Joint swelling better than joint tenderness for detecting RA synovitis

Janis Kelly

November 21, 2005

November 21, 2005

San Diego, CA- A study comparing the reliability of physical exam with magnetic resonance imaging (MRI) for detecting synovitis in rheumatoid arthritis (RA) or psoriatic arthritis (PsA) found that visual inspection may be better than the usual two-finger palpation in RA and that better exam methods are needed for PsA synovitis, according to Dr Millicent A Stone (University of Toronto, ON).

In data presented at the 2005 ACR/ARHP Annual Scientific Meeting, Stone said, "Joint tenderness is not as reliable or accurate as joint swelling in the assessment of synovitis. Visual inspection alone may be the simplest and most reliable technique for assessing synovitis in RA."

Clinical exam more accurate in RA than in PsA

Visual inspection alone may be the simplest and most reliable technique for assessing synovitis in RA.

"Rheumatologists base many of their clinical decisions regarding the management of inflammatory joint diseases such as rheumatoid arthritis and psoriatic arthritis on joint counts, but how accurate or reliable are clinical-exam skills? Joint swelling has been shown to be a prognostic marker for radiographic progression in RA, but tender-joint counts correlate less well with radiographic progression in RA. Early detection of synovitis and aggressive treatment has been shown to prevent long-term disability. The ability to detect synovitis by clinical examination may also differ with different forms of arthritis, such as PsA, where the joint swelling may be predominantly extrasynovial," Stone said.

The objective of this study was to determine the reliability of physical examination of the metacarpophalangeal joints (MCPJs) for detecting inflammatory synovitis compared with MRI. Five independent examiners assessed the second to fifth MCPJs in both hands of five patients with RA and five with PsA. Each patient was examined for joint-line swelling using the two-finger and four-finger techniques and by visual estimation for swelling. Patients were also assessed for tenderness by stress pain and joint-line tenderness.

The researchers reported that for RA, there was a strong positive relationship between two-finger assessments and MRI synovitis and erosion scores, and an even stronger relationship was present between four-finger assessments and synovitis and erosion scores. For PsA patients, there was no correlation between joint examination and MRI measurements. Visual estimation of swelling correlated well with MRI synovitis in RA but not with PsA. Tender-joint count was not significantly associated with MRI in either RA or PsA.

"Joint swelling, but not joint tenderness or stress pain, correlated significantly with synovitis and joint erosion. The four-finger palpation technique for evaluation of MCPJ swelling was superior to the standard two-finger technique for both disorders," Stone reports. "Palpation and visual inspection of MCPJs of RA patients is extremely reliable at determining synovitis. Palpation and visual inspection of MCPJs of PsA patients was unreliable. Assessment of joint swelling using the four-finger technique may further improve the sensitivity of detection."

This study was supported by Centocor.



  1. Stone MA, White L, Gladman D, et al. Reliability of physical examination in inflammatory arthritis: ROPE study. 2005 ACR/ARHP Annual Scientific Meeting; November 12-17. 2005; San Diego, CA. Abstract 224.



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