• 30-year-old female
  • Pain in wrists for 6-12 months
  • EMS – 10 mins; pain > stiffness
  • Depending on paracetamol; not wanting to use non-steroidal anti-inflammatory (NSAID)
  • Regular gym user; symptoms worse after use
    • O/E:
    • Hypermobile; score 5/9
    • Puffiness bilateral ulnocarpal joint; non-tender
  • C-reactive protein (CRP) < 5, ESR 10mm/hour
  • Cyclic citrullinated (CCP) Antibody – 3.6 U/ml (N < 2.99)
  • X-rays of hands and feet – normal
Ultrasound Findings

Scenario 1: Minimal grey scale in on wrist
Non-significant inflammation, possibly element of overuse in benign hypermobility. Suggested management: conservative (splint +/- IA injection), exercise advice)

Scenario 2: Grade 2 grey scale and grade 2 power Doppler (PD) in both ulnar carpal joints + mild erosive change of the ulna styloids bilaterally?
Evolving inflammatory arthritis – ­ risk of persistent erosive arthritis – grade 2 PD and erosions; suggested management: conventional sDMARD (csDMARD) +/- IA injection

How did ultrasound add value?

Changed diagnosis and management

  • Rheumatoid Arthritis (RA) of six-months duration
  • Rheumatoid factor (RF) positive
  • Anti-citrullinated protein/peptide antibodies (ACPA/anti-CCP) positive
  • Disease Activity Score 28 (DAS28) using erythrocyte sedimentation rate DAS28-ESR: 5.6
  • Methotrexate 25 mg/week (escalated from 15 mg/week at three months)
  • Clinical assessment at six months:
    • tender 28-joint count (TJC28): 1 (right wrist)
    • swollen 28-joint count (SJC28): 0
    • Global Visual Analogue Scale (VAS) score: 15
    • Erythrocyte sedimentation rate (ESR): 30 mm/hour
    • DAS28-ESR: 3.25
  • EULAR response: good
  • No structural damage
Ultrasound Findings
  • B-mode synovitis grade 2, power Doppler grade 1 in left elbow
  • B-mode synovitis grade 2, power Doppler grade 3 in right wrist
  • B-mode synovitis grade 1, power Doppler grade 3 in right metacarpophalangeal joint (MCP) 2
  • Erosion at right ulnar styloid, right MCP 2 and left metatarsophalangeal (MTP) 5
Summary and suggested management

Evidence of aggressive, sub-clinical disease, predictive of flare and radiological damage; suggested management: initiate biologic therapy.

Clinical assessment findings at nine months 
  • Tender 28-joint count (TJC28): 0
  • Swollen 28-joint count (SJC28): 0
  • Global Visual Analogue Scale (VAS): score 0
  • Erythrocyte sedimentation rate (ESR): 10 mm/hour
  • DAS28-ES: 1.6

Clinical remission

Ultrasound assessment findings at nine months
  • B-mode synovitis grade 1
  • power Doppler 0 in left elbow
  • B-mode synovitis grade 1
  • power Doppler 0 in right metacarpophalangeal (MCP) joint 2

Clinically unimportant synovitis in patient (i.e.) clinical remission on biologic

How did ultrasound add value?

Ultrasound was reassuring but not essential as biologics provide protection against radiological damage. This is when an ultrasound examination is of questionable value as a patient is clinically very well, and under biological “protection”.

  • 55-year-old male
  • Diagnosed seropositive rheumatoid arthritis 12 months ago
  • Treated with methotrexate, 25mg/week
  • Still active disease; Disease Activity Score 28 (DAS28) 6.0
  • Biologic added
  • Excellent response DAS28 = 2.1 (remission) after 6 months
  • No swollen or tender joints but persistent pain when walking
  • No morning stiffness
  • Positive squeeze test of metatarsophalangeal (MTP) joints, bilaterally
  • Tender metacarpophalangeal (MCP), proximal IP (PIP) and MTP joints
  • C-reactive protein (CRP) 4 mg/l ESR <20 mm/h
  • Referred for ultrasound of feet
Ultrasound findings

No MTP synovitis but several intermetatarsal bursae


History equivocal for continued, active disease

Ongoing management

Can taper biologic
Local injections under ultrasound guidance

How did ultrasound add value?

Changed diagnosis and management; used in management (ultrasound – guided injection)