The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

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Low back pain (LBP) occurs in various groups of the population, affects men and women equally, and is among the major reasons for rheumatological or orthopedic consultations. Its prevalence increases steadily with age and the rate of recurrence within one year could reach 44% [1]. Many imaging modalities are available to clinicians for evaluating LBP. The application of these modalities depends mainly on the working diagnosis, the urgency of the clinical problem, the availability, and the comorbidities of the patient [2]. Conventional radiography (CR) and computerized tomography (CT) are associated with radiation exposure and show primarily the bony elements of the lower back. Their widespread use in the 20th century might be among the reasons why paraspinal soft tissues have somehow been neglected as a cause for LBP [1]. Magnetic resonance imaging (MRI) shows both bony and soft tissue structures in the axial skeleton, but its use is hampered by the duration of the examination, its relatively high costs, its limited availability (mainly in the tertiary centers) and the contraindications for this diagnostic modality [2].Musculoskeletal ultrasound (US) is a safe, fast, inexpensive, and widely available imaging modality that is very well tolerated by patients [3]. It allows multiplanar and dynamic examinations of the musculoskeletal system and can show the soft tissues in great anatomical detail. US is used by a growing number of physicians and the list of its applications in rheumatology and orthopedics is growing [4].Therefore, the question of the possible diagnostic application of US in such a common condition as LBP is very relevant to the clinical practice. On one hand, this could decrease the radiation exposure associated with CR and CT, and reduce the costs paid for MRI. The effect could be even bigger in time, as LBP is frequently a chronic or recurrent disease [1]. On the other hand, by AbstractPatients with low back pain (LBP) frequently undergo various imaging studies in the pursuit of a more precise diagnosis. Ultrasound (US) has the advantage of being a widely available, multiplanar, fast and radiation-free diagnostic tool. Moreover, compared to most of the other imaging modalities, it is particularly efficient in the visualization and assessment of soft tissues. Consequently, the question about the possible diagnostic application of US in such a common pathology as LBP is very relevant to the clinical practice. For this reason, we performed a review of the literature on the diagnostic value of US in different conditions that could cause LBP. We hereby discuss available studies on the diagnostic application of US in spinal canal stenosis and disc herniation (probably of historical significance only), as well as in the pathology of soft tissue structures like the lumbar and pelvic ligaments, muscles and entheses, the thoracolumbar fascia and the sacroiliac joints (maybe of greater importance nowadays). The evidence for the diagnostic value of US is not equivocal, though promising for some of the causati...

Background Piriformis Syndrome is thought to account for about 5 to 10 percent of the cases of chronic low back and gluteal pain and could cause debilitating chronic suffering. However as at present there are no specific confirmatory tests, it remains mainly a diagnosis of exclusion. On the other hand musculoskeletal ultrasound is a rapidly developing imaging modality, particularly efficient in the evaluation of lesion in soft tissues. Objectives To study the piriformis muscles by sonography in patients with unilateral “nonspecific” chronic low back and gluteal pain, referred or not the thigh and in subjects without such complaints. The findings from the study were used to determine possible sonographic diagnostic features for the Piriformis syndrome. Methods We studied the piriformis muscles of 14 middle-aged patients (5 males, 9 females) with unilateral, regional chronic low back and gluteal pain of cause unidentified by clinical examination, conventional X-ray and routine laboratory tests. The contra lateral, non painful side of the same individuals as well as both piriformis muscles of another 12 adults (5 male, 7 female) of matching age, height and weight without such complaints served as control. Results Patients were examined in prone position. The thickness, echogenicity and structure of the muscle were evaluated by an ultrasound scan parallel to the long axis of the muscle. Then the smoothness of muscle gliding over the iliac bone was observed by dynamic scanning of the muscle while the unilateral hip was passively and repeatedly externally and internally rotated. The anterior-posterior thickness of the piriformis muscle measured by ultrasound varied widely between individuals: from 5.8 to 11.5 mm in males and from 4.4 to 9.6 mm in females probably reflecting the different level of physical conditioning. However the difference between the piriformis muscles in the same individual was neglect able: mean 0.51, maximum 1.34 mm. On the other hand there was significant asymmetry in size between painful and non-painful piriformis muscle in the same patient (in 13/14 subjects) with mean difference 3.98, maximal 10.4 mm. Regarding echogenicity and structure, painful muscles were more often hypoechogenic (10/14), than non-painful ones (4/38) and with buldging upper and lower margins (9/14), than non-painful (6/38). Dynamic scanning of the non painful muscles showed smooth movement of the muscle over the iliac bone in all subjects. On the other hand dynamic examination of 9 of the 14 painful muscles showed non smooth movements with catching and jumping of the inferior surface of the muscle over the iliac bone (signs of piriformis muscle impingement) with reduced distance between lower margin of the muscle and the iliac bone. That was only sonographic sign which correlated with the presence of positive tests for piriformis stressing in the given patient (FAIR and Pace tests were used). Conclusions Static and dynamic sonographic study of the piriformis muscle could be used to routinely evaluate patients wit...

BackgroundIliac crest pain syndrome is a regional pain syndrome that has been identified in many patients with low back pain. Based on anatomical studies, it was suggested that the potential substrate of this syndrome might be the enthesis of the erector spinae muscle at the posterior medial iliac crest. As there have been no imaging studies of this important enthesis, our aim was to assess its characteristics by ultrasound.MethodsErector spinae enthesis was first studied in a cadaver. Then its characteristics were recorded in 25 healthy volunteers (median age: 28.92, SD: 5.31, mean Body Mass Index 22.61, SD: 3.38), with Esaote My Lab 7 machine using linear transducer (4–13 MHz).ResultsThe cadaver study confirmed the attachment of a substantial part of erector spinae to a well-defined region on the medial posterior iliac crest. The US study in the volunteers consistently showed the entheses as typical hyperechoic fibrillar structures, slightly oblique to the skin in the longitudinal plane and attaching to the iliac crest. In the transverse plane, the entheses were seen as oval, densely dotted structures in contact with the superior edge of posterior superior iliac spine. Their mean thickness (4.9 ± 0.6 and 5.2 ± 0.7 mm longitudinally; 4.3 ± 0.6 and 4.4 ± 0.7 mm transversely), maximum width (16.3 ± 2.8 and 15.7 ± 2.3 mm) and depth (10.8 ± 7.3 and 10.6 ± 6.2 mm) on the left and right side, respectively, as well as their echostructure were recorded and described.ConclusionsThe erector spinae entheses could be assessed in detail by ultrasound, thus their pathological transformation associated with iliac crest pain syndrome could be identified.

Background:Ultrasonography (US) is a well established technique both for diagnosis and follow up in Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PSA)1. To date, there is no consensus regarding a standardized US evaluation of joint involvement by a validated score to be used for differential diagnosis.Objectives:1) To differentiate the ultrasound features of patients affected by active RA or active PSA by using a 6-joints score2. 2) To analyze correlations between those findings and clinical patterns of PSA disease.Methods:68 RA and 38 PSA patients (divided in two equal subgroups according to the clinical involvement i.e. polyarticular or oligoarticular) were enrolled in a multi-center cross-sectional study. All patients underwent clinical evaluation including demographic data, disease characteristics, laboratory test and tender/swollen joints count. SDAI and DAPSA were calculated in accordance to the disease and standard of care. The sonographic evaluation of wrists, II MCFs and knees, was performed using a multifrequency linear probe (13-18 MHz) with power Doppler (7.5 MHz, PRF500 Hz). High-end equipment was used and the scanning technique as well as the lesion assessment was previously agreed among the participants, who performed a consensus session 100 images. A validated ultrasound score2, which included effusion, synovial hypertrophy and synovial hypervascularization at 6 joints sites was used. Those lesions were assessed according to OMERACT definitions and semi-quantitatively graded (0-3). By summing the scores obtained at each joint site and globally, a joint score for articular involvement, a score for the severity of each lesion and a global 6-joint score for all abnormalities were calculated.Results:Clinical evaluation showed no statistically significant differences between RA and PSA (table I). Ultrasound detected significant differences in the score of joint effusion (SE) (p<0.021), synovial hypertrophy (SH) (p<0.001) and Doppler signal (p<0.011) between oligoarticular PSA and RA. Significant differences in the joint score of II MCF (p<0.000) and wrist (p<0.032) were also found between oligoarticular PSA and RA. The global 6-joint score was 10,88 in RA, 6,05 in PSA oligoarticular, 16,32 in PSA polyarticular. No differences were found between RA and polyarticular PSA.Conclusion:Ultrasound evaluation of 6 target joints might help to discriminate RA and PSA oligoarticular subset. The study of a limited number of joints is therefore a complementary tool to the clinic, fast and well integrated into the overall assessment of the arthritic patient.References:[1]Zabotti A. et al. Clin Exp Rheumatol. 2018; 36:519-525.[2]Perricone C et al. Rheumatology (Oxford) 2012; 51:866-73.Table 1.Dependent variablesStudy Populationp valuesUS_SEScoreRAPSA OLIGO.021PSA POLY.356PSARA.021OLIGOPSA POLY.014PSARA.356POLYPSA OLIGO.014US_SHScoreRAPSA OLIGO.001PSA POLY.336PSARA.001OLIGOPSA POLY.004PSARA.336POLYPSA OLIGO.004US_PDScoreRAPSA OLIGO.011PSA POLY.102PSARA.011OLIGOPSA POLY.006PSA POLYRA.102PSA OLIGO.006US_MCP2ScoreRAPSA OLIGO.000PSA POLY.276PSARA.000OLIGOPSA POLY.002PSA POLYRA.276PSA OLIGO.002US_WRISTScoreRAPSA OLIGO.032PSA POLY.610PSARA.032OLIGOPSA POLY.047PSA POLYRA.610PSA OLIGO.047US_KNEEScoreRAPSA OLIGO1.000PSA POLY.133PSA OLIGORA1.000PSA POLY.180PSA POLYRA.133PSA OLIGO.180US_KNEEScoreRAPSA OLIGO1.000PSA POLY.133PSARA1.000OLIGOPSA POLY.180PSA POLYRA.133PSA OLIGO.180US: ultrasound; SE synovial effusion; SH synovial hypertrophy;PD power Doppler; MCP metacarpophalangeal; PSA psoriatic arthritis;OLIGO oligoarticular; POLYpolyarticularDisclosure of Interests:Fabiana Figus: None declared, Luca Idolazzi: None declared, Porin Perić: None declared, Alen Zabotti Speakers bureau: Celgene, Janssen, Ilaria Tinazzi: None declared, Irene Azzolin: None declared, ERIKA MONTABONE: None declared, Tanya Sapundzhieva: None declared, Anastas Batalov: None declared, PLAMEN TODOROV: None declared, Rositsa Karalilova: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

Aim: To describe the sonoanatomy of the long posterior sacroiliac ligament (LPSL) in healthy volunteers and to assess by ultrasound the LPSL in patients with noninflammatory sacroiliac joint pain (SIP).Material and methods: We assessed 64 LPSLs of 32 healthy controls and 40 LPSLs of 40 patients with unilateral noninflammatory SIP and a positive Fortin finger test. LPSLs in both groups were assessed for the presence of alterations in their structure, continuity and echogenicity and their thickness was measured in three predefined points. All patients were examined in prone position following a strict scanning protocol.Results: Detailed sonoanatomy description and measurement of the LPSL in healthy volunteers are provided (length: 31.32±4.79 mm, width: 8.14±1.28 mm, thickness: 2.05±0.55 mm; 1.64±0.41 mm and 1.51±0.42 mm at the iliac and sacral entheses and in its middle part, respectively). The LPSLs were found to be significantly thicker in the SIP group, with an optimum criterion value of >2.0 mm in its middle part to identify pathologically thickened ligaments. In addition, LPSLs inthe SIP group presented significantly more often hypoechogenicity/altered fibrillar structure (57.5% vs.16%) and/or periligamentous edema (72.8% vs 28%). The combination of either altered structure or periligamentous edema, with thickening of theligament’s body showed the best diagnostic accuracy (sensitivity and specificity 83.9% and 94.7% for the first combination and 100% and 84.6% for the second combination) to identify LPSL pathology in noninflammatory SIP.Conclusions: LPSL could be assessed by ultrasound and sonopathological lesions could be identified in patients with SIP.