Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR "Train the trainers" course

Deep learning-based automatic scoring models for the disease activity of rheumatoid arthritis based on multimodal ultrasound images

OBJECTIVES

We aimed to investigate the value of deep learning (DL) models based on multimodal ultrasonographic (US) images to quantify RA activity.

METHODS

Static greyscale (SGS), dynamic greyscale (DGS), static power Doppler (SPD) and dynamic power Doppler (DPD) US images were collected and evaluated by two expert radiologists according to the EULAR-OMERACT Synovitis Scoring system. Four DL models were developed based on the ResNet-type structure, evaluated on two separate test cohorts, and finally compared with the performance of 12 radiologists with different levels of experience.

RESULTS

In total, 1244 images were used for the model training, and 152 and 354 for testing (cohort 1 and 2, respectively). The best-performing models for the scores of 0/1/2/3 were the DPD, SGS, DGS and SPD models, respectively (Area Under the receiver operating characteristic Curve [AUC] = 0.87/0.95/0.74/0.95; no significant differences). All the DL models provided results comparable to the experienced radiologists on a per-image basis (intraclass correlation coefficient: 0.239-0.756, P < 0.05). The SPD model performed better than the SGS one on test cohort 1 (score of 0/2/3: AUC = 0.82/0.67/0.95 vs 0.66/0.66/0.75, respectively) and test cohort 2 (score of 0: AUC = 0.89 vs 0.81). The dynamic DL models performed better than the static ones in most of the scoring processes and were more accurate than the most of senior radiologists, especially the DPD model.

CONCLUSION

DL models based on multimodal US images allow a quantitative and objective assessment of RA activity. Dynamic DL models in particular have potential value in assisting radiologists to improve the accuracy of RA US-based grading.

Variability in sonographic anterior drawer test measurements of the ankle: Experienced versus beginner examiners

BACKGROUND

This study aimed to clarify the variability in the measurements of stress sonography of the ankle and determine the effects of examiner experience on the measurements.

METHODS

Twenty examiners (10 experienced and 10 beginners) were included in the study. Each examiner performed stress ultrasonography on a patient with a chronic anterior talofibular ligament injury and a patient with an intact ligament using the reverse anterior drawer method. Changes in ligament length before versus after stress were determined. The same 20 examiners performed ultrasonography on two other patients with an injured or intact ATFL using the anterior drawer method. The length change values and variance were compared between the groups using t-tests and F-tests.

RESULTS

Using the reverse anterior drawer method, the change in the anterior talofibular ligament length was 3.3 mm (range, 2.2-4.8 mm) in the experienced group and 2.7 mm (0.0-4.1 mm) in the beginner group for the ligament injured patient. The length changes for the patient with intact anterior talofibular ligament were 0.5 mm (0.1-0.9 mm) and 0.4 mm (-0.1-1.5 mm) in the experienced and beginner groups, respectively. There were no significant intergroup differences in measurement amount (P = 0.37) or variance (P = 0.72). Similarly, using the anterior drawer method, no significant differences between the groups were found in measurement amount or variance.

CONCLUSION

The quantitative evaluation of stress sonography of the ankle was variable regardless of examiner experience or stress method, particularly in patients with an anterior talofibular ligament injury. The amount of variability appeared to be unacceptably large for clinical application. Our study results highlight the need for technical standardization.

Do standardization of the procedure reduce measurement variability of the sonographic anterior drawer test of the ankle?

BACKGROUND

In quantitative ankle stress sonography, different examiners use different techniques, which may cause measurement variability. This study aimed to clarify whether standardizing stress sonography techniques reduces variability in the quantitative measurement of anterior talofibular ligament length change.

METHODS

Fourteen examiners with a mean ultrasound experience of 8.7 years participated in this study. Each examiner performed stress ultrasonography of the ankle using their preferred method on one patient with an intact anterior talofibular ligament (Patient 1) and on two patients with chronic ankle instability (Patient 2 and 3). Changes in the ligament length between the resting and stressed positions were determined. A consensus meeting was then conducted to standardize the sonographic technique, which was used by the examiners during a repeat stress sonography on the same patients. The variance and measured values were compared between the preferred and standardized techniques using F-tests and paired t-tests, respectively.

RESULTS

At a consensus meeting, a sonographic technique in which the examiner pushed the lower leg posteriorly against the fixed foot was adopted as the standardized technique. In Patient 1, the change in the anterior talofibular ligament length was 0.4 (range, -2.3-1.3) mm and 0.6 (-0.6-1.7) mm using the preferred and standardized techniques, respectively, with no significant difference in the variance (P = 0.51) or the measured value (P = 0.52). The length changes in Patient 2 were 2.0 (0.3-4.4) mm and 1.7 (-0.9-3.8) mm using the preferred and standardized techniques, respectively. In Patient 3, the length changes were 1.4 (-2.7-7.1) mm and 0.7 (-2.0-2.3) mm. There were no significant differences between the techniques in either patient group.

CONCLUSION

Variability in the quantitative measurement of ankle stress sonography was not reduced despite the standardization of the technique among examiners. Hence, comparing the measured values between different examiners should be avoided.

Musculoskeletal ultrasonography in rheumatic diseases

Ultrasonography is an imaging technique based on sound waves used for the evaluation of soft tissues. Sound waves have been used for a long time in nonmedical fields, including military defense systems, radar systems, and detection of icebergs. Technological advances resulted in new techniques becoming available for medical imaging, including ultrasonography, magnetic resonance imaging, and computed tomography. Nowadays, the use of imaging has become a gold standard protocol in the diagnosis of many diseases, and recently developed diagnosis and therapy options provide more efficient treatment of rheumatic diseases. Thus, it has become possible to prevent structural damage and disability in patients with rheumatic disease. Musculoskeletal ultrasonography is becoming a preferred imaging technique for rheumatic diseases, as it has many advantages. Among its advantages are being inexpensive, being radiation-free, having a dynamic image capacity, helping to detect disease activity, and helping with early detection and diagnosis of structural damage. This review summarizes the use of ultrasonography in rheumatic diseases.

Optical spectral transmission to assess glucocorticoid therapy response in patients with arthritis: a longitudinal follow-up comparison with joint ultrasound

BACKGROUND

Optical spectral transmission (OST) is a modern diagnostic modality, able to assess the blood-specific absorption of light transmitted through a tissue, promising quantification of inflammation in the finger and wrist joints of patients with arthritis. To date, there are no adequate data regarding the diagnostic value of OST in the evaluation of inflammatory activity changes, during arthritis follow-up. Objectives of this study were therefore to examine the performance of OST in assessing response to anti-inflammatory therapy in patients with active arthritis and to explore OST associations with clinical, laboratory, and ultrasonographic (US) activity markers.

METHODS

1173 joints of 54 patients with arthritides of the wrist and finger joints were examined by OST before and after oral administration of glucocorticoids (GC), during a disease flare. For the same time-points patients underwent clinical, laboratory, and joint US [grayscale (GSUS), power-Doppler (PDUS)] examinations. The distribution of ΔOST-values between the two time-points was compared with the respective distributions of ΔPDUS and ΔGSUS by Bayesian statistical analyses. Moreover, the diagnostic performance of OST compared to a control group (2508 joints of 114 subjects) was examined by receiver operating characteristics and associations of OST values with clinical, laboratory, and arthrosonographic parameters were evaluated by correlation analyses.

RESULTS

OST and US performed similarly in the assessment of inflammatory changes caused by GC (same value-change tendency in 83.2% of the cases). Bayesian statistics revealed no significant differences between ΔOST and ΔPDUS for all 3 examined joint categories (accuracy: metacarpophalangeal (MCP): 68.1%; proximal interphalangeal (PIP): 60.4%; wrists: 50.4%) and between ΔOST and ΔGSUS for MCP and PIP joints (accuracy: 51.1% and 78.7%, respectively). OST diagnostic performance (patients vs. controls) was excellent in both time-points [area under the curve (AUC) before GC=0.883(95%CI=0.83-0.94) and after GC=0.811(95%CI=0.74-0.881); p<0.001]. Furthermore, OST correlated significantly with all examined sonographic activity scores (all; p<0.001) and with swollen joint counts (p<0.01).

CONCLUSIONS

OST was able to assess response to therapy in a similar way to joint US and correlated significantly with arthritis activity markers. Therefore, OST has proved to be a valuable tool to assist disease activity monitoring in the examined cohort.

TRIAL REGISTRATION

German Registry of Clinical Trials, DRKS00016752.

Intraobserver Reliability on Classifying Bursitis on Shoulder Ultrasound

Purpose: Bursitis is a common musculoskeletal cause of shoulder pain and treatment varies, thus correctly diagnosing and grading bursitis is paramount in deciding management. Our aim was to assess reliability in grading shoulder bursitis on ultrasonography among fellowship trained musculoskeletal radiologists at our institution. Methods: Retrospective study of patients diagnosed with bursitis on ultrasonography. Single-sonographic images of the subacromial-subdeltoid bursa were collected for each patient and randomized to form a test-bank of varying degrees of bursitis. Three months after the test was administered, the cases were randomized and readministered. The radiologists graded each case as: within normal limits, mild, moderate or severe. Intraobserver variability was measured using Cohen's kappa coefficient. Linear regression model was performed to assess correlation between years of experience and kappa. Results: 10 radiologists reviewed 70 cases of bursitis. Kappa values ranged from .53 to .91, indicating 'moderate' to 'almost perfect' variability amongst radiologists. A moderate positive correlation of improving variability (r = .69) with increasing years of experience exists. Conclusion: Fellowship trained musculoskeletal radiologists were able to grade shoulder bursitis with moderate to almost perfect variability, with a positive correlation of improved variability with increasing experience. This may help clinicians choose the correct treatment more confidently in their patients with shoulder pain.

Ultrasonic Evaluation of the Heel Fat Pad Under Loading Conditions Using a Polymethylpentene Resin Plate: Part 2. Reliability and Agreement Study

Previously, we developed an instrument to evaluate the heel fat pad (HFP) two-layer structure, under varying loading conditions, with ultrasonography from the plantar surface through a polymethylpentene resin plate; the measured values were equivalent to those obtained without this plate. The study described here aimed to determine the intra- and inter-examiner reliabilities of the HFP thickness measurements and the agreement between long- and short-axis measured values using this instrument. Two examiners successively recorded the HFPs of 40 healthy adults twice under the no loading and loading conditions on the long- and short-axis scans. The HFPs were classified into two layers, and their thicknesses were measured. Short-term intra- and inter-examiner reliabilities were determined using the intraclass correlation coefficients. Measurements were repeated 1 mo later to determine the long-term intra-examiner reliability. The agreement between the measured long- and short-axis values was investigated by calculating the minimal detectable changes. The determined short- and long-term intra-examiner reliabilities ranged from 0.750 to 0.999 and from 0.765 to 0.952, respectively. Inter-examiner reliability ranged from 0.765 to 0.997. Differences may occur between the values measured at different axes. The measurements using this evaluation instrument were reliable, and it is best to unify the measurement axis for quantitative research.

Ultrasound joint examination by an automated system versus by a rheumatologist: from a patient perspective

Background

The Arthritis Ultrasound Robot (ARTHUR) is an automated system for ultrasound scanning of the joints of both hands and wrists, with subsequent disease activity scoring using artificial intelligence. The objective was to describe the patient’s perspective of being examined by ARTHUR, compared to an ultrasound examination by a rheumatologist. Further, to register any safety issues with the use of ARTHUR.

Methods

Twenty-five patients with rheumatoid arthritis (RA) had both hands and wrists examined by ultrasound, first by a rheumatologist and subsequently by ARTHUR. Patient-reported outcomes (PROs) were obtained after the examination by the rheumatologist and by ARTHUR. PROs regarding pain, discomfort and overall experience were collected, including willingness to be examined again by ARTHUR as part of future clinical follow-up. All ARTHUR examinations were observed for safety issues.

Results

There was no difference in pain or discomfort between the examination by a rheumatologist and by ARTHUR (p = 0.29 and p = 0.20, respectively). The overall experience of ARTHUR was described as very good or good by 92% (n = 23), with no difference compared to the examination by the rheumatologist (p = 0.50). All (n = 25) patients were willing to be examined by ARTHUR again, and 92% (n = 23) would accept ARTHUR as a regular part of their RA clinical follow up. No safety issues were registered.

Conclusions

Joint ultrasound examination by ARTHUR was safe and well-received, with no difference in PRO components compared to ultrasound examination by a rheumatologist. Fully automated systems for RA disease activity assessment could be important in future strategies for managing RA patients.

Trial registration: The study was evaluated by the regional ethics committee (ID: S-20200145), which ruled it was not a clinical trial necessary for their approval. It was a quality assessment project, as there was no intervention to the patient. The study was hereafter submitted and registered to Odense University Hospital, Region of Southern Denmark as a quality assessment project and approved (ID: 20/55294).

The value of MRI for detecting subclinical joint inflammation in clinically suspect arthralgia

In the last decade, much research has focused on the development of rheumatoid arthritis (RA) and the symptomatic phase preceding the onset of clinical arthritis. Observational studies on imaging have revealed that subclinical joint inflammation in patients with arthralgia at risk for RA precedes and predicts the onset of clinically apparent arthritis. Moreover, the results of two placebo-controlled randomised proof-of-concept trials in patients with arthralgia and MRI-detected subclinical inflammation studies will soon be available. The initial results are encouraging and suggest a beneficial effect of DMARD treatment on subclinical inflammation. Since this may increase the necessity to detect subclinical joint inflammation in persons with arthralgia that are at risk for RA, we will here review what has been learnt about subclinical inflammation in at-risk individuals by means of imaging. We will focus on MRI as this method has the best sensitivity and reproducibility. We evaluate the prognostic value of MRI-detected subclinical inflammation and assess the lessons learnt from MRIs about the tissues that are inflamed early on and are associated with the clinical phenotype in arthralgia at risk for RA, for example, subclinical tenosynovitis underlying pain and impaired hand function. Finally, because long scan times and the need for intravenous-contrast agent contribute to high costs and limited feasibility of current MRI protocols, we discuss progress that is being made in the field of MRI and that can result in a future-proof way of imaging that is useful for assessment of joint inflammation on a large scale, also in a society with social distancing due to COVID-19 restrictions.

Immediate Effects of Long-Axis Talocrural Thrust Manipulation on the Length of the Anterior Talofibular and Calcaneofibular Ligaments Measured With Musculoskeletal Ultrasound Imaging

OBJECTIVE

The aim of the present study was to measure the immediate effect of a thrust manipulation on the length of the anterior talofibular and calcaneofibular ligaments in healthy patients.

METHODS

A convenience sample of 47 healthy patients were recruited for this quasi-experimental study. The patients had an age range from 22 to 54 years, with a mean age of 30.36 years. There were 23 female patients and 24 male patients. Musculoskeletal ultrasound imaging was used to measure the length of the anterior talofibular and calcaneofibular ligaments before and immediately after a high-velocity long-axis thrust manipulation of the talocrural joint during various validated test positions.

RESULTS

A single long-axis thrust manipulation did not result in a significant change in the length of the anterior talofibular ligament (P = .325). Additionally, there was no significant difference in calcaneofibular length after a long-axis thrust manipulation (P = .26).

CONCLUSION

The results indicate that the length of the anterior talofibular and calcaneofibular ligament did not significantly change after a single long-axis thrust manipulation of the talocrural joint in healthy patients. It appears that the joint capsule of the talocrural joint reached end-range during the manipulation before the ligament undergoes plastic length changes; thus, the increase in joint range of motion after a thrust manipulation was probably not due to increased plastic length changes of the anterior talofibular and calcaneofibular ligaments.

Reliability of detection of ultrasound and MRI features of hand osteoarthritis: a systematic review and meta-analysis

OBJECTIVES

To systematically review the literature on inter- and intra-rater reliability of scoring ultrasound and MRI changes in hand osteoarthritis (OA).

METHODS

Medline, EMBASE, CINHAL, Web of Science and AMED were searched from inception to January 2020. Kappa (K), weighted Kappa (Kw) and intra-class correlation coefficients (ICC) for dichotomous, semi-quantitative and summated scores respectively, and their 95% confidence intervals (CI) were pooled using random-effects model. Heterogeneity between studies was assessed and reliability estimates were interpreted using Landis-Koch's classification.

RESULTS

Fifty studies met the inclusion criteria (33 ultrasound, 21 MRI). The pooled K(95% CI) for inter-rater reliability was substantial for ultrasound-detected osteophytes [0.66 (0.54, 0.79)], grey-scale synovitis (GSS) [0.64 (0.32, 0.97)], and power Doppler (PD) [0.76, (0.47, 1.05)]; whereas intra-rater reliability was almost perfect for osteophytes [0.82 (0.80, 0.84)], central bone erosions (CBEs) [0.83 (0.78, 0.89)], and effusion [0.83 (0.74, 0.91)]; and substantial for GSS [0.64 (0.49, 0.79)] and PD [0.70 (0.59, 0.80)].Inter-rater reliability for dichotomous assessment was substantial for MRI-detected CBEs [0.75 (0.67, 0.83)] and synovitis [0.69 (0.51, 0.87)]; slight for osteophytes [0.14 (0.04, 0.25)]; and almost perfect for sum score of osteophytes, CBEs, joint space narrowing (JSN), and bone marrow lesions (BMLs) (0.81-0.89). Intra-rater reliability was almost perfect for sum score of MRI synovitis [0.92 (0.87, 0.96)], BMLs [0.88 (0.78, 0.98)], osteophytes [0.86 (0.74, 0.98)], CBEs [0.83 (0.66, 1.00)] and JSN [0.91 (0.87, 0.91)].

CONCLUSION

Ultrasound and MRI are reliable in detecting hand OA features. Ultrasound may be preferred due to low-cost and increasing availability.

Reliability in ultrasound measurements of plantar aponeurosis thickness

PURPOSE

Given the increasing research interest in ultrasound plantar aponeurosis (PA) thickness measurements, this study aimed to analyze the inter and intra-rater reliability of independent sonograms and to identify the error related to the image analysis procedure.

METHODS

Twenty-one healthy men participated in this study. Imaging of PA consisted of two independent sonograms per subject. Two raters (R1 and R2) evaluated each sonogram twice using standardized steps. Precision of the image analysis procedure was analyzed using the Bland and Altman plot and Intraclass Correlation Coefficient (ICC). Agreement estimates and ICC were used to assess absolute and relative inter and intra-rater reliability.

RESULTS

Reliability of PA thickness was found to depend strongly on the number of images acquired per subject. Intra-rater agreement for single measurements were 0.696 (R1) and 0.495 (R2), whereas average measurements yielded values of 0.821 (R1) and 0.662 (R2), respectively. Precision within a sonogram varied from ICC values of 0.873 to 0.960 (intra-rater) and 0.670 to 0.822 (inter-rater).

CONCLUSION

Most part of the error in PA thickness measurements seems to be related to the sonogram acquisition process and not to the visual inspection of the image. To minimize error, average values of a minimum of two images per subject should be used. The moderate agreement between raters found in this study ratifies the need of all measurements being made by the same rater or group of raters. If a single rater evaluates all subjects, performing multiple measurements over one image does not seem to affect ICC as much as acquiring multiple images.

EULAR recommendations for the reporting of ultrasound studies in rheumatic and musculoskeletal diseases (RMDs)

OBJECTIVE

To produce European League Against Rheumatism (EULAR) recommendations for the reporting of ultrasound studies in rheumatic and musculoskeletal diseases (RMDs).

METHODS

Based on the literature reviews and expert opinion (through Delphi surveys), a taskforce of 23 members (12 experts in ultrasound in RMDs, 9 in methodology and biostatistics together with a patient research partner and a health professional in rheumatology) developed a checklist of items to be reported in every RMD study using ultrasound. This checklist was further refined by involving a panel of 79 external experts (musculoskeletal imaging experts, methodologists, journal editors), who evaluated its comprehensibility, feasibility and comprehensiveness. Agreement on each proposed item was assessed with an 11-point Likert scale, grading from 0 (total disagreement) to 10 (full agreement).

RESULTS

Two face-to-face meetings, as well as two Delphi rounds of voting, resulted in a final checklist of 23 items, including a glossary of terminology. Twenty-one of these were considered 'mandatory' items to be reported in every study (such as blinding, development of scoring systems, definition of target pathologies) and 2 'optional' to be reported only if applicable, such as possible confounding factors (ie, ambient conditions) or experience of the sonographers.

CONCLUSION

An EULAR taskforce developed a checklist to ensure transparent and comprehensive reporting of aspects concerning research and procedures that need to be presented in studies using ultrasound in RMDs. This checklist, if widely adopted by authors and editors, will greatly improve the interpretability of study development and results, including the assessment of validity, generalisability and applicability.

Evaluation of anterotalofibular and calcaneofibular ligament stress tests utilizing musculoskeletal ultrasound imaging

Study Design: A quasi-experimentalBackground: The talar tilt test and the anterior drawer test are clinically used to evaluate the length of the anterotalofibular (ATFL) and calcaneofibular (CFL) ligaments. Based on the current literature, there is no clear diagnostic utility or preference for either test. This study investigated ligament lengthening during these special tests and compared the talar tilt test to the long axis distraction test for the CFL length.Methods: A convenience sample of 47 healthy subjects were recruited for this study. Musculoskeletal ultrasound imaging (MSK US) was used to measure the length of the ATFL and CFL during the talar tilt and anterior drawer tests. Additionally, CFL lengthening during the talar tilt was compared to the long axis distraction test.Outcomes: A significant difference was found (p < .001) in ATFL length between the talar tilt and anterior drawer test. This indicates that the talar tilt test is preferred to maximally lengthen the ATFL. There was a significant difference in CFL length (p < .001) between the talar tilt test and the long axis distraction test.Discussion: The results of this study identified that the talar tilt test resulted in more ATFL lengthening than the anterior drawer test and thus is the preferred test to assess ligament length. Additionally, both the long axis distraction test and the talar tilt test cause lengthening of the CFL. Therefore, the long axis distraction test can be used as a differentiation test to determine if either the ATFL or the CFL is the structure with increased laxity.

[Sonography of the foot in rheumatology : Ultrasound diagnostics of the ankle joint and foot in the rheumatological routine]

Ultrasound examination of the joints is an essential component of diagnostics in rheumatology. Due to its easy accessibility, excellent image definition of soft tissue and bone surfaces with standardized scan sections and scoring systems, ultrasound examination of the joints enables decisions to be made on early and differential diagnostics, treatment monitoring and prognosis. Involvement of the ankle and foot is a common problem in both inflammatory and degenerative rheumatological diseases. Persisting inflammatory processes and bone destruction increase the burden of disease by causing a loss of mobility due to pain. As treatment is often prolonged it is an important issue for both the quality of life of affected patients and a burden on the resources of the healthcare system. The anatomical characteristics of the foot make it difficult to draw diagnostic conclusions by physical examination only. These diagnostic gaps in the remaining rheumatological questions can often be answered by ultrasound examination of the joint.

A Standardized, Pragmatic Approach to Knee Ultrasound for Clinical Research in Osteoarthritis: The Johnston County Osteoarthritis Project

Objective

This study sought to develop and employ a comprehensive and standardized ultrasound (US) protocol and scoring atlas for the evaluation of features relevant to knee osteoarthritis (KOA) in a community‐based cohort in the United States, with the goals of demonstrating feasibility, reliability, and validity.

Methods

We utilized data from the fourth follow‐up (2016‐2018) of the Johnston County OA Project, which includes individuals with (~50%) and without radiographic KOA. All participants underwent standardized knee radiography and completed standard questionnaires including the Knee Injury and Osteoarthritis Outcome Score (KOOS). Bilateral knee US images were obtained by a trained sonographer using a standardized protocol and scored by trained rheumatologists using an atlas developed for this study. A total of 396 knees were each scored by two readers according to the atlas. Associations between US features, radiographic findings (graded by an expert radiologist), and KOOS scores were assessed.

Results

Overall interreader reliability for US scoring was fair to moderate. The strongest correlations between US and radiographic features were seen for osteophytes, and similarly strong correlations were seen between US osteophytes and overall radiographic Kellgren‐Lawrence Grade, demonstrating criterion validity. Features of effusion/synovitis and osteophytes were most associated with KOOS pain and impaired function.

Conclusion

US is a feasible, reliable, and valid method to assess features relevant to KOA in clinical and research settings. The protocol and atlas developed in this study can be utilized to evaluate KOA in a standardized fashion in future clinical studies, enabling greater utilization of this valuable modality in osteoarthritis.

THE MANAGEMENT OF PLANTAR FASCIITIS WITH A MUSCULOSKELETAL ULTRASOUND IMAGING GUIDED APPROACH FOR INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION IN A RUNNER: A CASE REPORT

BACKGROUND/AND PURPOSE

Musculoskeletal ultrasound imaging (MSK US) is an emerging diagnostic tool in physical therapy, which allows for dynamic visualization of tissues in real time. Plantar fasciitis is a common condition causing heel and arch pain and has been related with degenerative changes in the plantar fascia resulting in tissue thickening. Instrument Assisted Soft Tissue Mobilization (IASTM) is an intervention that allows clinicians deep penetration to treat tissues. The mechanical forces caused by IASTM might cause localized tissue trauma leading to stimulation of the body's natural inflammation and healing processes. The purpose of this case report is to demonstrate the use of ultrasound imaging to guide the decision-making process and to discern the optimal location for the application of IASTM.

CASE DESCRIPTION

The subject was a 46-year-old female yoga practitioner and runner, who presented with right foot pain. The clinical impression was formulated based on the combination of traditional physical therapy examination procedures and MSK US imaging findings of the plantar fascia demonstrating thickness and tendinosis like changes within the plantar fascia 3 cm distally from the calcaneus.

OUTCOMES

The subject was seen for eight treatment sessions over four weeks, at which time the goals of normal ankle dorsiflexion, no pain with palpation of the plantar fascia, negative windlass test, and no reported pain during gait were achieved.

DISCUSSION

This case report illustrates the use of MSK US imaging as a method to objectively assess tissue quality and guide decision-making when managing patients with plantar fascia related pain. MSK US was used to determine the optimal location for the application of IASTM during the conservative management of a runner with plantar fasciitis.

LEVEL OF EVIDENCE

Therapy, Level 5.

Ultrasound-Guided Injection of High Molecular Weight Hyaluronic Acid versus Corticosteroid in Management of Plantar Fasciitis: A 24-Week Randomized Clinical Trial

BACKGROUND AND AIMS

Plantar fasciitis (PF) is the leading cause of heel pain in adults. This study was designed to evaluate the effect of hyaluronic acid (HA) injection in reducing the symptoms of PF, compared with corticosteroid (CS) injection as a conventional treatment.

METHODS

In this triple-blind, randomized, clinical trial, 75 patients who had the symptoms of PF for at least 3 months were randomly divided into two groups of 38 and 37 individuals. Then, each patient received either a single injection of high molecular weight (>2000 kDa) HA (1 mL HA 20 mg + 1 mL lidocaine 2%) or CS (1 mL methylprednisolone 40 mg + 1 mL lidocaine 2%) under the ultrasonography (US) guidance. Visual analog scale (VAS), foot ankle ability index (FAAI), pressure pain threshold (PPT), functional foot index (FFI), and plantar fascia thickness (PFT) were measured using US at baseline, 6 weeks and 24 weeks after the injection. Eventually, at the end of the treatment period, the patients' satisfaction was measured. Intention to treat analysis was used to assess the results.

RESULTS

After 24 weeks of follow-up, results from 60 subjects were fully obtained; however, results of 73 patients included into intention to treat analysis in the sixth-week follow-up. In both groups, VAS, PFT and FFI decreased, while FAAI and PPT increased significantly (P <0.001). At the baseline and at the 24th-week, no significant difference between the two groups was observed in any of the variables. However, a comparison between the baseline and the sixth-week results shows a prominent decrease in PPT and PFT in the CS group compared to the HA group (P = 0.004 and P = 0.011). Finally, there were no statistical differences between the two groups in treatment satisfaction (P = 0.618).

CONCLUSION

Both CS and HA were effective modalities for PF and can improve pain and function with no superiority in 24th-week follow-ups, although CS seems to have a faster trend of improvement in the short term.

Use of artificial intelligence in imaging in rheumatology - current status and future perspectives

After decades of basic research with many setbacks, artificial intelligence (AI) has recently obtained significant breakthroughs, enabling computer programs to outperform human interpretation of medical images in very specific areas. After this shock wave that probably exceeds the impact of the first AI victory of defeating the world chess champion in 1997, some reflection may be appropriate on the consequences for clinical imaging in rheumatology. In this narrative review, a short explanation is given about the various AI techniques, including 'deep learning', and how these have been applied to rheumatological imaging, focussing on rheumatoid arthritis and systemic sclerosis as examples. By discussing the principle limitations of AI and deep learning, this review aims to give insight into possible future perspectives of AI applications in rheumatology.

Comparing the Accuracy of Radiography and Sonography in Detection of Knee Osteoarthritis: A Diagnostic Study

BACKGROUND:

Knee osteoarthritis (OA) is the most common degenerative disorder occurring in older people. Radiography and sonography are convenient techniques to detect diverse pathological features of knee OA.

AIM:

The aim of the present study was to evaluate the diagnostic efficacy of radiography and sonography in the detection of diverse features of knee OA.

METHODS:

In a prospective cross-sectional diagnostic accuracy study, 50 consecutive patients with suspected knee OA (40 women and 10 men, mean age 41.2 ± 6.1 years), referred to the rheumatology clinic of the Shohada Hospital of Khorramabad. All obtained magnetic resonance imaging (MRI), radiographic and sonography images were evaluated by two radiologists and rheumatologist with sufficient expertise in degenerative knee disorders. MRI has been considered as a gold standard test in evaluating other tests. The sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and accuracy with 95% confidence intervals of radiography and sonography in the diagnosis of knee OA were calculated.

RESULTS:

Prevalence of the marginal osteophyte, geode and decreased joint thickness were significantly higher in patients with age > 40 years compared to ≤ 40 years (P < 0.05). The incidence of diverse features of knee OA was not significantly different in terms of the patient’s gender, except for decreased joint space. The specificity of radiography was higher than its sensitivity.

CONCLUSION:

Our study showed that both radiography and sonography are useful imaging modalities, especially to diagnosis the positive cases of knee OA. The specificity of radiography is higher than to its sensitivity for all pathological features of knee OA. The sensitivity of sonography to detect some features of knee OA such as decreased joint thickness is considerably higher than radiography.

Musculoskeletal ultrasound imaging and clinical reasoning in the management of a patient with cervicogenic headache: a case report

Background: Clinical decision-making within the physical therapy treatment process typically follows the hypothetical-deductive method. The accuracy and reliability of clinical tests affect this reasoning process. Musculoskeletal ultrasound imaging (MSK US) is an emerging valid and reliable diagnostic tool in physical therapy. MSK US allows for dynamic visualization of tissues in real time with devices that are often portable.Case Description: The patient was a 55-year-old female, who presented by direct access. She had been suffering from cervicogenic headaches since the age of 18. It was hypothesized that this patient presented with a right rotation positional default of atlas and facet hypomobility at C5-6.Outcomes: After six visits (over 7 weeks) of manual therapy interventions, the patient reported that her headaches and neck pain were no longer present. Her physical therapy goals had been met and she was discharged with the instruction to continue working on her posture correction and self-management.Discussion: This case report describes the use of MSK US imaging as part of the clinical decision-making process when treating a patient with cervicogenic headaches. This case illustrates the successful management using manual therapy to restore position, mobility, decrease muscle tone, and normalize upright posture. Complementary research is necessary to further validate MSK US imaging as the preferred method to objectivize joint mobility and guide decision-making. Additionally, the cause-effect relationship between the treatment and positive outcomes in this case report has to be further validated.

Potential clinical utility of a novel optical tomographic imaging for the quantitative assessment of hand rheumatoid arthritis

Optical tomographic imaging (OTI) was reported to be a novel technique for the early diagnosis and disease activity assessment of rheumatoid arthritis (RA). This study aimed to evaluate the clinical utility of OTI for the detection of hand synovitis of RA patients. Manu-scan was used to perform imaging targeting the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints in 12 RA patients and three controls. The enrolled RA patients also underwent magnetic resonance imaging (MRI) and bone scintigraphy (BS) to provide reference images. Of the 181 joints feasible for OTI analysis, 140 joints (111 in RA patients and 29 in controls, 77.3%) in which the difference of the OTI indices in the two measurements was within 20% were evaluated. The OTI indices in RA joints were significantly lower than those in control joints (p < 0.001). Overall, the OTI indices in RA joints decreased as the synovitis grades on MRI or BS increased. Moreover, OTI was able to discriminate between RA and control joints (AUC = 0.815, 95% CI 0.739-0.891), even if RA joints were normal on physical examination (AUC = 0.714, 95% CI 0.594-0.834). OTI was in good agreement (kappa = 0.60) with MRI for evaluating synovitis in RA patients and showed positive results in 11.4% of clinically asymptomatic joints. OTI in this study showed the potential to be a supplementary imaging modality for the quantification of synovial inflammation in PIP and MCP joints of RA patients. Further large-scale trials are needed to confirm these findings.

Pre-Clinical Testing of Microwave Radiometer and a Pilot Study on the Screening Inflammation of Knee Joints

This article presents the pre-clinical evaluation of our custom-built, single-band microwave radiometer centered at 1.3 GHz for deep tissue thermometry, and a pilot study on volunteers for passive detection of inflammation in knee joints. The electromagnetic (EM) compatibility of the battery-operated radiometer for clinical use was assessed as per International Special Committee on Radio Interference (CISPR) 22 standard. The ability to detect inflammation in knee joints was assessed using a substrate integrated waveguide antenna connected to the radiometer. EM compatibility tests carried out in the laboratory indicated device immunity to intentional radiated interference up to -20 dBm injected power in the global system for mobile communication frequency band, and pre-compliance to CISPR 22 standard. Radiometer temperature measurements recorded at the lateral and medial aspects of both knees of 41 volunteers indicated mean temperature greater than 33°C for the diseased sites compared with the mean temperature of 28°C measured for the healthy sites. One-way analysis of variance statistics indicated significantly (P < 0.005) higher radiometer temperature at the diseased sites unlike the healthy sites. Thus, the EM pre-compliance of the device and the potential to measure deep tissue inflammation were demonstrated. Bioelectromagnetics. 2019;40:402-411. © 2019 Bioelectromagnetics Society.

Neural networks for automatic scoring of arthritis disease activity on ultrasound images

Background

The development of standardised methods for ultrasound (US) scanning and evaluation of synovitis activity by the OMERACT-EULAR Synovitis Scoring (OESS) system is a major step forward in the use of US in the diagnosis and monitoring of patients with inflammatory arthritis. The variation in interpretation of disease activity on US images can affect diagnosis, treatment and outcomes in clinical trials. We, therefore, set out to investigate if we could utilise neural network architecture for the interpretation of disease activity on Doppler US images, using the OESS scoring system.

Methods

Two state-of-the-art neural networks were used to extract information from 1342 Doppler US images from patients with rheumatoid arthritis (RA). One neural network divided images as either healthy (Doppler OESS score 0 or 1) or diseased (Doppler OESS score 2 or 3). The other to score images across all four of the OESS systems Doppler US scores (0–3). The neural networks were hereafter tested on a new set of RA Doppler US images (n=176). Agreement between rheumatologist’s scores and network scores was measured with the kappa statistic.

Results

For the neural network assessing healthy/diseased score, the highest accuracies compared with an expert rheumatologist were 86.4% and 86.9% with a sensitivity of 0.864 and 0.875 and specificity of 0.864 and 0.864, respectively. The other neural network developed to four class Doppler OESS scoring achieved an average per class accuracy of 75.0% and a quadratically weighted kappa score of 0.84.

Conclusion

This study is the first to show that neural network technology can be used in the scoring of disease activity on Doppler US images according to the OESS system.

Ultrasonographic criteria for the diagnosis of erosive rheumatoid arthritis using osteoarthritic patients as controls compared to validated radiographic criteria

OBJECTIVES

The aims of this study were to compare characteristics of radiography (RX) and ultrasound (US) erosive lesions in rheumatoid arthritis (RA) and osteoarthritis (OA) patients (prevalence, topography and severity), to determine thresholds for the diagnosis of erosive RA based on US and to evaluate the performance of US and RX to establish a diagnosis of erosive RA differentiated from hand OA.

METHODS

Patients fulfilling ACR 1987 and/or ACR/EULAR 2010 criteria for RA or ACR hand OA criteria were prospectively included. A modified Sharp erosion score was assessed by two blinded readers and one adjudicator for discordant cases (number of eroded joints ≤ three). Erosions in US were scored on six bilateral joints (MCP2-3, 5; MTP2-3, 5) with a four-grade scale to calculate total US score for erosions (USSe).

RESULTS

A total of 168 patients were included: 122 RA (32 early RA < 2 years; 90 late RA ≥ 2 years); 46 OA patients. On RX: 42 RA patients (6 early; 36 late) and 5 OA patients were eroded according to EULAR 2013 definition criteria with sensitivity at 34.4% and specificity at 89.1%. On US, 95 RA patients (21 early; 74 late) and 12 OA patients were eroded. Considering at least two joint facets eroded or at least one joint facet eroded at grade 2 on US, sensitivities were good (68-72.1%) and specificities excellent (89.1-100%). Agreement between RX and US was excellent (90-92%). The positive and negative likehood ratios were respectively 3.16 and 0.73 for radiography and 6.64 and 0.31 for US (for two facets eroded).

CONCLUSION

USSe can differentiate RA from OA in erosive disease and detect two times more patients with erosive RA than RX with excellent specificity and agreement.

Assessment of ultrasonography as a diagnostic tool in shoulder pain and alterations in glenohumeral range of motion in tennis players

Introduction

Shoulder pain and alterations in the range of motion are common disorders in tennis players. However, the relation between shoulder structures and these conditions is unknown.

Aim

To evaluate whether, using ultrasonography, one can identify tennis players with shoulder pain and those having specific changes of the range of rotation of the glenohumeral joint.

Material and methods

A total of 66 subjects were assessed through examination of the range of rotation of the glenohumeral joint and ultrasonography.

Results

The study group consisted of 37 people with shoulder pain (24.2 ±8.6 years) and the control group included 29 subjects without shoulder pain (21.9 ±10.8 years). The prevalence of pathologies of the supraspinatus (SSP), infraspinatus (ISP) or subscapularis (SSC) was significantly higher in the study group than in the control group (p = 0.044) but solely for the combined pathologies. The incidence rate of pathological shoulder changes (the SSP, ISP, SSC and the subacromial bursa) was not correlated with the ranges of rotations or intensity of pain. Glenohumeral internal rotation deficit (GIRD), total rotational motion (TROM) deficit and external rotation deficiency (ERD) were independent of pathological shoulder changes, except the significantly higher prevalence of SSP pathologies among subjects with ERD.

Conclusions

Ultrasonography could be helpful in identifying tennis players with painful shoulder having rotator cuff pathologies. However, the ability of the method to identify players having specific changes of the range of rotation of the glenohumeral joint is limited, with the exception of tennis players with ERD having SSP pathologies.

Subclinical crystal arthropathy: a silent contributor to inflammation and functional disability in knees with osteoarthritis-an ultrasound study

PURPOSE

This study aimed at investigating the prevalence of crystal deposits with knee osteoarthritis (OA) by ultrasonography and measure the inflammatory burden associated with crystal deposits in OA using WOMAC score.

METHODS

Adult patients with primary knee OA diagnosed according to the American College of Rheumatology criteria were included. Participants were subjected to history taking, clinical examination, knee US, and plain radiography. The EULAR and the OMERACT ultrasonography definitions and scanning protocols were used.

RESULTS

Fifty-three patients (44 females, 9 males) were enrolled. Mean values were 53.5 years ± 8.3 SD for age and 42.5 months ± 49.5 SD for disease duration. Crystals were detected by US in 73/106 knees (68.9%). Plain radiography revealed chondrocalcinosis in three patients. Mean values for WOMAC pain, stiffness, and disability scores were 14.38 ± 3.99, 4.93 ± 2.06, and 49.61 ± 13.06, respectively, with insignificant differences relative to presence of crystals (P > 0.05). Regression analysis revealed a 4.1-fold increase in the incidence of sonographic crystals with bursitis (OR = 4.13, CI = 1.5-11.2, p = 0.01) and a 3.2-fold increase in the incidence of sonographic crystals with synovial effusion (OR = 3.16, CI = 1.34-7.44, p = 0.01).

CONCLUSION

Subclinical crystals were detected in a considerable number of patients with primary knee OA. The incidence of crystal deposits was significantly higher in patients with bursitis and knee effusion.

Diagnosis of isolated extensor carpi radialis longus (ECRL) tendon avulsion fracture using ultrasound: a paradigm shift

Isolated avulsion fracture of the extensor carpi radialis longus (ECRL) tendon is a rare and poorly understood injury. We present a unique case of a 45-year-old male who fell on his flexed right hand. He presented with a subtle but extremely painful mass on the dorsum of his wrist. Ultrasound (U/S) imaging of the mass revealed an avulsed bone fragment attached to the ECRL tendon, confirming the clinical suspicion of an ECRL avulsion injury. Computed tomography and magnetic resonance imaging are well-documented imaging modalities to detect tendon avulsions. As demonstrated by this case report, U/S is an excellent diagnostic tool for ECRL rupture, a cost-effective alternative that provides real-time dynamic examination of hand injuries. To our knowledge, this is the first case of ECRL avulsion diagnosed by U/S. The purpose of this case report is to educate the reader on detection and diagnosis of ECRL tendon avulsion using U/S, a time-efficient and cost-effective imaging modality that is infrequently used for this purpose.

Ultrasound and its clinical use in rheumatoid arthritis: where do we stand?

High-resolution musculoskeletal ultrasound (MSUS) has been increasingly employed in daily rheumatological practice and in clinical research. In rheumatoid arthritis (RA), MSUS can be now considered a complement to physical examination. This method evaluates synovitis through gray-scale and power Doppler and it is also able to identify bone erosions. The utilization of MSUS as a marker of RA activity has received attention in recent literature. Current data account for good correlation of MSUS with classical measures of clinical activity; in some instances, MSUS appears to perform even better. Diagnosis of subclinical synovitis by MSUS might help the physician in RA management. With some variation, interobserver MSUS agreement seems excellent for erosion and good for synovitis. However, lack of MSUS score standardization is still an unmet need. In this review, we describe several MSUS scores, as well as their correlation with clinical RA activity and response to therapy. Finally, we look at the relationship of MSUS with synovial tissue inflammation and discuss future perspectives for a better interpretation and integration of this imaging method into clinical practice.

Medial meniscus extrusion increases with age and BMI and is depending on different loading conditions

PURPOSE

Meniscus extrusion has always been described as an indirect sign of meniscus pathology and is associated with a loss of function of the affected meniscus. The current cut-off value of 3 mm displacement is indicated as abnormal and has been determined on magnetic resonance images (MRI) and ultrasound (US). However, it has to be considered that there is no description of the physiological meniscus extrusion in healthy knees depending on age or different weight-bearing conditions. It was hypothesized that in healthy knees there is a physiological age and BMI dependent meniscal extrusion, and meniscus extrusion depends on different loading conditions.

METHODS

Healthy volunteers with non-symptomatic knee, and no history of knee injuries or operations were included in this prospective cross-sectional study. Exclusion criteria were age < 18years, subjective or objective instability, malalignment and positive medial meniscus test. Secondary exclusion criteria were osteoarthritis ICRS grade 3-4 or signs of meniscus tear on MRI. Every patient underwent standard knee examination following measurement of medial meniscus extrusion (MME) using US. In US extrusion was determined in supine position (unloaded) and in standing position with full weight-bearing and 20° of flexion (loaded). MRI was performed in a neutral knee position to compare ultrasound measurements with the current gold standard. Based on the power calculation of preliminary results a minimum of 70 volunteers was needed.

RESULTS

75 patients were enrolled to this study. The mean US MME was 1.1 mm ± 0.5 mm in supine position and 1.9 mm ± 0.9 mm under full weight-bearing. The mean US Δ-extrusion was 0.8 mm ± 0.6 mm. With rising age, a significant increased MME in US and MRI could be demonstrated (p < 0.001). Furthermore, elevated BMI was significantly correlated to increased US MME under full weight-bearing (p = 0.002) and to US Δ-extrusion (p = 0.003).

CONCLUSION

Based on the results of this study, medial meniscus extrusion is an age-depending phenomenon in healthy knees and depends on various load-bearing conditions. Ultrasound examination of the MME might be favorable compared to MRI due to the ability of dynamic evaluation. As a consequence, the current cut-off value of 3 mm for meniscus pathologies should be reconsidered.

LEVEL OF EVIDENCE

III.

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.

The development and validation of a custom built device for assessing frontal knee joint laxity

INTRODUCTION

This study reports the development and validation of a quantitative technique of assessing frontal knee joint laxity through a custom built device named KLICP. The objectives of this study were to determine: (i) the intra- and inter-rater reliability and (ii) the validity of the device when compared to real time ultrasound.

METHODS

Twenty-five participants had their frontal knee joint laxity assessed by the KLICP, by manual varus/valgus tests and by ultrasound. Two raters independently assessed laxity manually by three repeated measurements, repeated at least 48h later. Results were validated by comparing them to the medial and lateral joint space opening measured by the ultrasound. Intraclass correlation coefficients and standard error of measurement reliability were calculated. Pearson's correlation coefficients were calculated to determine the correlation between the KLICP and the joint space.

RESULTS

Intra-rater reliability (intra-session) for each rater was good on both sessions (0.91-0.98), intra-rater reliability (inter-sessions) was moderate to good (0.62-0.87), and inter-rater reliability (intra-session) was good (0.75-0.80). There is low agreement for intra-rater (inter-session) and for inter-rater (intra-session) reliability. The KLICP measurement has a significant positive fair to moderate correlation to the ultrasound measurement at the left (r: 0.61, p: 0.01) and right (r: 0.48, p: 0.02) knee in the valgus direction and at the left (r: 0.51, p: 0.01) and right (r: 0.39, p: 0.05) knee in the varus direction. There is low agreement between the KLICP and the RTU.

CONCLUSIONS

Reliability and agreement was good only when measured for intra-rater, within session.

Fluorescence optical imaging in pediatric patients with inflammatory and non-inflammatory joint diseases: a comparative study with ultrasonography

Background

Valid detection of arthritis is essential in differential diagnosis of joint pain. Indocyanin green (ICG)-enhanced fluorescence optical imaging (FOI) is a new imaging method that visualizes inflammation in wrist and finger joints. Objectives of this study were to compare FOI with ultrasonography (US, by gray-scale (GS) and power Doppler (PD)) and clinical examination (CE) and to estimate the predictive power of FOI for discrimination between inflammatory and non-inflammatory juvenile joint diseases.

Methods

FOI and GSUS/PDUS were performed in both hands of 76 patients with joint pain (53 with juvenile idiopathic arthritis (JIA), 23 with non-inflammatory joint diseases). Inflammation was graded by a semiquantitative score (grades 0–3) for each imaging method. Joints were defined clinically active if swollen or tender with limited range of motion. Sensitivity and specificity of FOI in three phases dependent on ICG enhancement (P1–P3) were analyzed with CE and GSUS/PDUS as reference.

Results

For JIA patients, FOI had an overall sensitivity of 67.3%/72.0% and a specificity of 65.0%/58.8% with GSUS/PDUS as reference; specificity was highest in P3 (GSUS 94.3%/PDUS 91.7%). FOI was more sensitive for detecting clinically active joints than GSUS/PDUS (75.2% vs 57.3%/32.5%). In patients with non-inflammatory joint diseases both FOI and US showed positive (i.e., pathological) findings (25% and 14% of joints). The predictive value for discrimination between inflammatory and non-inflammatory joint diseases was 0.79 for FOI and 0.80/0.85 for GSUS/PDUS.

Conclusions

Dependent on the phase evaluated, FOI had moderate to good agreement with CE and US. Both imaging methods revealed limitations and should be interpreted cautiously. FOI may provide an additional diagnostic method in pediatric rheumatology.

Trial registration

Deutsches Register Klinischer Studien DRKS00012572. Registered 31 July 2017.

Fluorescence optical imaging and musculoskeletal ultrasonography in juvenile idiopathic polyarticular disease before and during antirheumatic treatment - a multicenter non-interventional diagnostic evaluation

Background

Valid detection of inflamed joints is essential for correct classification, therapeutic decisions, prognosis and assessment of treatment efficacy in juvenile idiopathic arthritis (JIA). Fluorescence optical imaging (FOI) enables visualization of inflammation in arthritis of finger and hand joints and might be used for monitoring.

Methods

A 24-week observational study in polyarticular JIA patients newly starting treatment with methotrexate or an approved biologic was performed in three centers. Patients were evaluated clinically, by gray-scale ultrasonography (GSUS), power-Doppler ultrasonography (PDUS) and FOI at baseline, week 12 and week 24.

Results

Of 37 patients enrolled, 24 patients started methotrexate and 13 patients a biologic for the first time (etanercept n = 11, adalimumab and tocilizumab n = 1 each). Mean JADAS 10 decreased significantly from 17.7 at baseline to 12.2 and 7.2 at week 12 and 24 respectively. PedACR 30/50/70/100 response rates at week 24 were 85%/73%/50%/27%. The total number of clinically active joints in hand and fingers at baseline/week 12/week 24 was 262 (23.6%)/162 (16.4%)/162 (9.0%). By GSUS, at baseline/week 12/week 24, 192 (19.4%)/135 (16.1%)/83 (11.5%) joints showed effusions and 186 (18.8%)/107 (12.7%)/69 (9.6%) showed synovial thickening, and by PDUS 68 (6.9%)/15 (1.8%)/36 (5%) joints showed hyperperfusion. Any sign of arthritis was detected by US in a total of 243 joints (24.5%) at baseline, 161 joints (19.2%) at week 12 and 123 joints (17%) at week 24. By FOI at baseline/week 12/week 24, 430 (38.7%)/280 (29.2%)/215 (27.6%) showed a signal enhancement in at least one phase.

Summarizing all three points of time, the highest numbers of signals were detected by FOI with 32% of joints, especially in phase 2, while by US 20.7% and by clinical examination 17.5% of joints were active. A high number of joints (21.1%) had FOI signals but were inactive by clinical examination. A total 20.1% of joints with signals in FOI did not show effusion, synovial thickening or hyperperfusion by US.

Because of the high number of negative results, specificity of FOI compared with clinical examination/US/PD was high (84–95%), and sensitivity was only moderate.

Conclusion

FOI and US could detect clinical but also subclinical inflammation. FOI detected subclinical inflammation to a higher extent than US. Improvement upon treatment with either methotrexate or a biologic can be visualized by FOI and US.

Trial registration

Deutsches Register Klinischer Studien DRKS00011579. Registered 10 January 2017.

INVESTIGATING THE EFFECTIVENESS OF KINESIO® TAPING SPACE CORRECTION METHOD IN HEALTHY ADULTS ON PATELLOFEMORAL JOINT AND SUBCUTANEOUS SPACE

BACKGROUND

Limited quantitative, physiological evidence exists regarding the effectiveness of Kinesio® Taping methods, particularly with respect to the potential ability to impact underlying physiological joint space and structures. To better understand the impact of these techniques, the underlying physiological processes must be investigated in addition to the examination of more subjective measures related to pain in unhealthy tissues.

HYPOTHESIS/PURPOSE

The purpose of this study was to determine whether the Kinesio® Taping Space Correction Method created a significant difference in patellofemoral joint space, as quantified by diagnostic ultrasound.

STUDY DESIGN

Pre-test/post-test prospective cohort study.

METHODS

Thirty-two participants with bilaterally healthy knees and no past history of surgery took part in the study. For each participant, diagnostic ultrasound was utilized to collect three measurements: the patellofemoral joint space, the distance from the skin to the superficial patella, and distance from the skin to the patellar tendon. The Kinesio® Taping Space Correction Method was then applied. After a ten-minute waiting period in a non-weight bearing position, all three measurements were repeated. Each participant served as his or her own control.

RESULTS

Paired t tests showed a statistically significant difference (mean difference = 1.1 mm, t_[3,1] = 2.823, p = 0.008, g = .465) between baseline and taped conditions in the space between the posterior surface of the patella to the medial femoral condyle. Neither the distance from the skin to the superficial patella nor the distance from the skin to the patellar tendon increased to a statistically significant degree.

CONCLUSIONS

The application of the Kinesio® Taping Space Correction Method increases the patellofemoral joint space in healthy adults by increasing the distance between the patella and the medial femoral condyle, though it does not increase the distance from the skin to the superficial patella nor to the patellar tendon.

LEVEL OF EVIDENCE

3.

Inter-rater reliability in the classification of supraspinatus tendon tears using 3D ultrasound - a question of experience?

Background

Three-dimensional (3D) ultrasound of the shoulder is characterized by a comparable accuracy to two-dimensional (2D) ultrasound. No studies investigating 2D versus 3D inter-rater reliability in the detection of supraspinatus tendon tears taking into account the level of experience of the raters have been carried out so far.

Objectives

The aim of this study was to determine the inter-rater reliability in the analysis of 3D ultrasound image sets of the supraspinatus tendon between sonographer with different levels of experience.

Patients and methods

Non-interventional, prospective, observational pilot study of 2309 images of 127 adult patients suffering from unilateral shoulder pain. 3D ultrasound image sets were scored by three raters independently. The intra-and interrater reliabilities were calculated.

Results

There was an excellent intra-rater reliability of rater A in the overall classification of supraspinatus tendon tears (2D vs 3D κ = 0.892, pairwise reliability 93.81%, 3D scoring round 1 vs 3D scoring round 2 κ = 0.875, pairwise reliability 92.857%). The inter-rater reliability was only moderate compared to rater B on 3D (κ = 0.497, pairwise reliability 70.95%) and fair compared to rater C (κ = 0.238, pairwise reliability 42.38%).

Conclusions

The reliability of 3D ultrasound of the supraspinatus tendon depends on the level of experience of the sonographer. Experience in 2D ultrasound does not seem to be sufficient for the analysis of 3D ultrasound imaging sets. Therefore, for a 3D ultrasound analysis new diagnostic criteria have to be established and taught even to experienced 2D sonographers to improve reproducibility.

Ultrasonographic examination of plantar fasciitis: a comparison of patient positions during examination

BACKGROUND

Musculoskeletal ultrasound is a non-invasive and low-cost modality for real-time visualisation of the plantar fascia. Ultrasound examination for plantar fasciitis is generally performed with the patient in a prone position, although the rational for using a prone position has not been validated. The aim of the study was to investigate if ultrasound examination in a supine position, which is more comfortable than the prone position, is valid.

METHODS

We conducted a prospective study of 30 participants with plantar fasciitis, 8 men (27 %) and 22 women (73 %), with a mean age of 53.9 ± 12.6 (range, 32 to 77) years, and an equal distribution of left and right feet. The plantar heel was divided into three portions for ultrasound examination: medial, central and lateral. Two measurements of plantar fascia thickness were obtained for each portion, with participants in 2 positions (supine and prone) and for 2 ankle postures (neutral and 15° of plantarflexion). Mean measurements of plantar fascia thickness were compared between the two positions (Wilcoxon signed rank tests for non-normally distributed data and paired t-tests for normally distributed data). Participants were asked to report their preferred position for examination, supine or prone.

RESULTS

The measured thickness was comparable for both supine and prone positions, for both ankle postures, neutral and 15° of plantarflexion (p > 0.05). A specific self-reported preferred position was not identified.

CONCLUSIONS

Ultrasound examination of plantar fasciitis can be performed in the supine position without any significant difference in measurement compared to examination in the conventional prone position.

TRIAL REGISTRATION

The Catholic Medical Center Office of Human Research Protection Program (CMC-OHRP)/Institutional Review Board approved the current study (Approval No. KC12DISI0338), and all participants provided their written informed consent for participation and publication.

Structural damage in rheumatoid arthritis: comparison between tendon damage evaluated by ultrasound and radiographic damage

OBJECTIVE

To compare structural damage assessed by conventional radiography and tendon damage assessed by musculoskeletal US (MSUS) at wrist and ankle in RA patients.

METHODS

We evaluated 72 consecutive patients [56 (77.8%) females] with RA. The MSUS evaluation consisted in a B-mode examination of bilateral extensor carpi ulnaris and tibialis posterior tendons. Tendon damage was defined and scored according to OMERACT. A total score for the tendon damage score (TDS) was calculated by summing the grades for each tendon. For the radiographic evaluations we used the van der Heijde score; a total radiographic score (RTS) was calculated by summing a bone erosion score (ERS) and a joint space narrowing score (JSNS).

RESULTS

We evaluated 288 tendons. The mean (s.d.) of TDS was 2.3 (1.8). Fifty-four (75%) patients presented tendon damage of at least one tendon. From all evaluated tendons, 134 (46.5%) had no tendon damage, 146 (50.7%) had grade 1 and 8 (2.8%) had grade 2 tendon damage. The mean (s.d.) for RTS was 91.4 (97), for ERS was 47.3 (61.9) and for JSNS was 44.1 (37.2). We found a significant correlation between disease duration and both TDS and RTS (r = 0.413 and r = 0.560, respectively; P < 0.0001). We found a good significant correlation between TDS and all variables of radiographic structural damage (RTS, r = 0.65; ERS, r = 0.637; JSNS, r = 0.618; P < 0.001).

CONCLUSION

The MSUS assessment of only four tendons can be an additional feasible method to assess structural damage in RA patients.

Resident-Perceived Benefit of a Diagnostic and Interventional Musculoskeletal Ultrasound Curriculum: A Multifaceted Approach Using Independent Study, Peer Teaching, and Interdisciplinary Collaboration

Musculoskeletal ultrasound (MSUS) training is now a required component of physiatry residency, but formal curriculum guidelines are not yet required or established. The authors' objective was to assess the educational value of a collaborative residency MSUS training program. The authors designed a structured MSUS training curriculum for residents based on the authors' experience and previous literature. Twenty-five residents participated in this MSUS curriculum designed by faculty and chief residents. Resident volunteers were trained by the faculty as "table trainers" who taught their peers in small groups. Hands-on MSUS training sessions were led by a Physical Medicine and Rehabilitation faculty MSUS expert. A Likert scale-formatted questionnaire assessed resident-perceived value of the curriculum. Response rate was 96% (22 of 23). Self-reported MSUS knowledge comparing precurriculum and postcurriculum implementation resulted in significant improvement (P = 0.001). Peer teaching was highly valued, with 86% of residents rating it "very" or "extremely" beneficial (mean [SD] score, 3.9 [1.1]). Self-guided learning, by supplemental scanning and reading, was rated "beneficial" or "very beneficial" by 73% of residents (3.0 [0.7]). The authors' successful pilot program may serve as a teaching model for other residency programs.

Correlation of findings in clinical and high resolution ultrasonography examinations of the painful shoulder

Objective

High resolution ultrasonography is a non-painful and non-invasive imaging technique which is useful for the assessment of shoulder pain causes, as clinical examination often does not allow an exact diagnosis. The aim of this study was to compare the findings of clinical examination and high resolution ultrasonography in patients presenting with painful shoulder.

Methods

Non-interventional observational study of 100 adult patients suffering from unilateral shoulder pain. Exclusion criteria were shoulder fractures, prior shoulder joint surgery and shoulder injections in the past month. The physicians performing the most common clinical shoulder examinations were blinded to the results of the high resolution ultrasonography and vice versa.

Results

In order to detect pathology of the m. supraspinatus tendon, the Hawkins and Kennedy impingement test showed the highest sensitivity (0.86) whereas the Jobe supraspinatus test showed the highest specificity (0.55). To identify m. subscapularis tendon pathology the Gerber lift off test showed a sensitivity of 1, whereas the belly press test showed the higher specificity (0.72). The infraspinatus test showed a high sensitivity (0.90) and specificity (0.74). All AC tests (painful arc II^a, AC joint tenderness^b, cross body adduction stress test^c) showed high specificities (^a0.96, ^b0.99, ^c0.96). Evaluating the long biceps tendon, the palm up test showed the highest sensitivity (0.47) and the Yergason test the highest specificity (0.88).

Conclusion

Knowledge of sensitivity and specificity of various clinical tests is important for the interpretation of clinical examination test results. High resolution ultrasonography is needed in most cases to establish a clear diagnosis.

Effects of joint effusion on quadriceps muscles in patients with knee osteoarthritis

OBJECTIVES

To evaluate the effect of knee effusion on the quadriceps muscle in patients with knee osteoarthritis (OA).

DESIGN

Single-blind, randomized, controlled clinical trial.

SETTING

Single medical center.

PARTICIPANTS

Forty subjects with knee OA were assigned to a experimental (n = 20) or control (n = 20) group.

MAIN OUTCOME MEASURES

Quadriceps torque and root mean square (RMS) values of surface electromyography (EMG) of the vastus medialis and vastus lateralis muscles were measured during a maximal isometric contraction at 60° knee flexion. Thereafter, 20 mL of normal saline was injected into the knee joint of the experimental group. Quadriceps torque and RMS values were again measured.

RESULTS

Five subjects did not complete the study. No significant difference in quadriceps peak torque or RMS of EMG activity was observed at baseline, pre-effusion, or post-effusion measures in either group. The experimental group showed no significant change in quadriceps peak torque or RMS of EMG activity in any period compared with the control group.

CONCLUSIONS

These results demonstrate that a 20 ml joint effusion did not affect peak torque or RMS values of the quadriceps muscle in patients with knee OA.