Ultrasound in rheumatology: A practical guide

Katherine Smith1, Richard Wakefield2, Richard Craig1, 1Leeds Biomedical Research Centre, Leeds Teaching Hospitals, 2Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds


Rheumatoid arthritis (RA) is a common, chronic disabling inflammatory arthritis. The accurate early identification of inflammation, for both diagnosis and disease monitoring is imperative in order to reduce structural damage and to maintain joint function1. Traditional methods of evaluating joints such as clinical examination and X-ray are limited with respect to sensitivity and specificity2. Consequently, ultrasound is increasingly being employed by clinicians to asses and to quantify joint inflammation (synovitis, tenosynovitis) and damage (bone erosion) in RA3.

This poster introduces the current EULAR ultrasound definitions and semiquantative scoring systems employed at Leeds Biomedical Research Centre including images and scanning planes utilised, with a view to educating other health professionals and the standardisation of procedures. 

Ultrasound Signs

Synovial hypertrophy

Hands, wrists, and feet are commonly assessed for signs of abnormal intra-articular tissue to make/exclude the diagnosis of synovial hypertrophy (SH) with or without power Doppler (PD)4. A recommended approach for scoring SH is a semiquantative (SQ) grading of severity on a scale from 0 to 3, for both grayscale (GS) and PD imaging3.


Tenosynovitis is one of the key features of the clinical pattern in patients with rheumatoid arthritis (RA), with the Extensor Carpi Ulnaris (ECU) and flexor tendons being commonly involved5. Established tenosynovitis may end in tendon damage resulting in tendon rupture with consequent disability6. A SQ grading of severity on a scale from 0 to 3 allows for monitoring7.


Bone erosions are commonly found in RA and are considered one of the characteristic findings, and they appear in distinctive sites. They signify the destructive outcome of untreated synovitis 8.  A SQ grading of severity on a scale from 0 to 3 allows monitoring1.


The learning outcome of this poster will be to define and quantify inflammatory and structural pathology seen in RA to facilitate the early diagnosis and accurate monitoring of disease. It will also highlight high risk areas in joints for ultrasound evaluation.


1.    Zayat AS, Ellegaard K, Conaghan PG et al, The specificity of ultrasound-detected bone erosions for rheumatoid arthritis, Ann Rheum Dis 2015; 74:897-903 

2.    Colebatch AN, Edwards CJ, Østergaard M, et al, EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis, Ann Rheum Dis 2013;72:804–814. doi:10.1136/annrheumdis-2012-203158

3.    D’Agostino M-A , Terslev L, Aegerter p, et al, Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce—Part 1: definition and development of a standardised, consensus-based scoring system, RMD Open 2017; 3:e000428. Doi: 10.1136/rndopen-2016-000428

4.    Wakefield RJ,   Balint PV,  Szkudlarek  M, et al, Musculoskeletal Ultrasound Including Definitions for Ultrasonographic Pathology, The Journal of Rheumatology 2005; 32:12

5.    Terslev L, How to image tendon involvement in RA. Do we need and early diagnosis?, http://ard.bmj.com/content/72/suppl_3/A19.1  accessed July 2017

6.    Bruyn GAW, Hanova P, Iagnocco A, et al, Ultrasound definition of tendon damage in patients with rheumatoid arthritis. Results of a OMERACT consensus-based ultrasound score focussing on the diagnostic reliability, Ann Rheum Dis 2014;73:1929-1934

7.    Naredo E, D’Agostino M-A, Wakefield RJ, et al, Reliability of a consensus-based ultrasound score for tenosynovitis in rheumatoid arthritis, Ann Rheum Dis 2013;72:1328-1334

8.    Van der Heijde D, Van der Helm-van Mil AHM, Aletaha D, et al, EULAR definition of erosive disease in light of the 2010 ACR/EULAR rheumatoid arthritis classification criteria, Ann Rheum Dis 2013; 72:479-481

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