Musculoskeletal Ultrasound: 14 Clinical Uses Outlined

Janis C. Kelly

November 08, 2012

Musculoskeletal ultrasound (MSUS) is reasonable, if performed by a rheumatologist, for diagnosis of various joint, inflammatory, and neurological conditions but not as an outcome measurement for osteoarthritis, according to new recommendations from the American College of Rheumatology (ACR) MSUS Committee, published online October 30 and in the November print issue of Arthritis Care & Research by Timothy McAlindon, MD, MPH, Tufts Medical Center, Boston, Massachusetts, and colleagues.

Senior author John Fitzgerald, MD, PhD, told Medscape Medical News, "Point-of-care [MSUS] can be an important supplement to the physician's clinical examination of the patient. Ultrasound can image joints and tendons to provide more accurate or earlier diagnoses and more accurate procedures. MSUS is particularly useful for patients with inflammatory arthritis, gout, and tendon disorders. Ultrasound can be [a] useful adjunct for injections of difficult joints or periarticular regions."

Dr. Fitzgerald is associate clinical professor and director, Rheumatology Clinical Care, University of California, Los Angeles, Geffen School of Medicine.

The MSUS Committee presented recommendations for "reasonable" rather than "appropriate" use because the RAND analysis method used excludes cost consideration. The authors write, "Where risks of the procedure are minimal...and because costs are not considered, the analysis will inherently favor use of the procedure. Therefore, rather than use the term 'appropriate,' which we felt would be overstating the findings, we use the term 'reasonable' to mean that the evidence and/or consensus of the Talk Force Panel...supported the use of MSUS for the described scenario."

"Reasonable" includes use for:

  • articular pain, swelling, or mechanical symptoms without definitive diagnosis (glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, and midfoot and metatarsophalangeal joints);

  • inflammatory arthritis and new or ongoing symptoms (glenohumeral, acromioclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal, and entheseal joints);

  • shoulder pain or mechanical symptoms, but not adhesive capsulitis or as preparation for surgical intervention;

  • parotid and submandibular glands in suspected Sjögren's disease;

  • symptoms near a joint obscured by adipose tissue or soft tissue derangements (glenohumeral, acromioclavicular, elbow, wrist, hand, metacarpophalangeal, interphalangeal, hip, knee, ankle/foot, and metatarsophalangeal joints);

  • regional neuropathic pain to diagnose entrapment of the median nerve at the carpal tunnel, ulnar nerve at the cubital tunnel, and posterior tibial nerve at the tarsal tunnel; and

  • guiding articular and periarticular aspiration or injection at sites that include the synovial, tenosynovial, bursal, peritendinous, and perientheseal areas.

MSUS at the temporomandibular joint and costochondral joints was not considered reasonable because the interposition of bone often interferes with imaging in those areas.

The authors also emphasize that these recommendations apply to MSUS done as part of a thorough clinical evaluation in a rheumatology office. "It was not intended to include settings isolated from the rheumatologic assessment, such as might occur in a radiology department or operative setting, or other disciplines, such as podiatry or anesthesia," they write.

"Could Change Routine Clinical Practice"

The task force reviewed medical literature to come up with scenario-based recommendations for how MSUS could be used in rheumatology practice. These recommendations include a rating by type of evidence, with level A evidence supported by at least 2 randomized clinical trials or 1 or more meta-analyses of randomized trials; level B backed by a single randomized trial, nonrandomized studies, or meta-analyses of nonrandomized studies; and level C confirmed by consensus expert opinion, case studies, or standard clinical care.

Dr. Fitzgerald said, "The use of ultrasound is growing rapidly. Point-of-care ultrasound provides a nice supplement to the rheumatologist's clinical exam. The continued expansion of the use of [ultrasound] can provide significant value to patients through better diagnosis and more accurate procedures. Given the potential benefits highlighted in this manuscript and the few risks, I am hopeful that MSUS will continue to grow. The [ACR] has supported a program to expand training for potential ultrasound instructors at universities as well as the trainee fellows."

Dr. Fitzgerald said that the ACR is implementing a certification program for MSUS with a focus on care for rheumatology patients. In addition to quality-of-care issues, the hope is that certification will protect insurance reimbursement for rheumatologists who practice MSUS. The ACR program is expected to be available next year. The American Registry for Diagnostic Medical Sonography offers a certification exam more focused on the radiologist and radiology technician.

Paolo Gisondi, MD, professor of medicine at the University of Verona, Italy, reviewed the study for Medscape Medical News. Dr. Gisondi said, "The recommendations could significantly change the routine clinical practice of rheumatologists whenever widely applied. New generations of rheumatologists are more confident with the routine use of [ultrasound] than older generations.

Dr. Gisondi also said that the distinction between "reasonable" and "appropriate" use of MSUS is important. "In clinical practice it is very important to favor reasonable other than just appropriate procedures," he said.

Dr. McAlindon has received consultant fees, speaking fees, and/or honoraria from Flexion Therapeutics, URL Pharma, Novartis, and Bioiberica and holds a patent for a method for conducting clinical trials over the Internet. One coauthor has received consultant fees, speaking fees, and/or honoraria from SonoSite. One coauthor has received honoraria from being editor-in-chief of the Journal of Ultrasound in Medicine. One coauthor has received honoraria from serving on the advisory board for UCB and has received grant support from the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases, UCB, BMS, Celgene, and Roche. One coauthor has received consultant fees, speaking fees, and/or honoraria from Abbott. The other authors and Dr. Gisondi have disclosed no relevant financial relationships.

Arthritis Care Res. 2012;64:1625-1640. Abstract