costs are not considered, the analysis will inherently favor use of the procedure. Therefore, rather than use the term 'appropriate,' which we felt would be overstating the findings, we use the term 'reasonable' to mean that the evidence and/or consensus of the Talk Force Panel...supported the use of MSUS for the described scenario."

"Reasonable" includes use for:

• articular pain, swelling, or mechanical symptoms without definitive diagnosis (glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, and midfoot and metatarsophalangeal joints);
• inflammatory arthritis and new or ongoing symptoms (glenohumeral, acromioclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal, and entheseal joints);
• shoulder pain or mechanical symptoms, but not adhesive capsulitis or as preparation for surgical intervention;
• parotid and submandibular glands in suspected Sjogren's disease;
• symptoms near a joint obscured by adipose tissue or soft tissue derangements (glenohumeral, acromioclavicular, elbow, wrist, hand, metacarpophalangeal, interphalangeal, hip, knee, ankle/foot, and metatarsophalangeal joints);
• regional neuropathic pain to diagnose entrapment of the median nerve at the carpal tunnel, ulnar nerve at the cubital tunnel, and posterior tibial nerve at the tarsal tunnel; and
• guiding articular and periarticular aspiration or injection at sites that include the synovial, tenosynovial, bursal, peritendinous, and perientheseal areas.

MSUS at the temporomandibular joint and costochondral joints was not considered reasonable because the interposition of bone often interferes with imaging in those areas.

The authors also emphasize that these recommendations apply to MSUS done as part of a thorough clinical evaluation in a rheumatology office. "It was not intended to include settings isolated from the rheumatologic assessment, such as might occur in a radiology department or operative setting, or other disciplines, such as podiatry or anesthesia," they write.

Arthritis Care Res. 2012;64:1625-1640.

Study Highlights

• The ACR developed a summary of clinical scenarios achieving mainly positive recommendations for use of MSUS.
• For patients with joint pain, swelling, or mechanical symptoms, without definitive clinical diagnosis, use of MSUS is reasonable at the glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot, and metatarsophalangeal joints. However, use of MSUS is not reasonable at the temporomandibular joint and costochondral joints.
• For a patient with present or previous monoarthralgia or oligoarthralgia but without a definitive clinical diagnosis, it is reasonable to use MSUS to look for subclinical inflammatory arthritis or enthesitis at asymptomatic glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot, and metatarsophalangeal joints.
• For a patient with diagnosed inflammatory arthritis and new or ongoing symptoms without a definitive clinical diagnosis, use of MSUS is reasonable to detect inflammation, structural damage, or an additional diagnosis at the glenohumeral, acromioclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot, metatarsophalangeal, and entheseal sites.
• For a patient with hip pain or mechanical symptoms without a definitive clinical diagnosis, use of MSUS is reasonable to assess effusion, intraarticular and periarticular lesions, and adjacent regional soft tissue structures.
• For a patient with periarticular pain without a definitive clinical diagnosis, use of MSUS is reasonable to assess tendon and soft tissue disorders and adjacent swelling at the shoulder, elbow, hand, hip, knee, ankle, and forefoot.
• For a patient with inflammatory-sounding entheseal, sacroiliac, or spinal pain, use of MSUS is reasonable to detect evidence of enthesopathy.
• For a patient with shoulder pain or mechanical symptoms, without a definitive clinical diagnosis, use of MSUS is reasonable to detect underlying structural disorders. However, use of MSUS is not reasonable to detect adhesive capsulitis or to prepare for surgical intervention.
• For a patient with regional mechanical symptoms but without a definitive clinical diagnosis, it is reasonable to use MSUS to detect inflammation, tendon, and soft tissue disorders at the shoulder, elbow, hand, wrist, hip, knee, ankle, and foot joints.
• Use of MSUS is reasonable to assess the parotid and submandibular glands as part of an evaluation for Sjogren’s disease.
• For a patient with symptoms near a joint surrounded by adipose or other local soft tissue abnormalities, use of MSUS is reasonable to facilitate clinical assessment at the glenohumeral, acromioclavicular, elbow, wrist, hand, metacarpophalangeal, interphalangeal, hip, knee, ankle/foot, and metatarsophalangeal joints.
• For a patient with regional neuropathic pain without a definitive clinical diagnosis, use of MSUS is reasonable to diagnose entrapment of the median nerve at the carpal tunnel, the ulnar nerve at the cubital tunnel, and the posterior tibial nerve at the tarsal tunnel.
• Use of MSUS is reasonable to guide articular and periarticular aspiration or injection at synovial, tenosynovial, bursal, peritendinous, and perientheseal sites.
• Use of MSUS may be reasonable to guide synovial biopsy procedures.
• Use of MSUS may be reasonable to monitor disease activity and structural progression at the glenohumeral, acromioclavicular, elbow, wrist, hand, metacarpophalangeal, interphalangeal, hip, knee, ankle, foot, and metatarsophalangeal sites in patients with inflammatory polyarthritis.