A comparison of ultrasound and clinical examination in the detection of flexor tenosynovitis in early arthritis

Abstract

BackgroundTenosynovitis is widely accepted to be common in rheumatoid arthritis (RA) and postulated to be the first manifestation of RA, but its true prevalence in early disease and in particular the hand has not been firmly established. The aims of this study were first to investigate the frequency and distribution of finger flexor tenosynovitis using ultrasound in early arthritis, second to compare clinical examination with ultrasound (US) using the latter as the gold standard.Methods33 consecutive patients who had who were initially diagnosed with polyarthritis and suspected of polyarthritis and clinical suspicion of inflammatory arthritis of the hands and wrists were assessed during consecutive, routine presentations to the rheumatology outpatient clinic. We scanned a total of 165 finger tendons and subsequent comparisons were made using clinical examination.ResultsFlexor tenosynovitis was found in 17 patients (51.5%) on ultrasound compared with 16 (48.4%) of all patients on clinical examination. Most commonly damaged joint involved on US was the second finger followed by the third, fifth, and fourth. Both modalities demonstrated more pathology on the second and third metacarpophalangeal (MCP) compared with the fourth and fifth MCP. A joint-by-joint comparison of US and clinical examination demonstrated that although the sensitivity, specificities and positive predictive values of clinical examination were relatively high, negative predictive value of clinical examination was low (0.23).ConclusionsOur study suggest that clinical examination can be a valuable tool for detecting flexor disease in view of its high specificity and positive predictive values, but a negative clinical examination does not exclude inflammation and an US should be considered. Further work is recommended to standardize definitions and image acquisition for peritendinous inflammation for ultrasound.

Tenosynovitis US scoring systems follow synovitis and clinical scoring systems in RA and are responsive to change after biologic therapy

“…This incidence was much higher than was reported in other cohorts in the literature [25][26][27], which indicated the presence of tenosynovitis in approximately 50-60 % of included patients. In a group of 50 patients with early, untreated RA, Wakefield et al [36] found flexor tenosynovitis in 82% of patients with MRI and in only 48% of patients with US.…”

“…Some studies regarding US incidence [25][26][27], validity [13] and inter-observer reliability of US detection of tenosynovitis involving multiple investigators [28][29][30][31] have been performed. Tenosynovitis has been included together with synovitis without separation between joints and tendons' pathology in some described US scores [32][33][34][35].…”

Role of diagnostic ultrasound in the assessment of musculoskeletal diseases

“…Tenosynovitis is common in RA [Hmamouchi et al 2011] but its true prevalence in early disease has not been firmly established. A complication of persistent tenosynovitis is complete rupture of the tendon with loss of function [Mcqueen et al 2005].…”

Concepts in diagnosing, scoring, and monitoring tenosynovitis and other tendon abnormalities in patients with rheumatoid arthritis- the role of musculoskeletal ultrasound.

“…Musculoskeletal ultrasound (MSUS) has already proven its utility for directly visualization of the joint synovial tissue (morphology and quantification), the synovial vascularization (presence and quantification), and in monitoring the response to therapy [18][19][20][21][22][23][24][25][26][27]. Recently, much attention has been given to the presence of tenosynovitis, as a constant, complementary, but different facet of the inflammatory involvement in RA [28][29][30]. In this scenario, identification of tenosynovitis in early RA stages along with treatment monitoring in early and established disease should not only help in improving the new classification criteria but also in preventing or slowing down the development of structural damage at tendon and joint level [31][32][33][34].…”