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Imaging Ultrasound Imaging for the Rheumatologist XI. Ultrasound Imaging in Regional Pain Syndromes A

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Imaging Ultrasound Imaging for the Rheumatologist XI. Ultrasound Imaging in Regional Pain Syndromes A 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 soft tissue 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 tendon 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 tenosynovitis, 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 © CopyrightCopyright 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, tendons, bursae, Finally, US can be used for monitoring aponeuroses, ligaments 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 tendinopathy (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 knee pain 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: enthesopathy 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 Synovitis 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 bursitis 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 Retrocalcaneal bursitis surgical intervention, MRI) used to Plantar fasciitis 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) Prepatellar bursitis 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
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