10 Reasons We Might Want a Musculoskeletal Ultrasound (MSUS) of a Joint
Back in 2009, dozens of phone calls revealed no one in our area who could perform a musculoskeletal ultrasound (MSUS). Today, worried about my son, I made calls again to orthopedists and hospitals. When I called the top medical centers in our region, I found one ultrasound technologist who had heard of MSUS and she knew of no one who performs it yet. She agreed that there’s a great need for it, but some others I talked to asked, “Why would you want an ultrasound of a joint?” So I thought I’d write a post to answer that question.
Thousands of comments on this blog lament the inability of physicians to see and know with certainty the disease activity of their patients. This problem is particularly weighty when we read of how critical early diagnosis and treatment are for this disease to be “controlled.” Musculoskeletal ultrasound (MSUS) is one way to see what’s going on inside joints, one obvious focus of rheumatoid disease activity.
Two Boston doctors wrote a great overview of (MSUS) for the Journal of Musculoskeletal Medicine. They review numerous studies of MSUS, including one which shows that clinical evaluations and disease management plans were each altered 53% of the time after a MSUS in rheumatology patients. A clear reason: “MSUS is more sensitive than other modalities in assessing disease activity; as previously described, positive power Doppler signal in synovial sites has corresponded with histological evidence of vascularity, a marker for inflammation.”
Specific advantages of musculoskeletal ultrasound (MSUS) in rheumatology
- MSUS is much more sensitive to examine synovial tissue than clinical examinations.
- MSUS allows dynamic assessment. That means you can change the position of the joint or even evaluate it during movement which may make abnormality more obvious. Motion can be both active and passive, allowing examiners to learn more.
- MSUS is better for evaluating certain joints. “Because it is multiplanar, US is 3 or 4 times more sensitive than plain radiography for detecting erosions in the metacarpophalangeal (MCP) joints and metatarsophalangeal joints of patients with rheumatoid arthritis (RA), especially the second and fifth MCP joints, which are more accessible to US.”
- MSUS is done without radiation.
- Patients can guide the examiner by describing pain.
- Numerous joints can be examined; you don’t usually get MRI’s of multiple joints.
- No waiting is needed if there is MSUS equipment in the office.
- Other advantages to MSUS over MRI include comfort…
- convenience…
- and cost.
However, the great disadvantage of MSUS is its extreme user-dependency. I’ve read that in articles and been told that by several doctors I’ve interviewed. Sadly, we also learned about this first hand. If that disadvantage can be overcome by training, MSUS will be of great value to patients who need to obtain early and accurate diagnosis and treatments.
Recommended reading
- Three-part blog post series on musculoskeletal ultrasound.
- A Paradigm Shift in Rheumatoid Arthritis Disease Activity? Part 2
- Does It Matter Whether Rheumatoid Arthritis Affects DIP Joints?
- Rheumatoid Arthritis Swelling, Take Two
- Click here to see the SonoSite ultrasound video on the sexy post
Last year my rheumatologist did US training and got an US for her office. Just after she got it she asked if she could “practice” on me. As she examined my joints she explained what she was doing and what was showing on the ultrasound machine screen. She was able to view joints that were inflammed that may not have been detected without its use.
If use of the MSUS will result in earlier detection and/or a more appropriate treatment plan then there should be no hesitation about using them. As always, thank you Kelly for a well written and informative article. 🙂
Nice to see u Kathy ♥
Yes, MUCH training is needed as I’ve heard over and over. But it has to start somewhere. It needs to be used with humility as your dr did – by “practice” for a while. Inflammation can usually be described by the patient.
Here is a recommendation of training levels from my friend in Columbia (a rheumatologist himself). http://www.ncbi.nlm.nih.gov/m/pubmed/20375820/
Sounds like a “family vacation” to the med school at the University of Alabama – Birmingham is in order! Or the U of FL Gainsville? Best of luck. I hope you can find someone knowledgeable and professional close by.
thanks, Lisa. Talked about this on the phone w/my great ped today. We’re thinking likewise. If her calls to Shands find something, we’ll go there. If not maybe UAB. Need to get to the bottom of it. So sorry to notice it’s not moved any further in the past 3 yrs since I made all those calls last time.
My doctor must be super far ahead – I’ve been undergoing MSUS almost since the beginning of my diagnosis last March. He uses it almost every time I visit him to check the sinovial fluid in my hands and feet – it’s actually really cool because you can see why certain joints hurt more than others. Last month, it was used to help guide him in injecting cortisone into one of the joints on my hand that hasn’t responded to treatment. It is actually because of the US that I was able to be put on Enbrel w/o methotrexate (I am currently trying to get pregnant). He found a bone erosion thast suggested my RA was advancing faster than we had thought and needed to move on up to biologics – however, insurance companies want you to go with mtx first. I love MSUS. Anyone in RI or closeby MA – University Rheumatology at RI Hospital.
Thanks for the report, Heather! MSUS in skilled hands is a wonderful tool – yes!
and good luck w/the pregnancy!
I think my Rheumatologist uses the ultrasound equipment. She is with MIMA in Melbourne, Florida.
I just had ultrasound examination and cortisone shots into my hips and shoulders under ultrasound. The operator and radiologist could clearly see effusions, and synovitis where my x-rays are clean. I also had a shoulder MRI which showed some mild bursitis. The ultrasound was amazing – I now have ‘evidence’ that my rheumy can use to get me approvied for biologic thereapy. I hope more medical professionals realise the value in ultrasound! I’m in Australia.
My rheumatologist and his 2 partners also have ultrasound in their office. I am sure it takes advanced training and skill, as does any new piece of technology, to become proficient with it. Its another tool to be used to solve the puzzles. They also use it, to guide injections at times.
I guess I should have mentioned that use for guided injections does not require the same training as regular use as described in the link above as adopted by South American rheumatologists. Hopefully one use will lead to training for the other, which was not the case w/the Dr. DIP story linked to in the post.
My last Rheumy did this as part of my regar exams about once a year, sadly that I the only good thing he did for me and I no longer in practice, but it was neat to see what was going on in my joints and the tendons. He would do both wrists and hands every time and explained and showed everything to me.
Hi Kelly,
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This is a great post, very informational.
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MSUS is ready to revolutionize the way we treat patients (people). It turns out that the number of rheums that are using US is rapidly increasing. See an article co-authored by one of my mentors (Dr. Nazarian) in the current, Feb 2012, Journal of the American College of Radiology.
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You are right, MSUS is user dependent….
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The amount of training and experience required depends on what the your doctor is trying to evaluate. If one is just looking for a joint effusion or synovitis, that is really not that hard. However, if your doc is trying to diagnose supraspinatus tendinosis in the shoulder or a ligament tear in the ankle, that is more difficult.
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Not only can numerous joints be examined in one sitting, the doctor can further use this fact to his or her advantage by scanning one of the more “normal” or asymptomatic joints to use as a comparison.
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Another advantage of US is the image guidance for doing procedures. I have done many joint procedures, biopsies, and aspirations under fluoroscopy and ultrasound. US has the advantage of portability, lack of radiation, and great visibility of a wide range of pathology.
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In reference to advantage number 4, MRI does not use radiation.
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Bottom line, MSUS is a great addition to the armamentarium of physicians when it is done well and appropriately. I envision that in the near future the clinicians will be using it much more than the radiologists for point of care, efficient, timely, and optimal patient care.
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Sincerely,
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Dr. Brian Sabb
http://www.linkedin.com/in/briansabb
Thank you. I was simplifying to an extremely short list after having read numerous articles over the last several months on the topic. Post was mostly written from memory but the articles linked to were re-read at writing. Perhaps the radiation mentioned in some places refers to the use of CT listed with MRI or to the contrast when used. I should have added CT to that item. From one of the articles referenced in the post:
“The use of US in the diagnosis and management of musculoskeletal diseases has many practical advantages (see Table). US is less expensive than other imaging techniques, such as CT and MRI. It does not expose patients to ionizing radiation and does not require contrast for imaging of inflammation, thus avoiding potential problems with contrast-induced allergic reactions; contrast-induced nephropathy; and in the case of gadolinium (pertaining to patients with renal insufficiency), nephrogenic systemic fibrosis. MRI also has the drawbacks of usually requiring at least 30 minutes in an enclosed space, which may not be possible for claustrophobic or obese patients..”
While I’m aware some are being trained, the practice is far from mainstream. We called all of the big radiological and orthopedic practices in the area and talked with some nice folks who wish they did have MSUS capability. Unfortunately use of MSUS in every rheum practice I’ve contacted is limited to guiding injections, but of course without further training, that is probably a good thing. The point would be to add information to the clinical exam & patient report of course, and lack of training has an opposite effect.
Reason #4 – Do you believe that an MRI uses radiation?
If this is truly about concern for your son, as a parent I would question why you would put so much energy into tracking down diagnostic testing that is not readily available. My understanding is that he has not been evaluated by a specialist yet. He might not need any further testing to begin treatment.
This study says that for juvenile arthritis, physical exam and ultrasound were in agreement in 75% of cases.
http://www.ncbi.nlm.nih.gov/pubmed/21921099
I’d take those odds! If, after seeing a ped rheum, you feel like you are in the 25% that would benefit from an ultrasound, then go searching for one.
Its funny this post came up. I recommend every person I train with MS or JRA or RA or ANY joint pain to one of my friends who happens to be a Chiropractor and does Ultrasound Therapy. I know this is different than the article talks about but I’m bringing up Therapy because its never talked about in the same way as the article does about that type of Ultrasound. Yes Therapy, not just the ultrasound looking for damage (or whater else). Over the past 7 years we have worked together to reduce pain in our clients. NOTHING works better – NO DRUG – NOTHING!! Its unbeleiveable that what we do hasn’t been discovered. I’ve even had a client (4 brain sugeries) come in with her Physical Therapist to see what I was doing to help her progress. I told the Therapist I use Ultrasound to reduce the inflammation in the joint/muscle/tendon/ligament even bone fractures. The Therapist said its been proven that ultrasound does not work with her type of injuries. Really? I said. Well would it offend you if I asked her doctor (a Neurosurgeon)? No! She replied, very stern. LOL. Just so happened I also trained her Neurosurgeon, Dr. Juan Ronderiz of Mobile, AL. After I explained to Doc how it works he said it can’t hurt to try. We did and for the first time in years since her last sugery she was able to move her neck side to side. Theres a pic of her on my web site with me stretching her neck. She eventually walked again too (in a wheelchair in pic). Bottom line – YOU CANNOT PROVE ME WRONG…… Ultrasound, when done properly with someone who knows how to use it will releive ANY pain. Not cure it. Not make it go away 100%. Sometimes it only gives releif. But always gives some level of healing. There are many types of Ultrasound. You have to find which Ultrasound Therapy is right for you. But doctors are not trained in this and protocol for rehab is off. http://www.mikejanhorn.com contact me if you can’t find help on this. Mike Horn Alabama’s first IFBB Pro.
In the UK, the leading teaching hospitals now use ultrasound to identify early inflammatory arthritis but it isn’t widespread practice yet. My GP didn’t know it could be done but if it wasn’t for ultrasound I would never have been diagnosed. Let’s hope we see more of it.
Ultrasound certainly sounds like an excellent way to examine soft tissue – the xrays that are done always confuse me a bit since I know that unless this is chewing at my bones (what we are trying to avoid) there will be little to be seen there. I’m not sure that ultrasound is commonly used in clinical practice though. I receive my rheumatology treatment at the Cleveland Clinic – I don’t think anyone would claim they aren’t good, but while I have had numerous xrays, I haven’t had a single ultrasound. My Dr did suggest we might want to do an MRI of my shoulder since I continue to have significant problems with it. It does seem that the ultrasound would be less expensive if nothing else.
Wow – Dallas must still be in the “Dark Ages”. my Rheumy has never used and when I went to UT Southwestern Med Center for second opinion on my condition- they just did a slew of X rays and cut my meds. I became so bad I went back to first Rheumy.
I’ve had my joints ultrasounded two of the three times I’ve been to my rhumatologist (I was only diagnosed recently). The first time he used it to determine that there was indeed inflammation, and the second time it gave us the wonderful insight that there was no inflammation in my painful joint… it just hurt for no reason (maybe scar tissue? I don’t know).
Good morning Kelly, and other RA Warriors. I have to say that I wish I was in a city that had more than just the one RA doctor, in a city of over 75,000 ppl. One that had the Musculoskeletal Ultrasound. The doctor that i have informed me on the 6th of this month, that 2 yrs ago, blood worked showed that I had RA. Last year my bloodwork, (which at theis bloodwork, I wasnt in a flare and had no pain)..in April said that I didnt have any RA or any types of Arthritis, and an x-ray showed that i had no physical deformities, and yet here I am with twisted fingers and super large knuckles that I have had for many years, pain sometimes that i can barely move in the morning or during the day when im at work. The twisting in my fingers have gotten noticably worse as well. My RA doctor, is an RA that refuses to prescribe pain medication to RA patients, because the Soo is riddled with drug addicts. Like this is any RA’s fault that the general public has a pain popping problem. I gave her a list of all the issues and pain that I have had since seeing her last April, because I had had a hard time getting an appointment to see her, until this month. I also informed her that i was getting tons of back pain, and hip pain as well, and was having severe problems with walking up my basements stairs, as my legs were in pain and my breathing would become labored and my chest would hurt because of it. She told me that RA had nothing to do with back pain amongst other issues i was supposedly experiencing. Instead of believing me and suggesting other meds to help with my discomfort, she tried to put me on past meds that had had bad side effects resulting in me not taking them any longer. She then suggested anti-inflamatory drugs suggesting that would help, and when i told her that does not help with my pain…she literally shrugged her shoulders at me as if she did not care one way or the other. I was totally shocked! She had actually shrugged her shoulders at me! Im at a point right now, wondering if im really mentally unstable and making up all my pain and issues that ive had for the past year. She told me to get another blood work done if i wished when I believe I have a flare up and pain. issue with this, is that my husband has our vehicle in another country for school, leaving me without a vehicle until late into the evening when he comes home. At this time of night the medical labs have closed several hours past. Im not really sure whereim to go forth from here on. Obviously my RA doc is only treating me for general Arthritis, and not RA. Yet she is the only RA doctor here in Sault Ste. Marie, Ont.
Rosy, You are obviously not making it up because what you describe is so similar to countless others. Unfortunately many of them also are thought to be making it up.
Of course it is terrible that there is only one dr for that many people and this problem is the same in many places. And maybe that is why she thinks she can shrug and not help you instead of working hard alongside you to try every single option. Blood work, of course does not show a flare or pain – the only reliable way to measure that is to ask the patient, so yes this situation is awful. Have you thought of traveling to find a dr? Or maybe you can find an immunologist who can treat you? I’m sorry.
I guess in Austin, like Dallas, we are still in the stone ages for RA. I just had an MRI on my knee, which despite the management of most of my other pain refuses to stop hurting. It causes so much pain it wakes me at night. My Rhuemy, who I usually love, said, “well the bone is chewed up and there is a ganglian(sp?) cyst, but that shouldn’t be causing any pain.” “We’ll just do the artificial cartilage injections again.” Soooo frustrating. I’m beginning to feel like a whiner since my joints don’t get hot or externally swollen, they just HURT, I get the, ‘poor crazy lady’ face and the offer of more pills.