Imaging In Soft Tissue Rheumatis

by Dr. Parvez Sheik MD ( Rad) , DMRE

Introduction

The term "soft tissue rheumatism" is used to describe a group of conditions that cause pain, swelling, or inflammation in the soft tissue around the joints – tendons, muscles, bursas, and ligaments. Ultrasound imaging is non-invasive and does not involve ionizing radiation , high frequency ultrasound probes ( 5Mhz to 11Mhz) can provide useful information of soft tissues around the joints to diagnose and treat Rhematological conditions.

Synonyms: Rheumatology , Inflammatory joint diseases.

Keywords : Rheumatology , Rheumatoid nodule,      Arthritis , Gout trophi, bursitis, tenosynovitis, calcific tendonitis.

SOFT TISSUE ULTRASOUND IMAGING FEATURES

Inflammatory overgrowth of synovium (Pannus) around joints is the hallmark of Rheumatoid arthritis. These soft tissue changes can be seen around MCP joints , PIP joints and styloid process of ulna. Ultrasound can show synovial hyperaemia , synovial hypertrophy with destruction of articular cartilage and in later stages erosions and joint space narrowed. Important role of soft tissue imaging in RA of the hands and wrists is to exclude septic arthritis. Percutaneous ultrasonography-guided aspiration may be useful for localizing and obtaining samples of any collection that can be found.

Rheumatoid nodules around the PIP joints can be seen as hyperechoic or hypoechoic nodules on ultrasound .


Gouty trophi seen in gout involves deposition of sodium urate crystals in and around the small joints causing inflammation and swelling of soft tissues. The first MTP joint in foot is most commonly involved. Ultrasound findings include tiny hyperechoic foci of
( 1mm to 3mm ) of soft tissue trophi and central acoustic shadow representing centrally located crystal. Ultrasound guided aspiration of the joint fluid is useful in confirming the presence of urate crystals.

Bursitis on Ultrasound may reveal a small anechoic fluid collection in the intermuscular plane near the shoulder or knee joints commonly . Small floating echogenic debris in these conditions indicates long standing disease. Ultrasound guided aspiration can also be carried out.

Baker"s cyst ( Popliteal cyst) is a fluid-filled distended synovial lined bursa arising between the gastrocnemius and semimembranosus tendons via a communication with the knee joint . They are usually located at or below the joint line. Ultrasound findings include an anechoic fluid collection with thick septations and floating echogenic debris .The cyst has a neck at its deepest extent as the cyst arises from the joint . No increased vascularity in the septae noted. The main differential diagnosis for Bakers cyst is Deep vein thrombosis and ultrasound with color flow doppler is useful in diagnosing Baker"s cyst and exclude Deep vein thrombosis in cases of sudden onset of pain in calf.

Tenosynovitis on ultrasound can reveal anechoic peritendinous fluid collection or fluid streaks with thickened synovium. The tendons may appear hyperechoic and thickened on ultrasound . Tendon tears may be seen which appear as small linear anechoic slits in tendon in early cases and complete disruption in severe cases. Tenosynovitis can occur in Rheumatoid arthritis an Psoriatic arthritis.

Calcific tendonitis occurs in the periarticular regions commonly around the shoulder joints involving the supraspinatus tendon. Ultrasound findings include coarse echogenic calcific foci in the tendon.

Tendon ruptures may be seen in Rheumatoid arthritis. Ultrasound shows linear hypoechoic lesions in partial tendon tears, the affected tendon may also be buly and heteroechoic in appearance.


Suggested reading
1. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Lippincott Williams & Wilkins. (2007) ISBN:0781761352
2. Sommer OJ, Kladosek A, Weiler V et-al. Rheumatoid arthritis: a practical guide to state-of-the-art imaging, image interpretation, and clinical implications.
3. Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby Inc. (2003) ISBN:0323023282

4. Dixey J, Solymossy C, Young A et-al. Is it possible to predict radiological damage in early rheumatoid arthritis (RA)? A report on the occurrence, progression, and prognostic factors of radiological erosions over the first 3 years in 866 patients from the Early RA Study (ERAS). J Rheumatol Suppl. 2004;69 : 48-54

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  208. Today, I went to the beach with my kids. I found a sea shell and gave it to my 4 year old daughter and said “You can hear the ocean if you put this to your ear.” She put the shell to her ear and screamed. There was a hermit crab inside and it pinched her ear. She never wants to go back! LoL I know this is completely off topic but I had to tell someone!

  209. Hey there! Quick question that’s entirely off topic. Do you know how to make your site mobile friendly? My web site looks weird when viewing from my iphone 4. I’m trying to find a theme or plugin that might be able to correct this problem. If you have any suggestions, please share. Appreciate it!

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  212. With havin so much written content do you ever run into any problems of plagorism or copyright violation? My site has a lot of exclusive content I’ve either authored myself or outsourced but it looks like a lot of it is popping it up all over the web without my agreement. Do you know any solutions to help protect against content from being ripped off? I’d definitely appreciate it.

  213. With havin so much written content do you ever run into any problems of plagorism or copyright violation? My site has a lot of exclusive content I’ve either authored myself or outsourced but it appears a lot of it is popping it up all over the web without my agreement. Do you know any solutions to help reduce content from being ripped off? I’d truly appreciate it.

  214. Hey there! I know this is kinda off topic however , I’d figured I’d ask. Would you be interested in exchanging links or maybe guest writing a blog article or vice-versa? My site addresses a lot of the same subjects as yours and I believe we could greatly benefit from each other. If you might be interested feel free to send me an e-mail. I look forward to hearing from you! Fantastic blog by the way!

  215. My programmer is trying to persuade me to move to .net from PHP. I have always disliked the idea because of the expenses. But he’s tryiong none the less. I’ve been using Movable-type on several websites for about a year and am nervous about switching to another platform. I have heard fantastic things about blogengine.net. Is there a way I can transfer all my wordpress content into it? Any kind of help would be really appreciated!

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  219. When I originally commented I clicked the “Notify me when new comments are added” checkbox and now each time a comment is added I get three emails with the same comment. Is there any way you can remove me from that service? Thanks!

  220. Excellent website you have here but I was wanting to know if you knew of any user discussion forums that cover the same topics talked about in this article? I’d really love to be a part of online community where I can get responses from other knowledgeable individuals that share the same interest. If you have any recommendations, please let me know. Bless you!

  221. I don’t know if it’s just me or if everyone else experiencing problems with your blog. It appears as if some of the text on your posts are running off the screen. Can someone else please comment and let me know if this is happening to them too? This could be a problem with my browser because I’ve had this happen before. Thanks

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  224. Today, I went to the beach with my kids. I found a sea shell and gave it to my 4 year old daughter and said “You can hear the ocean if you put this to your ear.” She put the shell to her ear and screamed. There was a hermit crab inside and it pinched her ear. She never wants to go back! LoL I know this is completely off topic but I had to tell someone!

  225. Hiya! I know this is kinda off topic however I’d figured I’d ask. Would you be interested in exchanging links or maybe guest writing a blog article or vice-versa? My website goes over a lot of the same subjects as yours and I feel we could greatly benefit from each other. If you happen to be interested feel free to send me an e-mail. I look forward to hearing from you! Superb blog by the way!

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  227. Hey I know this is off topic but I was wondering if you knew of any widgets I could add to my blog that automatically tweet my newest twitter updates. I’ve been looking for a plug-in like this for quite some time and was hoping maybe you would have some experience with something like this. Please let me know if you run into anything. I truly enjoy reading your blog and I look forward to your new updates.

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