Value of Ultrasound in Rheumatologic Diseases
ABSTRACT The use of musculoskeletal ultrasound in rheumatology clinical practice has rapidly increased over the past decade. Ultrasound has enabled rheumatologists to diagnose, prognosticate and monitor disease outcome. Although international standardization remains a concern still, the use of ultrasound in rheumatology is expected to grow further as costs fall and the opportunity to train in the technique improves. We present a review of value of ultrasound, focusing on major applications of ultrasound in rheumatologic diseases.
Conference Paper: 3D reconstruction of ATFL ligament using ultrasound images[Show abstract] [Hide abstract]
ABSTRACT: Among all existing medical imaging modalities such as MRI, CT, PET and SPECT, ultrasound (US) imaging is one of the most widely used in various applications such as ligament injuries, tendon injuries, bone injuries, cardiac imaging, blood flow estimation and obstetrics. Although Three-Dimensional Ultrasound (3D-US) has many benefits such as non-invasive, low cost, portable, real-time and non-ionizing, however, it is limited in diagnosis and management of obstetrics and atherosclerosis, thus far. Since the current Two-Dimensional Ultrasound (2D-US) has many limitations in the diagnosis of ligament injuries and abnormalities. This study represents the 3D Ultrasound Reconstruction of Anterior talofibular Ligament (ATL) for obtaining the fruitful information for disease diagnosis and progression.2014 5th International Conference on Intelligent and Advanced Systems (ICIAS); 06/2014
© 2013 The Korean Academy of Medical Sciences.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Value of Ultrasound in Rheumatologic Diseases
The use of musculoskeletal ultrasound in rheumatology clinical practice has rapidly
increased over the past decade. Ultrasound has enabled rheumatologists to diagnose,
prognosticate and monitor disease outcome. Although international standardization
remains a concern still, the use of ultrasound in rheumatology is expected to grow further
as costs fall and the opportunity to train in the technique improves. We present a review of
value of ultrasound, focusing on major applications of ultrasound in rheumatologic
Key Words: Rheumatology Ultrasound; Musculoskeletal Ultrasound; Doppler; Arthritis
Taeyoung Kang,1,2 Laura Horton,2
Paul Emery,2 and Richard J. Wakefield2
1Department of Rheumatology, Yonsei Univeristy
Wonju College of Medicine, Wonju, Korea;
2Division of Rheumatic and Musculoskeletal Disease
and NIHR Leeds Musculoskeletal Biomedical
Research Unit (LMBRU), University of Leeds, Leeds,
Received: 30 May 2012
Accepted: 25 January 2013
Address for Correspondence:
Dr. Richard J. Wakefield
Division of Rheumatic and Musculoskeletal Disease and NIHR
Leeds Musculoskeletal Biomedical Research Unit (LMBRU),
Chapel Allerton Hospital, Leeds LS7 4SA, United Kingdom
Tel: +44.113-392-4916, Fax: +44.113-392-4991
http://dx.doi.org/10.3346/jkms.2013.28.4.497 • J Korean Med Sci 2013; 28: 497-507
Immunology, Allergic Disorders & Rheumatology
The use of musculoskeletal ultrasound in rheumatology has in-
creased dramatically over the past decade both as a result of
technological developments and a desire to identify and treat
inflammation early. High quality ultrasound machines with
good spatial resolution have provided rheumatologists with a
means of identifying inflammation and structural damage, mon-
itoring disease and predicting therapeutic responses. Ultrasound
has clear advantages over other imaging tools such as magnetic
resonance imaging (MRI) in terms of better tolerability, an abil-
ity to scan multiple joints at one sitting and its ability to directly
correlate clinical and imaging findings. Furthermore high reso-
lution gray scale images combined with Doppler technique
have made it possible to detect slow low volume blood flow,
opening new avenues for detecting and grading inflammation
in joints. Based on these developments and increasing interest,
a special Ultrasound Task Force on behalf of Outcome Measures
in Rheumatology Clinical Trial (OMERACT) organization was
formed to develop standardized ways of acquiring images in
addition to defining and scoring pathologies relevant to rheu-
matologists (1). This has provided a framework for collaborative
studies on ultrasound assessment and measurement issues. In
this review, we focus on major values of ultrasound in rheuma-
BRIEF DEVELOPMENTAL HISTORY OF
ULTRASOUND IN RHEUMATOLOGY
After the discovery of the piezo-electric effect in crystals by the
Pierre and Curie brothers in 1880, further research and devel-
opment in piezo-electricity followed. In particular, after the Ti-
tanic sank on its maiden voyage in 1912, scientists spurred on
the development of how to detect submerged objects. The threat
of German submarines to Allied shipping in World War I stimu-
lated more research into the development of ultrasound devic-
es (2). The first recorded detection and subsequent sinking of a
submarine using an ultrasound device (called a hydrophone at
that time) occurred in the Atlantic in 1916 during World War I.
The military use of ultrasound lead to the development of med-
ical diagnostic ultrasound. Of note during World War II, rapid
developments and refinements in military RADAR (Radio De-
tection and Ranging which used electromagnetic waves rather
than ultrasound) was the precursor for subsequent medical ul-
trasound devices. In 1942, the Austrian neurologist-psychiatrist
Karl Theodore Dussik was generally regarded as the first physi-
cian to use ultrasound for medical diagnosis (3). He attempted
to locate brain tumors by measuring the transmission of an ul-
trasound beam through the skull. Later in 1956, Ian Donald
from Scotland and Thomas Graham Brown from Glas gow made
the world’s first two dimensional contact scanner where the
transducer can be moved manually over the patient’s abdomen
Kang T, et al. • Ultrasound in Rheumatology
with a resultant 2-D image reproduced on an oscilloscope. This
brought the capability of ultrasound to a wider audience which
in turn stimulated its further growth.
The first report pertaining to musculoskeletal tissue was in
1958 by Karl Theodore Dussik; titled “Measurement of articular
tissue with ultrasound” and published in the American Journal
of Physical Medicine. In this ex-vivo study, the attenuation of
ultrasound during its propagation through human articular
cartilage was first measured. Since this study was not related
directly to clinical imaging, the study of “Ultrasound B-Scan-
ning in the differentiating of Baker’s Cyst and Thrombophlebi-
tis” in vivo in 1972 by Daniel McDonald and George Leopold is
widely regarded as the first publication of clinically relevant
musculoskeletal ultrasound (4). They described the use of a
contact B-mode scanner to differentiate Backer’s cysts from
thrombophlebitis. In 1969, Nicolaas Bom from the Netherlands
developed the real-time multi-element linear array scanner
which evolved into the very sophisticated real-time scanners
that are widely available today in musculoskeletal ultrasound.
ULTRASOUND IN RHEUMATOLOGY
Since the first gray scale ultrasound demonstration of synovitis
of knee joint in rheumatoid arthritis (5), numerous studies have
demonstrated the clinical utility of ultrasound in evaluating flu-
id, synovial hypertrophy in inflammatory arthritis (6, 7). This
was largely due to the fact that synovitis is the fundamental pa-
thology which is seen in all types of inflammatory arthritis. Gray
scale ultrasound can depict a range of abnormalities from the
minimally thickened synovium to severe hypertrophy with flu-
id, debris and villi (Fig. 1A). Ultrasound has shown its superior-
ity over clinical examination in the detection and assessment of
synovitis, drawing the most attention and support with regard
to the clinical use of ultrasound in rheumatology (8). Further-
more, with the administration of microbubbles contrast agents
to increase backscattering, the sensitivity for the detection of a
thickened, hypervascular synovium can be increased, and bet-
ter quantification of degree of inflammation can be achieved (9,
10). With regard to scoring of gray scale synovitis used in stud-
ies, different scoring systems have been used, ranging from bi-
nary (yes/no) to semiquantitative 4-point (0-3) grading (11, 12).
Assessment of synovial activity expressed by increased vas-
cularity is extremely important to the diagnosis and evaluation
of treatment effect. Traditionally, visualization of synovial in-
flammation has mainly been dominated by MRI. Recently, Dop-
pler ultrasound has been preferred to MRI in clinical practice,
since Doppler mode allows the visualization of microvasculari-
ty within joint cavity and periarticular tissue. Doppler can pro-
vide useful clinical information regarding the presence or ab-
sence of flow through the joint (Fig. 2), which correlates with
ongoing disease activities. The microvascular activity detected
by Doppler ultrasound correlated well with histology specimen
in knee and hip joint (13, 14). Moreover, intra-observer and in-
ter-observer reliability of still image interpretation is high for
gray scale and Doppler (15). Several studies used Doppler for
follow-up assessment after the treatment of corticosteroids and
tumor necrosis factor antagonists (9, 16, 17), showing Doppler
able to detect changes in synovial perfusion. In these studies,
the power or colour Doppler signal was determined semi-quan-
titatively graded on a 0-3 scale (17, 18) or qualitatively.
A semiquantitative grading system in which vascularity is
scored from 0 to 3 according to number or areas of vessel sig-
nals are widely used in clinical practice (19-21). However, the
semi-quantitative scales are not a precise method of vascularity
measurement and can be prone to intra-observer and inter-ob-
server variation. Alternatively, a quantitative scale quantified by
measuring the Doppler colour pixels in the region of interest
have also been used to measure inflammatory activity. Sono-
graphically measured disease activity was quantified by count-
ing colour pixels of region of interest using different vascularity
analysis computer softwares (16, 22, 23), colour fraction defined
as the fraction of colour pixels in a region of interest (24) and
the area under the time–intensity curve with intravenous ultra-
sound contrast agent (9). However, the sensitivity of Doppler
can be varied according to Doppler variables set by the ultraso-
nographer, as well as ultrasound units from different manufac-
turers (25). The lack of consensus make Doppler difficult to ap-
ply in routine clinical practice for assessment of disease activity,
thus there needs to be further agreement on classifying the vas-
With regard to Doppler modalities, both colour and power
Doppler have been used. Power Doppler displays the total back
scattered energy mainly from red blood cells instead of mean
Doppler shift used in colour Doppler. Power Doppler does not
measure blood velocity or direction but is more sensitive to de-
tect microvascular low-velocity flow. Moreover, power Doppler
is less angle dependent compared to colour Doppler and tech-
nologically does not aliase (26). Owing to these theoretical ad-
vantages, power Doppler has been better suited for assessing
musculoskeletal diseases in rheumatology. However, these ad-
vantages of power Doppler have been disappearing in the new-
er high-end machines where the trend is that colour Doppler
now is more sensitive than power Doppler (25).
Tendons are also frequently involved in a wide range of inflam-
matory and non-inflammatory rheumatic diseases. Ultrasound
is one of the best imaging modalities for assessing tendons due
to its high image resolution. When diseased, tendons may be-
come hypoechogenic with loss of a fibrillar pattern, thicker, have
Kang T, et al. • Ultrasound in Rheumatology
internal Doppler signals and a thickened surrounding tendon
sheath which may exhibit Doppler (Fig. 1B). Tendon itself can
show loss of fine fibrillar echotexture, focal thickening and hy-
poechoic (27). Ultrasound has been reported to be more sensi-
tive than MRI for the detection of tenosynovitis (28). However,
in a study by Wakefield et al, the sensitivity and specificity of ul-
trasound were reported 0.15-0.44, and 0.98-0.99 respectively for
tenosynovitis in finger joints of patients with early untreated
Fig. 1. Ultrasound images of joints and peri-articular tissue showing typical signs of common rheumatologic diseases. (A) Longitudinal dorsal scan of the tibiotalar joint. A large
ankle joint effusion with synovial proliferation (arrows) is seen. (B) Transverse and longitudinal scan of 3rd extensor tendon at dorsum of metacarpophalangeal joint showing
tendinopathy represented as swelling of tendon sheath (arrow) in both plane. (C) In the transverse anterior scan of shoulder at 90° internal rotation, bony erosion (arrow) is seen.
(D) MSD crystals are deposited within tendon sheath, causing tenosynovitis of extensor tendons. The high sparkling reflectivity of MSD crystals can make it easier to be detect-
ed and can be differentiated from synovial proliferation. (E) The sonographic double contour sign (arrow) is seen by the deposition of MSD crystals in the cartilage surface layers
of knee joint. It is also characterized by angle independency (not demonstrated). (F) Achilles tendon near calcaneal insertion shows focal increased thickness and loss of fibrillar
Extensor digitorum tendon
Femoral hyaline cartilage
3rd extensor tendon of hand
3rd extensor tendon of hand
Kang T, et al. • Ultrasound in Rheumatology
rheumatoid arhtritis using MRI as the gold standard (29). This
lower value may be related to the lack of standardization of def-
inition of tenosynovitis at that time, which was developed later
Ultrasound combined with power Doppler has been used to
investigate the cause of shoulder pain in patients with rheuma-
toid arthritis. Ultrasound can help to differentiate glenohumeral
synovitis with subdeltoid bursitis, tenosynovitis of biceps ten-
don as the cause of rheumatoid shoulder (30). A study showed
overall good agreement between ultrasound and MRI with re-
gard to synovitis, erosion and bursitis and cuff tear of shoulder
joint in patients with rheumatoid arthritis (31). Ultrasound can
also be used to assess non-inflammatory cause of shoulder
pain. Through a recent meta-analysis study with sixty-two stud-
ies assessing 6066 shoulders, it was concluded that ultrasound
can be regarded as an appropriate technique for the assessment
of rotator cuff tears with an acceptable sensitivity and specifici-
ty (32). In the elbow, both lateral and medial epicondylitis are
due to an overuse injury from repetitive movement of the fore-
arm and the wrist resulting in stressing of the common extensor
or flexor tendons. Ultrasound is also informative and accurate
for the detection of clinical lateral and medial epicondylitis (33,
34). These results can provide convincing evidence of capability
of ultrasound in depicting mechanical tendon diseases as well
as inflammatory causes in rheumatology clinical practice. Al-
though MRI can also detect low grade tendinopathies, the over-
all advantages of repeatability, non-invasiveness, wide availabil-
ity and ability to examine the tendon dynamically have made
ultrasound more valuable tool for detecting tendon diseases.
Thus ultrasound should be regarded as the first imaging mo-
dality for tendon involvement in rheumatologic diseases.
Radiographically detected bone erosion is an important diag-
nostic criterion for rheumatoid arthritis (35) and its presence
implies poor functional outcome. However, plain radiography
can show only the erosions which are tangential to the X-ray
beam direction. In contrast, ultrasound can visualize circum-
ferentially around the bone, which makes it possible to detect
more erosions than simple radiography where erosions may be
lost in the two dimensional projection (Fig. 1C). The first large
study demonstrating the superiority of ultrasound over radiog-
raphy was reported in 2000 (36), showing its ability to detect 6.5
fold more erosions than radiography in early rheumatoid ar-
thritis patients as well as 3.4 fold in late disease. With MRI con-
sidered the reference method, ultrasound has a slightly lower
sensitivity than MRI but similar accuracy for detecting erosions
(37, 38). With regard to scoring of erosions, although scoring
system based on size (36) and semiquantitative scores (39)
have been suggested, no consensus has been made in stan-
dardized scoring system. A wide variety of sizes and locations
within joints with sometimes inaccessible acoustic window
have made it difficult to standardize. In addition, erosions may
be difficult to detect in the context of concomitant osteoarthritis.
Osteoarthritis is traditionally evaluated by conventional radiog-
raphy in spite of the fact that radiography cannot depict articu-
lar cartilage. Ultrasound can overcome this barrier since it can
visualize articular hyaline cartilage as a well defined anechoic
band lacking internal echoes (40). Ultrasound can also show
pathologic signs of articular cartilage in terms of thickness, trans-
parency, sharpness and related osteophytes. Nevertheless, ul-
trasound for the assessment of osteoarthritis seems to have rel-
atively less been focused on compared to rheumatoid arthritis.
Recently, interest in the application of ultrasound in early and
late osteoarthritis is emerging (40, 41).
The first ultrasound study of cartilage in rheumatology dates
back to 1992, where Iagnocco et al. reported diminished knee
cartilage thickness, which is the hallmark of osteoarthritis, in
Fig. 2. Assessment of inflammatory activity can be achieved with power Doppler. (A, B) These are two longitudinal dorsal views through the wrist joint. Both show moderate lev-
els of gray scale and power Doppler abnormalities consistent with active joint disease.
Wrist jointWrist joint
Kang T, et al. • Ultrasound in Rheumatology
osteoarthritis patients, suggesting ultrasound as a useful non-
invasive method to study articular cartilage (42). Then, several
studies investigated ultrasonographic cartilage abnormalities,
reporting loss of sharp contour and clarity with increased echo-
genecity in joints involved by osteoarthritis (43, 44). MRI can
show precise cartilage loss more sensitively than radiography
and can also provide distinct advantages over radiography for
joint space narrowing and its location (45). However, its use for
the assessment of osteoarthritis has been limited due to high
cost and accessibility in clinical practice. Thus, ultrasound has
been focused on as an alternative valid non-invasive reproduc-
ible imaging modality to detect and quantify cartilage damage
in osteoarthritis. Reflecting these interests, it was reported that
insonation angle and sound speed in cartilage should be taken
into account for accurate thickness measure (46).
There has been increasing evidence that synovitis plays a sig-
nificant role as a contributor in the disease pathogenesis (47).
In osteoarthritic joints, synovitis with similar findings to rheu-
matoid arthritis has been shown (44), supporting major roles of
synovitis in the pathogenesis of osteoarthritis.
Osteophytes appearing as elevated small step-up bony frag-
ment seen in two perpendicular planes close to joint space can
be detected by ultrasound (Fig. 3). Depending on its interposi-
tion, it may be difficult to differentiate from bony erosions and
normal cortical irregularity. Ultrasound can detect more osteo-
phytes compared with conventional radiography osteoarthritis
of hand (48). In erosive osteoarthritis of hands, ultrasound also
found more osteophytes than the radiography although X-ray
may be better to detect the centrally placed erosions where the
acoustic window is poor (49). Several studies have introduced
semiquantitative scoring systems for osteoarthritis in the knee,
hand and hip joint (40, 50, 51), though no consensus has been
reached. Efforts in order to validate scoring systems are being
undertaken by the OMERACT Ultrasound Task Force (52).
Crystal deposit diseases
Crystal deposit diseases are a group of disorders characterized
by the intra and extra-articular deposition of crystals. Mo noso-
dium urate (MSU) crystals as a consequence of raised serum
uric acid level and calcium pyrophosphate dihydrate (CPPD)
crystals are the most common forms. Ultrasound has become a
useful diagnostic tool for gout and pseudogout. The highly spar-
kling reflectivity of MSU (Fig. 1D) and CPPD crystals can be
easily detected with even minimal aggregates within cartilage
and tendon sheaths. Once these crystals are deposited in the
cartilage, the reflectivity of the cartilage is no longer dependent
on the insonation angle of ultrasound beam (53).
The existence of a hyperechoic band over anechoic hyaline
cartilage surface described as a double contour sign are seen in
about 92% of gouty joints (Fig. 1E) (54). It has also been demon-
strated recently that the sonographic double contour signs of
deposition of MSU crystals can be reversed completely on fol-
low-up if sustained normouricemia was achieved (55). In a pi-
lot study in patients with asymptomatic hyperuricemia, the
presence of a double contour sign or hyperechoic cloud area
was predictive of the detection of MSU crystals (56). Moreover,
ultrasound can help distinguish tophi and other subcutaneous
nodules including rheumatoid nodules and lipoma. A tophus,
which is composed of MSU crystals, is most often seen as a het-
erogeneous mass often with intermittent hyperechoic foci com-
pared with rheumatoid nodules which are likely to be more ho-
mogeneous (57). In CPPD disease, the hyperechoic aggregates
are likely to form a band within articular cartilage, which is the
distinct ultrasound feature differentiating MSU crystals (53).
The dense deposit of CPPD crystals ranging from punctate to
large linear deposits can generate acoustic shadowing (58).
The use of ultrasound in spondyloarthropathy is mainly for the
detection of enthesitis such as Achilles tendonitis and plantar
Fig. 3. Osteophyte usually appears as elevated small bony prominence (arrow) at the end of normal bone contour, close to joint space (A). It usually does not show Doppler sig-
Kang T, et al. • Ultrasound in Rheumatology
fasciitis. The other indication is for the detection of peripheral
joint arthritis, similar to rheumatoid arthritis (59). Affected en-
theseal sites show signs of gray scale abnormality characterized
by loss of normal fibrillar structures with an increased thick-
ness or intra-tendinal focal changes with or without Dopper
signals (Fig. 1F). In a large scale study for peripheral enthesitis
in patients with spondyloarthropathies, greater sensitivity for
the detection of enthesitis over clinical examination was re-
ported (60). Power Doppler can also display the degree of se-
verity of enthesial involvement. In contrast, the role of MRI in
the assessment of spondyloarthropathies has mainly been con-
fined to assess axial involvement since MRI lacks sensitivity
and specificity for peripheral enthesitis.
Different scoring systems have also been suggested for en-
thesisitis. Each assesses different sites and different scoring sys-
tems. The earlier ones are only gray scale with the more recent
ones involving Doppler. The first of these reported in 2006 was
the Glasgow Ultrasound Enthesitis Scoring System (GUESS)
which assesses five entheses of lower limb with gray-scale find-
ings (61). Another scoring system SEI (Sonographic Enthesitis
Index) also uses gray scale findings but assess different enthe-
seal sites (62). A more recent Madrid Sonographic Enthesis In-
dex (MASEI) scoring system combined gray scale abnormali-
ties and Doppler activity. However, a recent systematic litera-
ture review by the OMERACT Ultrasound Task Force concluded
that there remains a lack of consensus of how to define and score
enthesitis. One important remit is to develop a score which sep-
arates inflammation from damage. This is a priority area cur-
rently under review by the OMERACT group (63).
Ultrasound guided interventions
Diagnostic and therapeutic musculoskeletal interventions in
rheumatology include a wide range of procedures such as aspi-
ration of fluid from joints, bursa, tendon sheath and cystic le-
sions for diagnostic and therapeutic purpose as well as steroid
injections into joint cavities and soft tissues. Real time visualiza-
tion of the needle and injected steroid by ultrasound enables
the reliable placement of the needle tip in the joint cavity, bursa,
tendon sheaths and intra-tendon (Fig. 4) (64). However, some
studies reported no significant difference in accuracy between
the blind and ultrasound-guided method (65, 66), although
these results are studies of the larger joints such as knee and
shoulder. In the relatively small interphalangeal joints and diffi-
cult joints to be accessed due to complex anatomy such as wrist
and ankle, accurate needle positioning can be a particular chal-
lenge (67). In these joints, sonographic needle guidance have
demonstrated improved accuracy and better clinical outcomes
com pared with conventional palpation-guided blind methods
(68, 69). Furthermore, Doppler can help the precise placement
of the needle tip into the most inflamed intra-region, making
the overall clinical outcomes better. A recent systematic review
compared the accuracy of ultrasound-guided intra-articular in-
jections with blind injections using palpation or anatomic land-
marks, and confirmed that ultrasound-guidance raised the ac-
curacy of injections independent of anatomic site (70).
Vasculitis is an autoimmune disease characterized by the in-
flammation of the vessel wall. The lumen of large arteries can
be measured and information about vessel wall, pulsatility and
blood flow characteristics can be obtained using duplex mode.
In rheumatology, the first ultrasound report for the diagnosis of
arteritis was for giant cell (temporal) arteritis in 1995 (71). Since
then, giant cell arteritis has drawn the most interest in arterits
in rheumatology (71, 72). Affected temporal arteries showed
edema, stenosis or occlusion characterized by a hypoechoic
halo around a narrowed lumen due to edema of arterial wall,
which may make possible the diagnosis of temporal arteritis
without performing a temporal-artery biopsy (73).
Since then, the scope of vasculitis evaluated with ultrasound
Fig. 4. Ultrasound guided intra-articular injection of 3rd proximal interphalageal joint of hand. (A) The tip and shaft of metallic needle (arrows) can be easily identified. (B) The
crystalline steroid suspension can be observed on the screen as fine hyperechoic clouds or spots (arrow), which can increase the accuracy of injection.
3rd proximal interphalangeal joint 3rd proximal interphalangeal joint
Proximal phalanxProximal phalanx Distal phalanx Distal phalanx
Kang T, et al. • Ultrasound in Rheumatology
in rheumatology has expanded to Wegener’s granulomatosis
(74), finger arteritis in systemic sclerosis (75) and Raynaud’s
phenomenon (76), in which ultrasound showed superiority to
visualize the narrowed lumen with thicken arterial wall. High
resolution ultrasound may aid to differentiate primary and sec-
ondary Raynaud’s phenomenon by depicting the vessels as an-
giography. At present, ultrasound for the assessment of arteritis
is expected to be a valuable tool for diagnostic workup and mon-
itoring in rheumatology.
Sjögren syndrome/salivary glands
The normal ultrasound echogenicity of major salivary glands is
homogeneous. As affected glands gradually become fibrotic,
the parenchyma becomes inhomogeneous with multiple scat-
tered small oval hypoechoic or anechoic areas with flow ob-
served within the glands in Doppler (Fig. 5) (77, 78). These find-
ings appear to have a high sensitivity and specificity for primary
Sjögren syndrome (79). Ultrasound findings of parotid glands
correlated well with MRI, showing a similar diagnostic accura-
cy compared to MRI (80) and sialography (81). Moreover, addi-
tional vascularity information in the glands obtained by spec-
tral Doppler in terms of resistive index and pulsatility index can
be helpful for the diagnosis of Sjögren syndrome (82). However,
inconsistent ultrasonographic diagnostic sensitivity ranging
43%-93% and specificity ranging 64%-100% for Sjögren syn-
drome have been reported (81, 83, 84). These inconsistencies
could be caused by lack of ultrasonographic classification crite-
ria for Sjögren syndrome. Moreover, a different ultrasonograph-
ic scoring system based on morphologic changes observed in
gray scale ultrasound has been suggested for primary Sjögren
syndrome (79, 85). Despite these flaws, the overall diagnostic
accuracy of an ultrasound scoring system for primary Sjögren
syndrome was comparable to salivary scintigraphy and salivary
gland biopsy (81). Since ultrasound can demonstrate valuable
objective evidence of glandular involvement of Sjögren syn-
drome, it is regarded as an emerging imaging method of first
choice in patients suspected of having sicca syndrome (86).
Sjögren syndrome is frequently associated with a variety of B
cell lymphomas and other lymphoproliferative disorders (87).
Sometimes the differential diagnosis of ultrasonographic find-
ings can be challenging, thus meticulous studies should be un-
dertaken if concomitant lymphoma cannot be ruled out as well
as the appreciation that ultrasound cannot always exclude more
severe pathologies in which case other imaging may be employ-
Inflammatory muscle diseases
Skeletal muscles appears relatively hypoechogenic under nor-
mal circumstances in contrast to echogenic fibroadipose septa
and fascia. In rheumatology, idiopathic inflammatory muscle
diseases including polymyositis, dermatomyositis and inclu-
sion body myositis can affect skeletal muscles focally and dif-
fusely. On ultrasound, affected muscle can show thickening
and areas of hypoechogenicity different to the normal surroun-
ding muscle. Increased Doppler activity within the affected
muscles can be observed. Ultrasound-guided closed muscle
biopsy can also provide a minimally invasive approach for the
diagnosis of focal myositis (89). However, the role of ultrasound
in the assessment of inflammatory muscle diseases in rheuma-
tology have not yet been fully identified.
Limitations of ultrasound in rheumatology
The use of ultrasound in rheumatological diseases may be lim-
ited by several factors. The ultrasound beam cannot penetrate
bone, making it impossible to visualize intraosseous changes
such as bone marrow edema. Additionally, the ultrasound beam
is attenuated (absorbed, refracted, diffracted or lost as heat) the
deeper into tissue it goes and so images are less clear when in-
terrogating deeper structures even when low frequency probes
are used. Moreover, joints with a limited acoustic window due
to anatomical restriction such as the hip, and wrist may have a
lower sensitivity to detect erosions and involvement of synovial
pathologies. Although high intra-observer and inter-observer
reliability have been reported (31, 90, 91), the detection of ultra-
sonographic abnormalities depends on the individual operator.
However the studies from the OME RACT group have demon-
strated that with standardization, operator dependency can be
diminished. To become an expert, plenty of clinical experience
and a long period of training is needed. EULAR (European Lea-
gue Against Rheumatism) and the ACR (American College of
Rheumatology) are currently setting out curricula and standard
operating procedures for the acquisition and reading of ultra-
Three dimensional (3D) ultrasound provides an interesting as-
pect for the volumetric assessment of tissue blocks and quanti-
fication of region of interests. The saved images can be viewed
Fig. 5. Transverse view of the parotid gland in a patient with primary Sjögren syn-
drome. Affected glands can show parenchymal inhomogenecity with multiple oval
shaped small hypoechoic changes (courtesy of Sandrine Jousse-Joulin).
Dist 4.68 cm
Dist 1.38 cm
Surf 4.99 cm2
Kang T, et al. • Ultrasound in Rheumatology
in sagittal, coronal and axial planes and relatively operator in-
dependent compared to two dimensional (2D) ultrasound im-
aging. The 3D images had a good correlation with 2D images
for detection of synovitis and bone erosion (92) and was able to
delineate the shape of the synovium in the knee joint (93). The
use of 3D ultrasound currently remains mainly in the research
area due to relatively low image quality and additional cost.
Sonoelastography measures the strain of the tissues by ana-
lyzing ultrasound echo signals while the probe compresses or
relaxes the tissue (94). The compression wave may be generat-
ed by the operator (compression elastography) or by the probe
(shear wave elastography). In rheumatology, sonoelastography
has shown promising results in detecting changes in Achilles
tendons (95) (Fig. 6), and elbow ligaments (96) and has allowed
the differentiation between rheumatoid nodules and gout to-
phi (97). In systemic sclerosis patients, sonoelastography can
demonstrate reduction of strain caused by loss of elasticity in
the dermis (98). Since sonoelastography has started to be ap-
plied in rheumatologic diseases recently, more comprehensive
and extended studies are needed to establish the contribution
of sonoelastography in rheumatologic diseases.
Another interesting advance is known as fusion imaging. Here
the ultrasound image is fused with MRI or Computed Tomog-
raphy (CT) image to combine the advantages of real time image
acquisition by ultrasound with better depiction of bone and
soft tissue lesions. This technique can be used to improve injec-
tion accuracy of joints with difficult access such as sacroiliac
joint (99). However, the usefulness of fusion imaging in rheu-
matology should be decided in the future since there is lack of
clinical research data.
Ultrasound is becoming an essential tool in the management of
rheumatology patients through its gradual incorporation into
routine clinical use in many countries and rheumatology cen-
ters. Evidence for the reliability, validity as well as clinical value
of ultrasound is increasing with continuing studies of this mo-
dality. Future development in technology together with con-
sensus of international and national educational programs will
spur the wider application of ultrasound for various rheumato-
logic diseases, enabling it to become a powerful imaging tool
1. Wakefield RJ, Balint PV, Szkudlarek M, Filippucci E, Backhaus M, D’Agos-
tino MA, Sanchez EN, Iagnocco A, Schmidt WA, Bruyn GA, et al. Mus-
culoskeletal ultrasound including definitions for ultrasonographic pa-
thology. J Rheumatol 2005; 32: 2485-7.
2. Kane D, Grassi W, Sturrock R, Balint PV. A brief history of musculoskele-
tal ultrasound: ‘from bats and ships to babies and hips’ . Rheumatology
(Oxford) 2004; 43: 931-3.
3. Dussik KT. On the possibility of using ultrasound waves as a diagnostic
aid. Z Neurol Psychiatr 1942; 174: 153-68.
4. McDonald DG, Leopold GR. Ultrasound B-scanning in the differentia-
tion of Baker’s cyst and thrombophlebitis. Br J Radiol 1972; 45: 729-32.
5. Cooperberg PL, Tsang I, Truelove L, Knickerbocker WJ. Gray scale ul-
trasound in the evaluation of rheumatoid arthritis of the knee. Radiolo-
gy 1978; 126: 759-63.
6. Grassi W, Tittarelli E, Pirani O, Avaltroni D, Cervini C. Ultrasound ex-
amination of metacarpophalangeal joints in rheumatoid arthritis. Scand
J Rheumatol 1993; 22: 243-7.
7. Backhaus M. Ultrasound and structural changes in inflammatory ar-
Fig. 6. Elastography of wrist joint. In the left image, longitudinal gray scale image over the ulnocarpal area in rheumatoid arthritis patient shows loss of fibrillar pattern and peri-
tendinous synovial proliferation (arrows). In the right elastography image, tissue elasticity was displayed using colours. The hard tissue areas are seen as blue and soft tissue
areas are seen as red colour. Swollen tendon regions in the gray scale are seen as red in the elastography (arrow), representing the decreased elasticity (hardness) of this re-
gion due to tendinopathies affected by rheumatoid arthritis.
Wrist joint Wrist joint
Kang T, et al. • Ultrasound in Rheumatology
thritis: synovitis and tenosynovitis. Ann N Y Acad Sci 2009; 1154: 139-51.
8. Jain M, Samuels J. Musculoskeletal ultrasound in the diagnosis of rheu-
matic disease. Bull NYU Hosp Jt Dis 2010; 68: 183-90.
9. Salaffi F, Carotti M, Manganelli P, Filippucci E, Giuseppetti GM, Grassi
W. Contrast-enhanced power Doppler sonography of knee synovitis in
rheumatoid arthritis: assessment of therapeutic response. Clin Rheuma-
tol 2004; 23: 285-90.
10. Szkudlarek M, Court-Payen M, Strandberg C, Klarlund M, Klausen T,
Østergaard M. Contrast-enhanced power Doppler ultrasonography of
the metacarpophalangeal joints in rheumatoid arthritis. Eur Radiol
2003; 13: 163-8.
11. Scheel AK, Hermann KG, Kahler E, Pasewaldt D, Fritz J, Hamm B, Brun-
ner E, Müller GA, Burmester GR, Backhaus M. A novel ultrasonograph-
ic synovitis scoring system suitable for analyzing finger joint inflamma-
tion in rheumatoid arthritis. Arthritis Rheum 2005; 52: 733-43.
12. Karim Z, Wakefield RJ, Quinn M, Conaghan PG, Brown AK, Veale DJ,
O’Connor P, Reece R, Emery P. Validation and reproducibility of ultra-
sonography in the detection of synovitis in the knee: a comparison with
arthroscopy and clinical examination. Arthritis Rheum 2004; 50: 387-
13. Walther M, Harms H, Krenn V, Radke S, Faehndrich TP, Gohlke F. Cor-
relation of power Doppler sonography with vascularity of the synovial
tissue of the knee joint in patients with osteoarthritis and rheumatoid
arthritis. Arthritis Rheum 2001; 44: 331-8.
14. Walther M, Harms H, Krenn V, Radke S, Kirschner S, Gohlke F. Synovial
tissue of the hip at power Doppler US: correlation between vascularity
and power Doppler US signal. Radiology 2002; 225: 225-31.
15. Cheung PP, Dougados M, Gossec L. Reliability of ultrasonography to
detect synovitis in rheumatoid arthritis: a systematic literature review of
35 studies (1,415 patients). Arthritis Care Res (Hoboken) 2010; 62: 323-
16. Taylor PC, Steuer A, Gruber J, McClinton C, Cosgrove DO, Blomley MJ,
Marsters PA, Wagner CL, Maini RN. Ultrasonographic and radiograph-
ic results from a two-year controlled trial of immediate or one-year-de-
layed addition of infliximab to ongoing methotrexate therapy in patients
with erosive early rheumatoid arthritis. Arthritis Rheum 2006; 54: 47-53.
17. Fiocco U, Ferro F, Vezzù M, Cozzi L, Checchetto C, Sfriso P, Botsios C,
Ciprian L, Armellin G, Nardacchione R, et al. Rheumatoid and psoriatic
knee synovitis: clinical, grey scale, and power Doppler ultrasound assess-
ment of the response to etanercept. Ann Rheum Dis 2005; 64: 899-905.
18. Naredo E, Möller I, Cruz A, Carmona L, Garrido J. Power Doppler ultra-
sonographic monitoring of response to anti-tumor necrosis factor thera-
py in patients with rheumatoid arthritis. Arthritis Rheum 2008; 58: 2248-
19. Szkudlarek M, Court-Payen M, Strandberg C, Klarlund M, Klausen T,
Ostergaard M. Power Doppler ultrasonography for assessment of syno-
vitis in the metacarpophalangeal joints of patients with rheumatoid ar-
thritis: a comparison with dynamic magnetic resonance imaging. Ar-
thritis Rheum 2001; 44: 2018-23.
20. Stone M, Bergin D, Whelan B, Maher M, Murray J, McCarthy C. Power
Doppler ultrasound assessment of rheumatoid hand synovitis. J Rheu-
matol 2001; 28: 1979-82.
21. Newman JS, Adler RS, Bude RO, Rubin JM. Detection of soft-tissue hy-
peremia: value of power Doppler sonography. AJR Am J Roentgenol 1994;
22. Hau M, Kneitz C, Tony HP, Keberle M, Jahns R, Jenett M. High resolu-
tion ultrasound detects a decrease in pannus vascularisation of small
finger joints in patients with rheumatoid arthritis receiving treatment
with soluble tumour necrosis factor alpha receptor (etanercept). Ann
Rheum Dis 2002; 61: 55-8.
23. Fukae J, Kon Y, Henmi M, Sakamoto F, Narita A, Shimizu M, Tanimura K,
Matsuhashi M, Kamishima T, Atsumi T, et al. Change of synovial vascu-
larity in a single finger joint assessed by power doppler sonography cor-
related with radiographic change in rheumatoid arthritis: comparative
study of a novel quantitative score with a semiquantitative score. Arthri-
tis Care Res (Hoboken) 2010; 62: 657-63.
24. Ellegaard K, Christensen R, Torp-Pedersen S, Terslev L, Holm CC, Kønig
MJ, Jensen PS, Danneskiold-Samsøe B, Bliddal H. Ultrasound Doppler
measurements predict success of treatment with anti-TNF-α drug
in patients with rheumatoid arthritis: a prospective cohort study. Rheu-
matology (Oxford) 2011; 50: 506-12.
25. Torp-Pedersen ST, Terslev L. Settings and artefacts relevant in colour/
power Doppler ultrasound in rheumatology. Ann Rheum Dis 2008; 67:
26. Rubin JM, Bude RO, Carson PL, Bree RL, Adler RS. Power Doppler US:
a potentially useful alternative to mean frequency-based color Doppler
US. Radiology 1994; 190: 853-6.
27. Grassi W, Filippucci E, Farina A, Cervini C. Sonographic imaging of ten-
dons. Arthritis Rheum 2000; 43: 969-76.
28. Backhaus M, Kamradt T, Sandrock D, Loreck D, Fritz J, Wolf KJ, Raber H,
Hamm B, Burmester GR, Bollow M. Arthritis of the finger joints: a com-
prehensive approach comparing conventional radiography, scintigra-
phy, ultrasound, and contrast-enhanced magnetic resonance imaging.
Arthritis Rheum 1999; 42: 1232-45.
29. Wakefield RJ, O’Connor PJ, Conaghan PG, McGonagle D, Hensor EM,
Gibbon WW, Brown C, Emery P. Finger tendon disease in untreated
early rheumatoid arthritis: a comparison of ultrasound and magnetic
resonance imaging. Arthritis Rheum 2007; 57: 1158-64.
30. Stegbauer J, Rump LC, Weiner SM. Sites of inflammation in painful rheu-
matoid shoulder assessed by musculoskeletal ultrasound and power Do-
ppler sonography. Rheumatol Int 2008; 28: 459-65.
31. Bruyn GA, Naredo E, Möller I, Moragues C, Garrido J, de Bock GH, d’Ag-
ostino MA, Filippucci E, Iagnocco A, Backhaus M, et al. Reliability of
ultrasonography in detecting shoulder disease in patients with rheuma-
toid arthritis. Ann Rheum Dis 2009; 68: 357-61.
32. Smith TO, Back T, Toms AP, Hing CB. Diagnostic accuracy of ultrasound
for rotator cuff tears in adults: a systematic review and meta-analysis.
Clin Radiol 2011; 66: 1036-48.
33. Park GY, Lee SM, Lee MY. Diagnostic value of ultrasonography for clini-
cal medial epicondylitis. Arch phys Med Rehabil 2008; 89: 738-42.
34. Tran N, Chow K. Ultrasonography of the elbow. Semin Musculoskelet
Radiol 2007; 11: 105-16.
35. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS,
Healey LA, Kaplan SR, Liang MH, Luthra HS, et al. The American Rheu-
matism Association 1987 revised criteria for the classification of rheu-
matoid arthritis. Arthritis Rheum 1988; 31: 315-24.
36. Wakefield RJ, Gibbon WW, Conaghan PG, O’Connor P, McGonagle D,
Pease C, Green MJ, Veale DJ, Isaacs JD, Emery P. The value of sonogra-
phy in the detection of bone erosions in patients with rheumatoid arthri-
tis: a comparison with conventional radiography. Arthritis Rheum 2000;
Kang T, et al. • Ultrasound in Rheumatology
37. Døhn UM, Ejbjerg BJ, Court-Payen M, Hasselquist M, Narvestad E, Sz-
kudlarek M, Møller JM, Thomsen HS, Østergaard M. Are bone erosions
detected by magnetic resonance imaging and ultrasonography true ero-
sions? a comparison with computed tomography in rheumatoid arthri-
tis metacarpophalangeal joints. Arthritis Res Ther 2006; 8: R110.
38. Szkudlarek M, Narvestad E, Klarlund M, Court-Payen M, Thomsen HS,
Østergaard M. Ultrasonography of the metatarsophalangeal joints in
rheumatoid arthritis: comparison with magnetic resonance imaging,
conventional radiography, and clinical examination. Arthritis Rheum
2004; 50: 2103-12.
39. Reynolds PP, Heron C, Pilcher J, Kiely PD. Prediction of erosion progres-
sion using ultrasound in established rheumatoid arthritis: a 2-year fol-
low-up study. Skeletal Radiol 2009; 38: 473-8.
40. Naredo E, Acebes C, Möller I, Canillas F, de Agustín JJ, de Miguel E, Filip-
pucci E, Iagnocco A, Moragues C, Tuneu R, et al. Ultrasound validity in
the measurement of knee cartilage thickness. Ann Rheum Dis 2009; 68:
41. Conaghan P, D’Agostino MA, Ravaud P, Baron G, Le Bars M, Grassi W,
Martin-Mola E, Wakefield R, Brasseur JL, So A, et al. EULAR report on
the use of ultrasonography in painful knee osteoarthritis: part 2: explor-
ing decision rules for clinical utility. Ann Rheum Dis 2005; 64: 1710-4.
42. Iagnocco A, Coari G, Zoppini A. Sonographic evaluation of femoral
condylar cartilage in osteoarthritis and rheumatoid arthritis. Scand J
Rheumatol 1992; 21: 201-3.
43. Grassi W, Filippucci E, Farina A. Ultrasonography in osteoarthritis. Semin
Arthritis Rheum 2005; 34: 19-23.
44. D’Agostino MA, Conaghan P, Le Bars M, Baron G, Grassi W, Martin-
Mola E, Wakefield R, Brasseur JL, So A, Backhaus M, et al. EULAR re-
port on the use of ultrasonography in painful knee osteoarthritis: part 1:
prevalence of inflammation in osteoarthritis. Ann Rheum Dis 2005; 64:
45. Amin S, LaValley MP, Guermazi A, Grigoryan M, Hunter DJ, Clancy M,
Niu J, Gale DR, Felson DT. The relationship between cartilage loss on
magnetic resonance imaging and radiographic progression in men and
women with knee osteoarthritis. Arthritis Rheum 2005; 52: 3152-9.
46. Torp-Pedersen S, Bartels EM, Wilhjelm J, Bliddal H. Articular cartilage
thickness measured with US is not as easy as it appears: a systematic re-
view of measurement techniques and image interpretation. Ultraschall
Med 2011; 32: 54-61.
47. Attur M, Samuels J, Krasnokutsky S, Abramson SB. Targeting the syno-
vial tissue for treating osteoarthritis (OA): where is the evidence? Best
Pract Res Clin Rheumatol 2010; 24: 71-9.
48. Keen HI, Wakefield RJ, Grainger AJ, Hensor EM, Emery P, Conaghan
PG. Can ultrasonography improve on radiographic assessment in osteo-
arthritis of the hands? a comparison between radiographic and ultraso-
nographic detected pathology. Ann Rheum Dis 2008; 67: 1116-20.
49. Vlychou M, Koutroumpas A, Malizos K, Sakkas LI. Ultrasonographic
evidence of inflammation is frequent in hands of patients with erosive
osteoarthritis. Osteoarthritis Cartilage 2009; 17: 1283-7.
50. Keen HI, Lavie F, Wakefield RJ, D’Agostino MA, Hammer HB, Hensor E,
Pendleton A, Kane D, Guerini H, Schueller-Weidekamm C, et al. The
development of a preliminary ultrasonographic scoring system for fea-
tures of hand osteoarthritis. Ann Rheum Dis 2008; 67: 651-5.
51. Qvistgaard E, Torp-Pedersen S, Christensen R, Bliddal H. Reproducibil-
ity and inter-reader agreement of a scoring system for ultrasound evalu-
ation of hip osteoarthritis. Ann Rheum Dis 2006; 65: 1613-9.
52. Naredo E, Wakefield RJ, Iagnocco A, Terslev L, Filippucci E, Gandjbak-
hch F, Aegerter P, Aydin S, Backhaus M, Balint PV, et al. The OMERACT
ultrasound task force: status and perspectives. J Rheumatol 2011; 38:
53. Grassi W, Meenagh G, Pascual E, Filippucci E. “Crystal clear”-sono-
graphic assessment of gout and calcium pyrophosphate deposition dis-
ease. Semin Arthritis Rheum 2006; 36: 197-202.
54. Thiele RG, Schlesinger N. Diagnosis of gout by ultrasound. Rheumatol-
ogy (Oxford) 2007; 46: 1116-21.
55. Thiele RG, Schlesinger N. Ultrasonography shows disappearance of
monosodium urate crystal deposition on hyaline cartilage after sustained
normouricemia is achieved. Rheumatol Int 2010; 30: 495-503.
56. De Miguel E, Puig JG, Castillo C, Peiteado D, Torres RJ, Martín-Mola E.
Diagnosis of gout in patients with asymptomatic hyperuricaemia: a pi-
lot ultrasound study. Ann Rheum Dis 2012; 71: 157-8.
57. Nalbant S, Corominas H, Hsu B, Chen LX, Schumacher HR, Kitumnu-
aypong T. Ultrasonography for assessment of subcutaneous nodules. J
Rheumatol 2003; 30: 1191-5.
58. Ciapetti A, Filippucci E, Gutierrez M, Grassi W. Calcium pyrophosphate
dihydrate crystal deposition disease: sonographic findings. Clin Rheu-
matol 2009; 28: 271-6.
59. Jain M, Samuels J. Musculoskeletal ultrasound in the diagnosis of rheu-
matic disease. Bull NYU Hosp Jt Dis 2010; 68: 183-90.
60. McGonagle D, Marzo-Ortega H, O’Connor P, Gibbon W, Pease C, Re-
ece R, Emery P. The role of biomechanical factors and HLA-B27 in mag-
netic resonance imaging-determined bone changes in plantar fascia en-
thesopathy. Arthritis Rheum 2002; 46: 489-93.
61. Balint PV, Kane D, Wilson H, McInnes IB, Sturrock RD. Ultrasonogra-
phy of entheseal insertions in the lower limb in spondyloarthropathy.
Ann Rheum Dis 2002; 61: 905-10.
62. Alcalde M, Acebes JC, Cruz M, González-Hombrado L, Herrero-Beau-
mont G, Sánchez-Pernaute O. A sonographic enthesitic index of lower
limbs is a valuable tool in the assessment of ankylosing spondylitis. Ann
Rheum Dis 2007; 66: 1015-9.
63. Gandjbakhch F, Terslev L, Joshua F, Wakefield RJ, Naredo E, D’Agostino
MA; OMERACT Ultrasound Task Force. Ultrasound in the evaluation of
enthesitis: status and perspectives. Arthritis Res Ther 2011; 13: R188.
64. Schirmer M, Duftner C, Schmidt WA, Dejaco C. Ultrasonography in in-
flammatory rheumatic disease: an overview. Nat Rev Rheumatol 2011;
65. Wiler JL, Costantino TG, Filippone L, Satz W. Comparison of ultrasound-
guided and standard landmark techniques for knee arthrocentesis. J
Emerg Med 2010; 39: 76-82.
66. Rutten MJ, Maresch BJ, Jager GJ, de Waal Malefijt MC. Injection of the
subacromial-subdeltoid bursa: blind or ultrasound-guided? Acta Or-
thop 2007; 78: 254-7.
67. Raza K, Lee CY, Pilling D, Heaton S, Situnayake RD, Carruthers DM,
Buckley CD, Gordon C, Salmon M. Ultrasound guidance allows accu-
rate needle placement and aspiration from small joints in patients with
early inflammatory arthritis. Rheumatology (Oxford) 2003; 42: 976-9.
68. Sibbitt WL Jr, Peisajovich A, Michael AA, Park KS, Sibbitt RR, Band PA,
Bankhurst AD. Does sonographic needle guidance affect the clinical out-
come of intraarticular injections? J Rheumatol 2009; 36: 1892-902.
Kang T, et al. • Ultrasound in Rheumatology
69. Koski JM. Ultrasound guided injections in rheumatology. J Rheumatol
2000; 27: 2131-8.
70. Gilliland CA, Salazar LD, Borchers JR. Ultrasound versus anatomic gui-
dance for intra-articular and periarticular injection: a systematic review.
Phys Sportsmed 2011; 39: 121-31.
71. Schmidt WA, Kraft HE, Völker L, Vorpahl K, Gromnica-Ihle EJ. Colour
Doppler sonography to diagnose temporal arteritis. Lancet 1995; 345:
72. Nesher G, Shemesh D, Mates M, Sonnenblick M, Abramowitz HB. The
predictive value of the halo sign in color Doppler ultrasonography of the
temporal arteries for diagnosing giant cell arteritis. J Rheumatol 2002;
73. Schmidt WA, Kraft HE, Vorpahl K, Völker L, Gromnica-Ihle EJ. Color
duplex ultrasonography in the diagnosis of temporal arteritis. N Engl J
Med 1997; 337: 1336-42.
74. Schmidt WA, Seipelt E, Molsen HP, Poehls C, Gromnica-ihle EJ. Vascu-
litis of the internal carotid artery in Wegener’s granulomatosis: compari-
son of ultrasonography, angiography, and MRI. Scand J Rheumatol 2001;
75. Schmidt WA, Wernicke D, Kiefer E, Gromnica-Ihle E. Colour duplex so-
nography of finger arteries in vasculitis and in systemic sclerosis. Ann
Rheum Dis 2006; 65: 265-7.
76. Schmidt WA, Krause A, Schicke B, Wernicke D. Color Doppler ultraso-
nography of hand and finger arteries to differentiate primary from sec-
ondary forms of Raynaud’s phenomenon. J Rheumatol 2008; 35: 1591-8.
77. Niemelä RK, Takalo R, Pääkkö E, Suramo I, Päivänsalo M, Salo T, Haka-
la M. Ultrasonography of salivary glands in primary Sjogren’s syndrome:
a comparison with magnetic resonance imaging and magnetic resonance
sialography of parotid glands. Rheumatology (Oxford) 2004; 43: 875-9.
78. Steiner E, Graninger W, Hitzelhammer J, Lakits A, Petera P, Franz P,
Gritzmann N. Color-coded duplex sonography of the parotid gland in
Sjögren’s syndrome. Rofo 1994; 160: 294-8.
79. Hocevar A, Ambrozic A, Rozman B, Kveder T, Tomsic M. Ultrasono-
graphic changes of major salivary glands in primary Sjogren’s syndrome:
diagnostic value of a novel scoring system. Rheumatology (Oxford) 2005;
80. Makula E, Pokorny G, Kiss M, Vörös E, Kovács L, Kovács A, Csernay L,
Palkó A. The place of magnetic resonance and ultrasonographic exami-
nations of the parotid gland in the diagnosis and follow-up of primary
Sjögren’s syndrome. Rheumatology (Oxford) 2000; 39: 97-104.
81. Milic VD, Petrovic RR, Boricic IV, Marinkovic-Eric J, Radunovic GL, Jer-
emic PD, Pejnovic NN, Damjanov NS. Diagnostic value of salivary gland
ultrasonographic scoring system in primary Sjogren’s syndrome: a com-
parison with scintigraphy and biopsy. J Rheumatol 2009; 36: 1495-500.
82. Chikui T, Yonetsu K, Izumi M, Eguchi K, Nakamura T. Abnormal blood
flow to the submandibular glands of patients with Sjögren’s syndrome:
Doppler waveform analysis. J Rheumatol 2000; 27: 1222-8.
83. De Vita S, Lorenzon G, Rossi G, Sabella M, Fossaluzza V. Salivary gland
echography in primary and secondary Sjögren’s syndrome. Clin Exp
Rheumatol 1992; 10: 351-6.
84. Yonetsu K, Takagi Y, Sumi M, Nakamura T, Eguchi K. Sonography as a
replacement for sialography for the diagnosis of salivary glands affected
by Sjögren’s syndrome. Ann Rheum Dis 2002; 61: 276-7.
85. Milic VD, Petrovic RR, Boricic IV, Radunovic GL, Pejnovic NN, Soldato-
vic I, Damjanov NS. Major salivary gland sonography in Sjögren’s syn-
drome: diagnostic value of a novel ultrasonography score (0-12) for pa-
renchymal inhomogeneity. Scand J Rheumatol 2010; 39: 160-6.
86. Salaffi F, Carotti M, Iagnocco A, Luccioli F, Ramonda R, Sabatini E, De
Nicola M, Maggi M, Priori R, Valesini G, et al. Ultrasonography of sali-
vary glands in primary Sjögren’s syndrome: a comparison with contrast
sialography and scintigraphy. Rheumatology (Oxford) 2008; 47: 1244-9.
87. McCurley TL, Collins RD, Ball E, Collins RD. Nodal and extranodal lym-
phoproliferative disorders in Sjogren’s syndrome: a clinical and immu-
nopathologic study. Hum Pathol 1990; 21: 482-92.
88. Bialek EJ, Jakubowski W, Zajkowski P, Szopinski KT, Osmolski A. US of
the major salivary glands: anatomy and spatial relationships, patholog-
ic conditions, and pitfalls. Radiographics 2006; 26: 745-63.
89. Nair JR, Nijjar M, Chiphang A, Binymin KA. Ultrasound-guided closed
muscle biopsy: a useful tool for rheumatologists : case report: recurrent
focal myositis of the gastrocnemius muscle. Rheumatol Int 2011. doi:
90. Micu MC, Serra S, Fodor D, Crespo M, Naredo E. Inter-observer reliabil-
ity of ultrasound detection of tendon abnormalities at the wrist and an-
kle in patients with rheumatoid arthritis. Rheumatology (Oxford) 2011;
91. Dougados M, Jousse-Joulin S, Mistretta F, d’Agostino MA, Backhaus M,
Bentin J, Chalès G, Chary-Valckenaere I, Conaghan P, Etchepare F, et al.
Evaluation of several ultrasonography scoring systems for synovitis and
comparison to clinical examination: results from a prospective multi-
centre study of rheumatoid arthritis. Ann Rheum Dis 2010; 69: 828-33.
92. Filippucci E, Meenagh G, Delle Sedie A, Salaffi F, Riente L, Iagnocco A,
Scirè CA, Montecucco C, Bombardieri S, Valesini G, et al. Ultrasound
imaging for the rheumatologist: XX. sonographic assessment of hand
and wrist joint involvement in rheumatoid arthritis: comparison between
two- and three-dimensional ultrasonography. Clin Exp Rheumatol 2009;
93. Ju JH, Kang KY, Kim IJ, Yoon JU, Kim HY, Park SH. Three-dimensional
ultrasonographic application for analyzing synovial hypertrophy of the
knee in patients with osteoarthritis. J Ultrasound Med 2008; 27: 729-36.
94. Gao L, Parker KJ, Lerner RM, Levinson SF. Imaging of the elastic proper-
ties of tissue: a review. Ultrasound Med Biol 1996; 22: 959-77.
95. De Zordo T, Fink C, Feuchtner GM, Smekal V, Reindl M, Klauser AS.
Real-time sonoelastography findings in healthy Achilles tendons. AJR
Am J Roentgenol 2009; 193: W134-8.
96. De Zordo T, Lill SR, Fink C, Feuchtner GM, Jaschke W, Bellmann-Wei-
ler R, Klauser AS. Real-time sonoelastography of lateral epicondylitis:
comparison of findings between patients and healthy volunteers. AJR
Am J Roentgenol 2009; 193: 180-5.
97. Sconfienza LM, Silvestri E, Bartolini B, Garlaschi G, Cimmino MA. So-
noelastography may help in the differential diagnosis between rheuma-
toid nodules and tophi. Clin Exp Rheumatol 2010; 28: 144-5.
98. Iagnocco A, Kaloudi O, Perella C, Bandinelli F, Riccieri V, Vasile M, Porta
F, Valesini G, Matucci-Cerinic M. Ultrasound elastography assessment
of skin involvement in systemic sclerosis: lights and shadows. J Rheuma-
tol 2010; 37: 1688-91.
99. Klauser A, De Zordo T, Feuchtner G, Sögner P, Schirmer M, Gruber J,
Sepp N, Moriggl B. Feasibility of ultrasound-guided sacroiliac joint in-
jection considering sonoanatomic landmarks at two different levels in
cadavers and patients. Arthritis Rheum 2008; 59: 1618-24.