Clinical Examination, Ultrasound and MRI Imaging of The Painful Elbow in Psoriatic Arthritis and Rheumatoid Arthritis: Which is Better, Ultrasound or MR, for Imaging Enthesitis?

Abstract

IntroductionThe purpose of the current study was to examine the painful elbow, and in particular enthesitis, in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) using clinical examination, ultrasonography (US) and magnetic resonance imaging (MRI).MethodsPatients with elbow pain (11 with PsA and 9 with RA) were recruited. Clinical examination, US and MRI studies were performed on the same day. For enthesitis, the common extensor and flexor insertions and the triceps insertion were imaged (20 patients, giving a total of 60 sites with comparative data). Imaging was performed with the radiologists blinded to the diagnosis and clinical findings. US was used to assess ‘inflammatory activity’ (Power Doppler signal, oedema, tendon thickening and bursal swelling) and ‘damage’ (erosions, cortical roughening and enthesophytes). MRI was used to assess ‘inflammation’ (fluid in paratenon, peri-entheseal soft-tissue oedema, entheseal enhancement with gadolinium, entheseal oedema and bone oedema) and ‘damage’ (erosion, cortical roughening and enthesophyte).ResultsComplete scan data were not available for all patients as one patient could not tolerate the MRI examination. No significant differences in imaging scores were found between PsA and RA. Analysis of damage scores revealed complete agreement between US and MRI data in 43/55 (78%) comparisons; in 10/55 (18%) cases the US data were abnormal but the MRI data normal; in 2/55 (4%) cases, the MRI data were abnormal and the US data normal. Analysis of the inflammation scores revealed complete agreement between US and MRI data in 33/55 (60%) comparisons; in 3/55 (5%) cases US data were abnormal but MRI data normal; in 19/55 (35%) cases the MRI data were abnormal and the US data normal. There was a poor relationship between assessments based on clinical examination and imaging studies. Readers could not accurately identify the disease from imaging findings.ConclusionBased on our results, at the elbow, US and MR have different roles in assessing enthesitis, with US apparently the better diagnostic tool for assessing damage and MR the better tool for assessing inflammation. In this study enthesitis and synovitis in the painful elbow were found equally in cases of established RA and PsA.

Anterolateral hip pain: Sonographic evaluation of the proximal iliotibial band and tensor fascia lata

“…Several studies have found that enthesophytes are more likely to show on US than on MRI. 10,11 The patient shown in Figure 4 is a 34-year-old female runner presenting with ITB/TFL tendinosis. In addition to the thickening and hypoechogenicityof the ITB origin ( Figure 4A), US focused on the focally tender area revealed enthesophyte formation.…”

Assessment of Enthesitis in Psoriatic Arthritis

“…Might we improve the accuracy of our examinations for this clinical feature in PsA? We have previously suggested that if swelling, as well as tenderness, is present at the enthesis then it is more likely to be associated with US-demonstrated enthesitis 8 . However, swelling is infrequently seen at the enthesis, and is hard to detect at entheses around the shoulder, pelvis, and knee, particularly if the person is obese.…”

“…However, swelling is infrequently seen at the enthesis, and is hard to detect at entheses around the shoulder, pelvis, and knee, particularly if the person is obese. I have also advocated stressing the enthesis mechanically, by opposing the appropriate muscle contraction, to improve the specificity of clinical examination 8 . This is easy to do at the lateral epicondyle of the humerus, the insertion of supraspinatus, the quadriceps, and at the Achilles, but less easy to do elsewhere and especially if the insertion is purely ligamentous.…”

Identification of differentially expressed genes and signaling pathways in rheumatoid arthritis by integrated bioinformatics analysis

“…At present, the frequently used methods for early detection and diagnosis of RA are magnetic resonance imaging, ultrasound and serological examination (including rheumatoid factor, anti-cyclic citrullinated peptide, etc). Be that as it may, there are con nements of these techniques, so the exactness and accuracy is not high [5,6] . Computed tomography and X-rays can only detect lesions in its advanced stage, but do not detect early impairment.…”