sign in sign up
<<
Home , Enthesophyte, Infrapatellar bursitis, Pes anserine bursitis

Imaging Ultrasound imaging for the rheumatologist XI. Ultrasound imaging in regional pain syndromes A. Iagnocco1, E. Filippucci2, G. Meenagh3, L. Riente4, A. Delle Sedie4, S. Bombardieri4, W. Grassi2, G. Valesini1

1Cattedra di Reumatologia, Sapienza - ABSTRACT In the present review, an update of the Università di Roma, Roma, Italy; Regional pain syndromes (RPS) are available data about US imaging in 2 Cattedra di Reumatologia, Università common complaints in clinical rheu- RPS is provided and the research agen- Politecnica delle Marche, Jesi, Italy; matological practice. Ultrasound (US) da relating to US imaging of local soft 3AntrimAntrim AreaArea Hospital,Hospital, Antrim,Antrim, NorthernNorthern Ireland, United Kingdom; allows a detailed assessment of soft tis- tissue rheumatism is discussed. 4Unità Operativa di Reumatologia, sue involvement and its use may have Università di Pisa, Pisa, Italy. considerable impact on the manage- Clinical applications Annamaria Iagnocco, MD; Emilio ment of RPS. The present review pro- A list of the most common RPS to- Filippucci, MD; Gary Meenagh, MD; vides an update of the available data gether with the corresponding patho- Lucrezia Riente, MD; Andrea Delle Sedie, about US imaging in RPS together with logical conditions that may be revealed MD; Stefano Bombardieri, MD, Professor research issues relating to periarticu- by US is presented in Table I. Differ- of Rheumatology; Walter Grassi, MD, lar pathology. The research ent pathological conditions may mani- Professor of Rheumatology; Guido agenda covers: defi nition of standard fest with similar clinical features and Valesini, MD, Professor of Rheumatology. scanning protocols for US examination US assessment may be critical for the Please address correspondence to: of the most common RPS assessed by Dr. Annamaria Iagnocco, Cattedra di identifi cation of the involved tissue and Reumatologia, Sapienza - Università di the rheumatologist and the clinical im- its pathology (9). In cases with Roma, Viale del Policlinico 155, pact of US fi ndings in the management pathology, for example, US can demon- Roma 00161, Italy. of patients with RPS. strate , calcifi c tendinopa- E-mail: [email protected] thy, partial or complete tears and tendon Received and accepted on October 16, Introduction dislocation. Moreover, in the clinical 2007. Regional pain syndromes (RPS) ac- setting of a suspected tendon rupture, Clin Exp Rheumatol 2007; 23: 672-675. count for a substantial quantity of rheu- US can provide quantitative fi ndings © CCopyrightopyright CLINICAL AND matic disease and are frequent reasons which may direct the rheumatologist EXPERIMENTAL RHEUMATOLOGY 2007.2007. for new patient consultations in rheu- in the management approach. Fur- matology units. Pain and restriction of thermore, power Doppler permits the Key words: Ultrasonography, regional movement are common denominators detection of active infl ammation with pain syndromes, painful shoulder, in all these conditions which are usu- the demonstration of local increased carpal tunnel syndrome. ally linked to local infl ammation and/or perfusion. US is also useful for needle tissue damage (1, 2). Different peri-ar- guidance during fl uid aspirations, biop- ticular soft tissues may be involved in- sies and intra or periarticular injections. cluding tendon sheaths, , bursae, Finally, US can be used for monitoring aponeuroses, and nerves. the effects of specifi c local therapeutic Ultrasound (US) has become increas- approaches including intra and peri- ingly relevant in the imaging of soft articular injections or ‘eccentric load- tissue pathology in clinical rheumato- ing’ training programmes for treating logical practice in recent years (3, 4). Achilles (10-13). Furthermore, the specifi c characteris- There are some limitations to the use of tics of US: noninvasiveness, low-cost, US in RPS that must be born in mind. acceptance by patients and portability US fi ndings are strongly dependent have led to its use as a bedside inves- on both the operator experience and tigation performed by rheumatologists the quality of the equipment. Further- (5, 6). In experienced hands, US can be more, some pathological lesions, espe- an accurate and reliable imaging tool cially those related to trauma, may not for the assessment of a wide range of be detectable by US due to an inadequate soft tissue pathologies in patients with acoustic window (i.e. cruciate ligaments Competing interests: none declared. RPS (7, 8). and, anterior part of the glenoid labrum).

672 Ultrasound imaging in regional pain syndromes / A. Iagnocco et al. IMAGING

Literature review Since the earliest US investigations of popliteal cysts, the indications for US have steadily increased.Currently the literature to date would strongly sup- port the use of US in the assessment of several types of RPS, including pain- ful shoulder, carpal tunnel syndrome, heel pain, wrist pain, sausage fi nger, anterior and lateral and me- dial epicondylitis (Table I) (14-41). US can sensitively identify the anatomical structure involved and assess the extent of the lesion. The shoulder has been the subject of multiple US investigations to date. In experienced hands US is a reliable im- aging modality for assessing shoulder Fig. 1. A. Dactylitis due to tenosynovitis of the fi nger fl exor tendons (FT) involving the 3rd fi nger of the hand. MC: metacarpal bone; PP: proximal phalanx; MP: middle phalanx; DP: distal phalanx. abnormalities such as bicipital tendon B. Painful shoulder with partial thickness tear (arrow) of the subscapularis tendon (ST). H: humerus. involvement, rotator cuff tears, bursi- C. Lateral epicondylitis: of the common extensor tendon (ET) with tendon thickening and hypoechogenicity, presence of calcifi cations and enthesophyte (arrow). H: humerus. tis, gleno-humeral joint infl ammation For further ultrasound images, please go to www.clinexprheumatol.org and humeral head fractures (15-21). When compared to physical examina- Table I. Regional pain syndromes and pathological conditions detectable by ultrasonography. tion, US demonstrates higher accuracy in the diagnosis of peri-articular shoul- Regional pain syndrome Pathological conditions detectable by ultrasonography der lesions (15). Using US as the gold Carpal tunnel syndrome Median nerve pathology standard, sensitivity of physical exami- (9,(9, 22-26)22-26) Tenosynovitis of the fi nger fl exor tendons nation was low (less than 20%) for the of the wrist detection of supraspinatus tendon tears Tophaceous deposits Aberrant muscle and other studies show that it can vary Painful shoulder Long head of the biceps tendon pathology (i.e. complete or partial tear, teno- between 33% to 100% (16). Physical (2, 9, 15-21) synovitis, tendon dislocation) examination does, however, have a spe- Rotator cuff pathology (i.e. complete or partial tear, calcifi cation) cifi city of 100% for the recognition of Subdeltoid supraspinatus tendon tears but is unable Gleno-humeral joint pathology (i.e. joint effusion, synovitis, osteophytes) Acromio- clavicular joint pathology (i.e. joint effusion, synovitis, osteophytes) to differentiate partial from full thick- Humeral head fractures (i.e. greater tuberosity fracture, Hill-Sachs impac- ness tears. This can be explained by the tion fracture) specifi c experience of the operator, the Heel pain (3, 30-33) Achilles tendinopathy (i.e. complete or partial tear, calcifi cation, intratendi- variable quality of the equipment and nous xanthomas or tophi) the gold standard (i.e. arthrography, Calcaneal enthesopathy surgical intervention, MRI) used to Plantar confi rm the US fi ndings. Wrist pain (9, 22, 34-36) Radio-ulnar, radio-carpal and intercarpal joint pathology (i.e. joint effusion, In patients with carpal tunnel syndrome, synovitis, arthrogenic cyst) US has been proposed as fi rst step in Carpo-metacarpal joint pathology (i.e. joint effusion, synovitis, osteophytes) the diagnostic work-up after clinical Tenosynovitis of the fi nger extensor tendons, including De Quervain’s teno- synovitis examination. US provides information Tenosynovitis of the fl exor carpi radialis tendon on both median nerve and carpal tun- Calcifi cation of the triangular fi brocartilage complex nel pathology. Cross-sectional studies Anterior knee pain Patellar tendon pathology (i.e. calcifi cation, partial tear, tophaceous deposits) using electromyography as the gold (9, 37-39) standard, demonstrated the effi cacy of Infrapatellar bursitis Enthesopathy of both the upper and lower poles of the patella US in detecting median nerve neuropa- Pes anserine bursitis thy (22-25). US measurement of medi- Pes anserine tendinopathy an nerve cross-sectional area correlates Sausage fi nger (9, 22,40) Finger fl exor tendons (i.e. tenosynovitis, tendon tear) well with EMG fi ndings. Proximal interphalangeal joint infl ammation Normal value has been determined as Oedema of the subcutaneous soft tissues less than 10 mm2 while an area higher Lateral and medial Humeral enthesopathy than 15 mm2 is an indicator for surgical epicondylitisepicondylitis ((41)41) Calcifi c tendinopathy intervention in some centres (22-26).

673 IMAGING Ultrasound imaging in regional pain syndromes / A. Iagnocco et al.

US assessment of the carpal tunnel can References ing equivalent for the assessment of full- reveal different pathological conditions 1. CANOSO JJ CARETTE S: Regional pain thickness rotator cuff tears. Arthritis Rheum problems. In KLIPPEL JH, DIEPPE PA (Eds.): 1999; 42: 2231-8. which may be targets for specifi c treat- Rheumatology. Mosby, London, 1998; 4.1.1- 19. TEEFEY SA, HASAN SA, MIDDLETON WD, ment (9, 10, 22). 4.18.8. PATEL M, WRIGHT R, YAMAGUCHI K: Ultra- US guidance for synovial fl uid aspira- 2. IAGNOCCO A, FILIPPUCCI E, MEENAGH G et sonography of the rotator cuff: a comparison tion and intra and periarticular injec- al.: Imaging ultrasound for the rheumatolo- of ultrasonographic and arthroscopic fi ndings gist. I Ultrasonography of the shoulder. Clin in one hundred consecutive cases. J Bone tions improves accuracy and reduces Exp Rheumatol 22006;006; 224:4: 66-11.-11. Joint Surg Am 2000; 82: 498-504. the risk of tissue damage (27-29). In a 3. BIANCHI S, MARTINOLI C, GAIGNOT C, DE 20. JACOBSON JA, LANCASTER S, PRASAD A, study aimed at comparing the success GAUTARD R, MEVER JM: Ultrasound of the VAN HOLSBEECK MT, CRAIG JG, KOLOWICH rate of conventional and US guided ankle: anatomy of the tendons, bursae, and P: Full-thickness and partial-thickness su- ligaments. Semin Musculoskelet Radiol praspinatus tendon tears: value of US signs joint aspiration, the use of US resulted 2005; 9: 243-59. in diagnosis. Radiology 2004; 230: 234-42. in an improvement of the rate of suc- 4. MARTINOLI C, BIANCHI S, DAHMANE M, 21. CRAIG JG, JACOBSON JA, MOED BR: Ultra- cessful aspiration from 32% to 97% PUGLIESE F, BIANCHI-ZAMORANI MP, sound of fracture and bone healing. Radiol Clin North Am 1999; 37: 737-51. (29). VALLE M: Ultrasound of tendons and nerves. Eur Radiol 22002;002; 112:2: 444-55.4-55. 22. FILIPPUCCI E, IAGNOCCO A, MEENAGH G Moreover, using US for guiding corti- 5. GRASSI W, FILIPPUCCI E: Ultrasonography et al.: Ultrasound imaging for the rheuma- costeroid injections may improve ther- and the rheumatologist. Curr Opin Rheuma- tologist II. Ultrasonography of the hand and apeutic effectiveness both at shoulder tol 2007; 19: 55-60. wrist. Clin Exp Rheumatol 2006; 24: 118-22.118-22. 23. LEE D, VAN HOLSBEECK MT, JANEVSKI PK, and ankle level (11, 12). 6. FILIPPUCCI E, IAGNOCCO A, MEENAGH G et al.: Imaging ultrasound for the rheumatolo- GANOS DL, DITMARS DM, DARIAN VB: Di- gist. VII Ultrasound imaging in rheumatoid agnosis of carpal tunnel syndrome. Ultra- Research agenda arthritis. Clin Exp Rheumatol 2007; 25: 5-10. sound versus electromyography. Radiol Clin The most important topics for future 7. MARTINOLI C, BIANCHI S, DERCHI LE: Ul- North Am 1999; 37: 859-72. trasonography of peripheral nerves. Semin 24. EL MIEDANY YM, ATY SA, ASHOUR S: Ultra- research activity in the assessment of Ultrasound CT MR 2000; 21: 205-13. sonography versus nerve conduction study in RPS are listed in Table II. In particu- 8. MARTINOLI C, BIANCHI S, DERCHI LE: Ten- patients with carpal tunnel syndrome: sub- lar, this agenda should concentrate on don and nerve sonography. Radiol Clin North stantive or complementary tests? Rheumatol- the development of standard scanning AM 1999; 37: 691-711. ogy 2004; 43: 887-95. 9. GRASSI W, FILIPPUCCI E, CAROTTI M, 25. WONG SM, GRIFFITH JF, HUI AC, LO SK, FU protocols for the assessment of patients SALAFFI F: Imaging modalities for identify- M, WONG KS: Carpal tunnel syndrome: diag- with the most frequent RPS seen in ing the origin of regional musculoskeletal nostic usefulness of sonography. Radiology rheumatological practice. Further stud- pain. Best Pract Res Clin Rheumatol 2003;2003; 2004; 232: 93-9. ies are needed to provide evidence of 17: 17-32. 26. HAMMER HB, HAAVARDSHOLM EA, KVIEN 10. GRASSI W, FARINA A, FILIPPUCCI E, CER- TK: Ultrasonographic measurement of the me- the US impact on both making diag- VINI C: Intralesional therapy in carpal tunnel dian nerve in patients with rheumatoid arthri- nosis and choosing therapy of patients syndrome: a sonographic-guided approach. tis without symptoms or signs of carpal tunnel with RPS. Clin Exp Rheumatol 2002; 20: 73-6. syndrome. Ann Rheum Dis 2007; 66: 825-7. 11. NAREDO E, CABERO F, BENEYTO P et al.: A 27. GRASSI W, FARINA A, FILIPPUCCI E, CERVI- randomized comparative study of short term NI C: Sonographically guided procedures in rhematology. Semin Arthritis Rheum 2001; Table II. US imaging in RPS: research response to blind injection versus sonograph- 30: 347-53. agenda. ic-guided injection of local corticosteroids in patients with painful shouder. J Rheumatol 28. KOSKI JM, SAARAKKALA SJ, HEIKKINEN 2004; 31: 308-14. JO, HERMUNEN HS: Use of air-steroid-sa- To develop standard scanning protocols for the 12. D’AGOSTINO MA, AYRAL X, BARON G, line mixture as contrast medium in greyscale US examination of patients with RPS frequently RAVAUD P, BREBAN M, DOUGADOS M: Im- ultrasound imaging: experimental study and assessed by the rheumatologist, including pain- pact of ultrasound imaging on local corti- practical applications in rheumatology. Clin ful shoulder carpal tunnel syndrome and anterior costeroid injections of symptomatic ankle, Exp Rheumatol 22005;005; 223:3: 3373-8.73-8. knee pain. hind-, and mid-foot in chronic infl ammatory 29. BALINT PV, KANE D, HUNTER J, MCINNES IB, diseases. Arthritis Rheum 2005; 53: 284-92. FIELD M, STURROCK RD: Ultrasound guided To compare physical examination and US fi nd- 13. REES JD, WILSON AM, WOLMAN RL: Current versus conventional joint and soft tissue fl uid ings and evaluate the impact of US fi ndings in concepts in the management of tendon disor- aspiration in rheumatology practice: a pilot the management of patients with RPS. ders. Rheumatology 2006; 45: 508-21. study. J Rheumatol 2002; 29: 2209-13. 14. RUDIKOFF JC, LYNCH JJ, PHILLIPS E, CLAPP 30. BUDE RO, NESBITT SD, ADLER RS, RUBEN- To investigate the value of power Doppler in the PR: Ultrasound diagnosis of Baker cyst. FIRE M: Sonographic detection of xanthomas assessment of the soft tissues involvement in- JAMA 1976; 235: 1054-5. in normal-sized Achilles’ tendons of individ- cluding: chronic tendinopathy and enthesopathy, 15. NAREDO E, AGUADO P, DE MIGUEL E et al.: uals with heterozygous familial hypercholes- tendon tear, tophaceal deposits. Painful shoulder: comparison of phisical terolemia. AJR Am J Roentgenol 11998;998; 1170:70: examination and ultrasonographic fi ndings. 621-5. To use US as tool for assessing the benefi ts Ann Rheum Dis 2002; 61: 132-6. 31. RIENTE L, DELLE SEDIE A, IAGNOCCO A provided by different therapeutic choices in the 16. JACOBSON JA: Musculoskeletal sonography et al.: Imaging ultrasound for the rheuma- management of the most common RPS. and MR imaging. A role for both imaging tologist. V Ultrasonography of the ankle and methods. Radiol Clin North Am 1999; 37: foot. Clin Exp Rheumatol 22006;006; 224:4: 4493-98.93-98. 713-35. 32. FESSELL DP, JAMADAR DA, JACOBSON JA et 17. ALASAARELA E, LEPPILAHTI J, HAKALA M: al.: MT.Sonography of dorsal ankle and foot Link Ultrasound and operative evaluation of ar- abnormalities. AJR Am J Roentgenol 2003;2003; For further ultrasound images, go to thritic shoulder joints. Ann Rheum Dis 1998; 181: 1573-81. 57: 357-60. 33. GIBBON WW, LONG G: Ultrasound of the www.clinexprheumatol.org/ultrasound 18. SWEN WAA, JACOBS JWG, ALGRA PR et al.: plantar aponeurosis (). Skeletal Radiol Sonography and magnetic resonance imag- 1999; 28: 21-6.

674 Ultrasound imaging in regional pain syndromes / A. Iagnocco et al. IMAGING

34. WANG G, JACOBSON JA, FENG FY, GIRISH Ultrasound CT MR 2000; 21: 192-204. study. Clin J Sport Med 1997; 7: 199-206. G, CAOILI EM, BRANDON C: Sonography of 37. MEENAGH G, IAGNOCCO A, FILIPPUCCI E 40. OLIVIERI I, BAROZZI L, FAVARO L et al.: wrist ganglion cysts: variable and noncystic et al.: Ultrasound imaging for the rheumatol- Dactylitis in patients with seronegative appearances. J Ultrasound Med 2007;2007; 26:26: ogist IV. Ultrasonography of the knee. Clin spondylarthropathy. Assessment by ultra- 1323-8. Exp Rheumatol 22006;006; 224:4: 3357-60.57-60. sonography and magnetic resonance imaging. 35. DAENEN B, HOUBEN G, BAUDUIN E, DEBRY 38. PTASZNIK R: Ultrasound in acute and chronic Arthritis Rheum 1996; 39: 1524-8. R, MAGOTTEAUX P: Sonography in wrist knee injury. Radiol Clin North Am 1999; 37: 41. DELLE SEDIE A, RIENTE L, IAGNOCCO A et tendon pathology. J Clin Ultrasound 2004; 797-830. al.: Imaging ultrasound for the rheumatolo- 32: 462-9. 39. KHAN KM, COOK JL, KISS ZS et al.: Patellar gist. VI Ultrasonography of the elbow, sac- 36. TEEFEY SA, MIDDLETON WD, BOYER MI: tendon ultrasonography and jumper’s knee roiliac, parasternal andtemporomandibular Sonography of the hand and wrist. Semin in female basketball players: a longitudinal joints. Clin Exp Rheumatol 2006;2006; 224:4: 6617-21.17-21.

675