The power of us: breaking barriers and bridging the gap of ultrasound in rheumatology to empower a new generation.

OBJECTIVE: This study assesses musculoskeletal ultrasound (MSUS) knowledge, attitudes, and practices among young rheumatologists in Mexico, aiming to identify barriers and facilitators to its clinical use. METHODS: An online survey distributed to a network of young rheumatologists captured demographics, institutional, and personal MSUS information. Multivariable analysis identified factors associated with positive MSUS attitudes. RESULTS: Ninety-six rheumatologists (39.18% national response rate) completed the survey. Of respondents (54.2% females, median age 35.1 years), 81.2% deemed MSUS necessary in clinical rheumatology. The main barriers included limited training access (56.2%) and required training time (54.1%). Lack of scientific evidence was not a major barrier (60.4%). Positive MSUS attitudes were associated with learning from conferences (p = 0.029) and colleagues (p = 0.005), formal (p = 0.043), and in-person training (p = 0.020), MSUS use in practice (p = 0.027), and use by radiologists in their institute (p < 0.001). Interest in learning MSUS (88.5%) was significantly higher in those with positive attitudes (94.4%, p < 0.001). Elastic net analysis identified key drivers, including learning MSUS from conferences, colleagues, and in residency; using MSUS in practice; respondent-performed MSUS; and MSUS use by radiologists. Statistically significant associations were found with using MSUS for synovitis/inflammatory joint disease (OR = 1.43, 95% CI 1.00-2.05) and MSUS use by radiologists in respondent's institutes (OR = 1.70, 95% CI 1.20-2.90). CONCLUSION: Most young rheumatologists in Mexico recognize the necessity of MSUS in clinical practice. By addressing identified barriers, encouraging rheumatologist-radiologist collaboration, and establishing a regulatory body to certify rheumatologist's MSUS experience, there is an opportunity to empower them with the necessary skills for effective MSUS use, ultimately benefiting patient care.

Intermittent flexor hallucis longus dislocation: ultrasound findings.

We report a case of intermittent dislocation of the flexor hallucis longus at its passage in the retro-malleolar area, related to a post-traumatic detachment of the retrotalar pulley from the medial tubercle of the talus. High-resolution ultrasound depicted the anterior dislocation of the tendon during dynamic stress, by asking the patient to flex his hallux against the examiner resistance, with the ankle in slight dorsiflexion. The tendon normally relocated after the dynamic maneuver. Tendon dislocation was associated with a painful snap.

Review of ultrasound-guided labeling: exploring its potential in teaching cadaveric ligaments during anatomical dissection courses.

Objectives: This scoping review aimed to give an overview of the existing literature about ultrasound-guided labeling techniques of human cadaver ligaments and tried to work out the possibilities of integrating ultrasound into dissection courses. Methods: A literature review was carried out on the 3rd of January 2023, with relevant studies discovered in the following databases: MEDLINE, EMBASE, CENTRAL, BIOSIS Previews and Web of Science Core Collection. Grey literature was also considered. The reference lists of all relevant papers were scanned. Only ultrasound studies on human cadaver ligaments were included. The included studies' general characteristics and ultrasound-guided approaches to label the ligaments were taken from them and examined. Results: The search found 8899 matches, but only 96 of them met the criteria. The transverse carpal ligament (15.62%) and the annular pulleys (19.79%) were the ligaments that had received the greatest research attention. Twenty-three studies are included in the methodological analysis. Both the marking substrate and the injected volume were diverse. Although 65% of the included studies achieved 100% accuracy using the ultrasound directed labeling approaches. Conclusions: Ultrasound-guided labeling techniques achieve a high accuracy. Therefore, this methodology could be a potential teaching tool for students during the dissection course. But caution is advised in drawing general conclusions because of the small sample sizes and different methodologies in the studies. Future larger-scale research is necessary.

Ultrasound-guided injection of the achilles paratenon: A cadaveric investigation.

BACKGROUND: Injections around the Achilles tendon (AT) are commonly performed in clinical practice to manage non-insertional Achilles tendinopathy, but the presence/distribution of the injectate with relation to its sheath has not been assessed specifically. Accordingly, the aim of this cadaveric investigation was to demonstrate the feasibility of Achilles paratenon injection under ultrasound guidance - by confirming the exact needle positioning as well as the dye distribution inside the paratenon lumen. METHODS: A descriptive laboratory study with three human cadaveric specimens (one fresh cadaver and two cadavers embalmed using the Fix for Life (F4L) method) was performed in a tertiary-care academic institution. The interventional technique and the related anatomical findings were illustrated. During the injection, the needle was advanced inside the Achilles paratenon under ultrasound guidance i.e. in-plane medial-to-lateral approach. With the objective to confirm its correct placement, the needle was kept in situ on the right AT of the fresh cadaver. Likewise, to demonstrate the location of the dye inside the lumen of Achilles paratenon, the other five ATs - four on the embalmed cadavers and one on the fresh cadaver - were injected with 5 mL of green color dye. After removal of the needle, a layer-by-layer anatomical dissection was performed on all three cadavers. RESULTS: On the right AT of the fresh cadaver, the position of the needle's tip within the Achilles paratenon was confirmed. Accurate placement of the dye inside the paratenon lumen was confirmed in four (80%) ATs, one of the fresh and three of the embalmed cadavers. No spread inside the crural fascia compartment or between the AT and the Kager's fat pad was observed. Herewith, unintentional spilling of the dye within the superficial soft tissues of the posterior leg was reported in the left AT of one of the two embalmed cadavers (20%). CONCLUSIONS: Ultrasound-guided injection using the in-plane, medial-to-lateral approach can accurately target the lumen of Achilles paratenon.

High-resolution ultrasound imaging of elementary lesions in dactylitis.

OBJECTIVE: The aim of the present study was to illustrate the (potential) diagnostic role of high resolution US images in assessing the elementary lesions of dactylitis. METHODS: Using high-frequency US machines/probes, we matched the micro-anatomical cadaveric architecture of the digit with multiple sonographic findings of dactylitis. High-sensitive color/power Doppler assessments have also been performed to evaluate the digital microvasculature. DISCUSSION: Modern US equipment/features guarantee prompt and in-depth B-mode and color/power Doppler imaging of tiny anatomical structures of the digit which are usually not properly visible with standard US machines. More specifically, hypervascularization of the digital subcutaneous tissue, fibrous pulleys of flexor tendons, dorsal synovial pads as well as pathological changes of the distal entheseal anchorage network can be accurately detected. CONCLUSION: In clinical practice, high-end US equipment can be used to accurately assess the digits in patients with dactylitis. This way, simple and convenient sonographic diagnosis of different elementary lesions can be timely established.

[CME Sonography 108: Achilles Tendon Ultrasound: Sonoanatomy and Pathologies]. / CME Sonografie 108: Die Achillessehne im Ultraschall: Sonoanatomie und Pathologien CME-Fragen.

CME Sonography 108: Achilles Tendon Ultrasound: Sonoanatomy and Pathologies Abstract. The Achilles tendon is the thickest tendon in the human body. Due to its superficial location and the high prevalence of its pathologies, the Achilles tendon is one of the most frequently sonographed tendons. As a cost-effective and quickly available diagnostic tool, sonography has become indispensable as an examination method for "achillodynia", which occurs in both athletes and non-athletes alike. With modern, high-resolution ultrasound devices, the ultrastructure of the Achilles tendon can be shown in such detail that the term "sonohistology" was formed. Using Doppler sonography and elastography, tendon characteristics which no other modality is capable to show can be visualized. Ultrasound has also been established in the guidance of therapeutic interventions for Achilles tendon disorders. In this article, the sonopathology of the most common Achilles tendon disorders - degenerative and traumatic - are addressed.

[CME Sonography 107: Ultrasound Elbow Cases]. / CME Sonografie 107: Sonografische Ellenbogenfälle CME-Fragen.

CME Sonography 107: Ultrasound Elbow Cases Abstract. In this article, we discuss exemplary sonographic pathologies at the anterior, lateral, medial, and posterior elbow, highlighting important structures that should be systematically examined in the corresponding elbow region.

Ultrasonography for Injecting (Around) the Lateral Epicondyle: EURO-MUSCULUS/USPRM Perspective.

Lateral epicondylitis (LE) is a very common and painful condition seen in the daily practice of musculoskeletal physicians. Ultrasound-guided (USG) injections are commonly performed to manage the pain, promote the healing phase, and plan a tailored rehabilitation treatment. In this aspect, several techniques were described to target specific pain generators i the lateral elbow. Likewise, the aim of this manuscript was to extensively review those USG techniques together with the patients' pertinent clinical/sonographic features. The authors believe that this literature summary could also be refined as a practical, ready-to-use guide for planning the USG interventions of the lateral elbow in clinical practice.

Anatomy and Sonographic Examination for Lateral Epicondylitis: EURO-MUSCULUS/USPRM Approach.

OBJECTIVE: The aim of the study is to define a standardized comprehensive sonographic approach for evaluating the different histoanatomical compartments of the lateral elbow. DESIGN: Using high-frequency ultrasound probes, we tried to match the anatomical features of the lateral elbow and its different sonographic patterns in patients with the diagnosis of lateral epicondylitis. Moreover, high-sensitive color/power Doppler assessments have also been performed to evaluate the microcirculation. RESULTS: Modern ultrasound equipment seems to provide an extremely detailed sonographic assessment of the different anatomical layers located in the lateral compartment of the elbow. Moreover, high-sensitive color/power Doppler imaging allows for clear visualization of the perfusion patterns in pathological conditions. CONCLUSIONS: In clinical practice, high-frequency B-mode and high-sensitive color/power Doppler imaging can be integrated with the clinical findings to better define the pain generator(s) for optimizing the management of patients with lateral epicondylitis.

From histology to sonography in synovitis: EURO-MUSCULUS/USPRM approach.

OBJECTIVES: The aim of the present study was to propose a methodologically innovative sonographic approach for optimal evaluation of synovial tissues (starting from histopathology). METHODS: Using high-frequency ultrasound probes and high-level ultrasound machines, we matched the histological microarchitecture of synovial tissues with multiple sonographic patterns in physiological and pathological conditions. Likewise, high-sensitive color/power Doppler assessments have also been performed to evaluate the microcirculation. RESULTS: Modern equipment allows for a macroscopic classification of synovial pathologies recognizing different morphological patterns; however, intimal and subintimal layers of the synovium cannot be distinguished from each other on ultrasound. High-sensitive Doppler imaging clearly defines the microvascular pattern, especially in patients with hypertrophic synovial pathologies. CONCLUSIONS: In clinical practice, using adequate technological equipment i.e. high-frequency B-mode and high-sensitive Doppler imaging, detailed sonographic assessment of synovial tissues can be performed - defining the main sono-histological patterns.

[CME-Sonography 106: Subacromial Bursa - A Myth]. / CME Sonografie 106: Bursa subacromialis ­ ein Mythos CME-Fragen.

CME-Sonography 106: Subacromial Bursa - A Myth Abstract. In everyday clinical practice, we frequently encounter bursitis. It can occur in practically any joint region, for example in local mechanical overload situations, after a trauma or in the context of an inflammatory systemic disease. In this review we focus on the location of bursitis in the shoulder region and would like to contribute to get away from the "myth" called subacromial bursitis.

[CME Rheumatology 26: Bone Marrow Edema of the Sacro-Iliac Joint = Spondyloarthritis? What the General Practicioner Should Know]. / CME Rheumatologie 26: Knochenmarködem im Iliosakralgelenk = Spondyloarthritis? Was die Hausärztin/der Hausarzt wissen sollte CME-Fragen.

CME Rheumatology 26: Bone Marrow Edema of the Sacro-Iliac Joint = Spondyloarthritis? What the General Practicioner Should Know Abstract. Axial spondyloarthritis is a chronic inflammatory joint disease mainly involving the sacroiliac joints (ISG) and the spine. The diagnosis can be made early due to acute inflammatory changes in the ISG on magnetic resonance imaging (MRI). Radiographs of the ISG do not help in early diagnosis because structural damage is not apparent on radiographs until an advanced stage. In recent years, however, several studies have shown that bone marrow edema - hyperintense signals (= bright spots) as a possible MRI correlate for inflammation - does not specifically occur in axial spondyloarthritis, but can also be seen in healthy people, athletes, people with high mechanical stress (e.g. military recruits) and postpartum women. The diagnosis of axial spondyloarthritis should therefore never be based solely on an MRI finding, but must always include the overall clinical context.

[CME-Sonography 105: Ultrasound in Sports Injuries]. / CME-Sonografie 105: Sportverletzungen im Ultraschall CME Fragen.

CME-Sonography 105: Ultrasound in Sports Injuries Abstract. Muscle injuries are frequent in athletes and in the general population. For therapy and prognosis, it is important to understand the total extent of the injury and to be aware of possible complications. In most cases ultrasound is a useful tool for diagnostics of muscle injuries. However, muscle ultrasound is not as common as joint ultrasound; this article discusses the possibilities of high-resolution dynamic ultrasound in diagnostics and its limitations.

[CME Rheumatology 26: Rheumatological Cases]. / CME-Rheumatologie 25: Rheumatologische Fälle CME Fragen.

CME Rheumatology 26: Rheumatological Cases Abstract. Special rheumatological cases are illustrated using various examples. On the one hand we present differential diagnoses and causes of a "Baker's cyst", on the other hand a case of involvement of the cervical spine in rheumatoid arthritis. Usually, the medical history and precise clinical examination will lead us in the right diagnostic direction. Further clarifications such as laboratory analyses or imaging procedures are used in a targeted manner, taking into account the clinic.

Does tenosynovitis of the hand detected by B-mode ultrasound predict loss of clinical remission in rheumatoid arthritis? Results from a real-life cohort.

Objective: The role of US-detected tenosynovitis (USTS) in the management of rheumatoid arthritis remains controversial. The aim of this study was to investigate whether tenosynovitis can predict a flare in rheumatoid arthritis patients in remission in a real-life cohort. Methods: Rheumatoid arthritis patients from the Swiss Clinical Quality Management cohort were included in this study if they were in clinical remission, defined by 28-joint disease activity score (DAS28-ESR) <2.6, and had an available B-mode tenosynovitis score. The patients were stratified according to the presence or absence of tenosynovitis (USTS+ vs. USTS-). Cox proportional hazard models were used for time-to-event analysis until the loss of remission, after adjustment for multiple confounders. The impact of baseline US performed early in remission and the advent of flares at different fixed time periods after baseline were investigated in sensitivity analysis. Results: Tenosynovitis was detected in 10% of 402 rheumatoid arthritis patients in remission. At baseline, USTS+ patients in remission had significantly higher DAS28-ESR (mean (SD): USTS- 1.8 (0.5) versus USTS+ 2.0 (0.5); p = 0.0019) and higher additional disease activity parameters, such as physician global assessment, and simplified- and clinical-disease activity index. Joint synovitis detected by B-mode US was associated with tenosynovitis (mean (SD) 7.2 (6.3) in USTS- versus 9.0 (5.4) in USTS+, respectively; p = 0.02). A disease flare was observed in 69% of remission phases, with no differences in the time to loss of remission between USTS+ and USTS- groups. Conclusion: While US-detected tenosynovitis was associated with higher disease activity parameters in rheumatoid arthritis patients in clinical remission, it was not able to predict a flare.

[CME Sonography 103: Subacromial Pain Syndrome (SAPS) and Subcoracoid Impingement (SCI)]. / CME-Sonografie 103: Subakromiales (SAI) und subkorakoidales Impingement (SCI).

CME Sonography 103: Subacromial Pain Syndrome (SAPS) and Subcoracoid Impingement (SCI) Abstract. Pain in the shoulder can have its origin in different structures of the shoulder joint or in affected periarticular structures. Therefore, it is important to be able to make a specific diagnosis and identify the exact pathology behind it in order to initiate the most appropriate individually precise treatment. In this review, we discuss possible causes of impingement of the shoulder.

EULAR points to consider for the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs).

OBJECTIVES: To develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs). METHODS: European Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously. RESULTS: A total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel. CONCLUSION: These are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs.

Development of a new ultrasound scoring system to evaluate glandular inflammation in Sjögren's syndrome: an OMERACT reliability exercise.

OBJECTIVE: The aim of this exercise from the OMERACT Ultrasound subgroup on Sjögren's syndrome was to develop and assess the reliability of a consensus-based semiquantitative colour Doppler US scoring system for pathologic salivary gland vascularization in patients with primary Sjögren's syndrome (pSS). METHODS: Using the Delphi method, a colour Doppler semiquantitative scoring system for vascularization of bilateral parotid and submandibular glands was developed and tested in static images and on patients (9 pSS patients and 9 sonographers). Intra-reader and inter-reader reliability of grading the salivary glands were computed by weighted Cohen and Light's kappa analysis, respectively. RESULTS: The consensus-based semiquantitative score was: grade 0, no visible vascular signals; grade 1, focal, dispersed vascular signals; grade 2, diffuse vascular signals detected in <50% of the gland; grade 3, diffuse vascular signals in >50% of the gland. In static images, the intra- and inter-reader reliability showed excellent kappa values (95% CI) of 0.90 (0.87, 0.93) and 0.80 (0.74, 0.84), respectively, for all four salivary glands together. In patients, the intra- and inter-reader reliability for all four salivary glands together was kappa = 0.84 (0.73, 0.92) and 0.70 (0.64, 0.76), respectively. CONCLUSION: The consensus-based colour Doppler US scoring for the evaluation of salivary gland vascularization in pSS showed a good inter-reader reliability and excellent intra-reader reliability in static images and in patients. The clinical application of the developed scoring system should be tested in clinical settings.

[CME Rheumatology 24/Answers: DISH of the Hand and Undifferentiated Polyarthritis]. / CME-Rheumatologie 24/Antworten: DISH der Hand und undifferenzierte Polyarthritis.

CME Rheumatology 24/Answers: DISH of the Hand and Undifferentiated Polyarthritis Abstract. We present a case with undifferentiated, unclassified polyarthritis and with peripheral diffuse idiopathic skeletal hyperostosis (DISH). We discuss the differential diagnoses of "seronegative" polyarthritis and explain the radiographic findings of the little-known peripheral aspects of DISH.