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More doctors use ultrasound to diagnose, manage rheumatic diseases

ACR supports best practices for ultrasonography use in rheumatology

More rheumatologists are embracing musculoskeletal ultrasound (MSUS) to diagnose and manage rheumatic diseases. In response, the American College of Rheumatology (ACR) assembled a task force to investigate and determine best practices for use of MSUS in rheumatology practice.

The resulting scenario-based recommendations, which aim to help clinicians understand when it is reasonable to integrate MSUS into their rheumatology practices, now appear online in Arthritis Care & Research.

In Europe, more than 100 million individuals are affected by rheumatic diseases, according to the European League Against Rheumatism (EULAR). The ACR estimates that nearly 50 million Americans are burdened by arthritis and more than 7 million individuals suffer from inflammatory rheumatic diseases such as systemic lupus erythematosus, rheumatoid arthritis and gout.

"With so many people affected by rheumatic diseases, including arthritis, a diagnostic tool such as MSUS that is minimally invasive and with little risk to patients is an important tool for rheumatologists," explains lead researcher Dr. Tim McAlindon from Tufts Medical Center in Boston, Mass. "Our task force goal was to establish when use of MSUS was 'reasonable' in a number of medical situations."

The task force reviewed medical literature to come up with scenario-based recommendations for how MSUS could be used in rheumatology practice. These recommendations include a rating by type of evidence, with Level A supported by at least two randomized clinical trials or one or more meta-analyses of randomized trials; Level B backed by one randomized trial, non-randomized studies or meta-analyses of non-randomized studies; and Level C confirmed by consensus expert opinion, case studies, or standard clinical care.

The complete list of 14 recommendations of the reasonable use of MSUS in rheumatology, along with level of evidence, is published in the article. Partial list of recommendations includes:

For a patient with articular pain, swelling or mechanical symptoms, without definitive diagnosis on clinical exam, it is reasonable to use MSUS to further elucidate the diagnosis at the following joints: glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal. Level of evidence: B.

For a patient with diagnosed inflammatory arthritis and new or ongoing symptoms without definitive diagnosis on clinical exam, it is reasonable to use MSUS to evaluate for inflammatory disease activity, structural damage or emergence of an alternate cause at the following sites: glenohumeral, acromioclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal, and entheseal. Level B.

For a patient with shoulder pain or mechanical symptoms, without definitive diagnosis on clinical exam, it is reasonable to use MSUS to evaluate underlying structural disorders; but not for adhesive capsulitis or as preparation for surgical intervention. Level B.

It is reasonable to use MSUS to evaluate the parotid and submandibular glands in a patient being evaluated for Sjögren's disease to determine whether they have typical changes as further evidence of the disorder. Level B.

For a patient with symptoms in the region of a joint whose evaluation is obfuscated by adipose or other local derangements of soft tissue, it is reasonable to use MSUS to facilitate clinical assessment at the glenohumeral, acromioclavicular, elbow, wrist, hand, metacarpophalangeal, interphalangeal, hip, knee, ankle/foot, and metatarsophalangeal joints. Level C.

For a patient with regional neuropathic pain without definitive diagnosis on clinical exam, it is reasonable to use MSUS to diagnose entrapment of the median nerve at the carpal tunnel; ulnar nerve at the cubital tunnel; and posterior tibial nerve at the tarsal tunnel. Level B.

It is reasonable to use MSUS to guide articular and peri-articular aspiration or injection at sites that include the synovial, tenosynovial, bursal, peritendinous and perientheseal areas. Level A.

The benefits of MSUS use include a faster, more accurate diagnosis, better measurement of treatment success, reduced procedural pain, and improved patient satisfaction. However, the authors highlight that economic impact was not part of this study. Dr. McAlindon concludes, "Further study of the cost-effectiveness and long-term outcomes of MSUS is necessary to determine its value compared to other interventions."

This study is published in Arthritis Care & Research. Media wishing to receive a PDF of this article may contact

Full citation: American College of Rheumatology Report on Reasonable Use of Musculoskeletal Ultrasonography in Rheumatology Clinical Practice." Timothy McAlindon, Eugene Kissin, Levon Nazarian, Veena Ranganath, Shraddha Prakash, Mihaela Taylor, Raveendhara R Bannuru, Sachin Srinivasan, Maneesh Gogia, Maureen A McMahon, Jennifer Grossman, Suzanne Kafaja, John FitzGerald. Arthritis Care and Research; Published Online: October 29, 2012 (DOI: 10.1002/acr.21836).

URL Upon publication:

About the Journal:

Arthritis Care & Research is an official journal of the American College of Rheumatology (ACR), and the Association of Rheumatology Health Professionals (ARHP), a division of the College. Arthritis Care & Research is a peer-reviewed research publication that publishes both original research and review articles that promote excellence in the clinical practice of rheumatology. Relevant to the care of individuals with arthritis and related disorders, major topics are evidence-based practice studies, clinical problems, practice guidelines, health care economics, health care policy, educational, social, and public health issues, and future trends in rheumatology practice. The journal is published by Wiley on behalf of the American College of Rheumatology (ACR). For more information, please visit

About Wiley

Founded in 1807, John Wiley & Sons, Inc. has been a valued source of information and understanding for more than 200 years, helping people around the world meet their needs and fulfill their aspirations. Wiley and its acquired companies have published the works of more than 450 Nobel laureates in all categories: Literature, Economics, Physiology or Medicine, Physics, Chemistry, and Peace.

Wiley is a global provider of content and content-enabled workflow solutions in areas of scientific, technical, medical, and scholarly research; professional development; and education. Our core businesses produce scientific, technical, medical, and scholarly journals, reference works, books, database services, and advertising; professional books, subscription products, certification and training services and online applications; and education content and services including integrated online teaching and learning resources for undergraduate and graduate students and lifelong learners. Wiley's global headquarters are located in Hoboken, New Jersey, with operations in the U.S., Europe, Asia, Canada, and Australia. The Company's Web site can be accessed at The Company is listed on the New York Stock Exchange under the symbols JWa and JWb.

Media Advisory

2012 ACR/ARHP Annual Meeting Press Registration Now Open.

What: Press registration is now open to journalists planning to attend the 2012 ACR/ARHP Annual Meeting

Where: Walter E. Washington Convention Center; Washington, D.C.

When: November 10 - 14, 2012

Policies: Please make sure to review our press guidelines as they may impact your ability to receive press credentials

Registration: To register for a press pass, please visit

Key dates:

Press registration closes: Monday, October 29, 2012
Press conference schedule now available at
On-site Newsroom opens: Saturday, November 10, 2012
Opening Lecture/Embargo lifts: 4:30 PM Eastern Time on Saturday, November 10, 2012

Contact: Suzanne Forte,, 404-633-3777
Headquartered in Atlanta, Ga., the American College of Rheumatology is an international professional medical society that represents more than 9,000 rheumatologists and rheumatology health professionals. Rheumatologists are internists or pediatricians who are qualified by training and experience in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. Over 50 million Americans - including nearly 300,000 children - suffer from the painful, disabling and sometimes fatal effects of arthritis and rheumatic diseases. The ACR's mission is to advance rheumatology. Learn more by visiting or follow ACR on Twitter at

Dawn Peters | EurekAlert!
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