Rheumatology Ultrasound Improves Diagnosis of Inflammation

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Use of musculoskeletal ultrasound is relatively new to the field of rheumatology, but it is quickly becoming a preferred tool for diagnosis, monitoring and treatment. The Massachusetts General Hospital Rheumatology Musculoskeletal Ultrasound Program leads the field in early detection of joint and tendon inflammation, assessment of disease progression, treatment with image-guided injections and monitoring response to therapy.

"People often present with a possible case of psoriatic arthritis 12 to 15 years after their symptoms begin," says Minna Kohler, MD, RhMSUS, director of the program. "They may have seen doctors and obtained blood tests that were negative. X-rays may have shown nothing or mild degenerative changes, and so they may be undiagnosed for years."

"Musculoskeletal ultrasound allows a different way to evaluate for inflammation, not only in the joint but also within tendons, ligaments and soft tissue. It's fast, noninvasive and radiation-free, and it has really revolutionized the ability to expedite diagnoses."

DUET Study to Improve Diagnosis of Psoriatic Arthritis

Psoriatic arthritis is a chronic inflammatory disease in the joints that affects about 30% of people who have psoriasis. Early diagnosis and treatment can help to limit joint damage and prevent pain and disability, but diagnosis can be difficult. There is no blood test or other easy way to confirm the diagnosis and differentiate it from mechanical conditions.

Dr. Kohler's group has joined the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in developing a scoring system that uses ultrasound to detect enthesitis (inflammation where tendons or ligaments insert into the bone; a key feature of psoriatic arthritis) and identify psoriatic arthritis earlier. The goal is to create a validated scoring tool that will help clinicians identify the condition much earlier.

"We know that patients with psoriasis have a higher chance of developing psoriatic arthritis," Dr. Kohler says. "If we're able to use this tool to identify those people before damage sets in, it could really change clinical outcomes and patient function by preserving joints, muscles and tendons."

The Diagnostic Ultrasound Enthesitis Tool (DUET) Study is enrolling:

• Patients newly diagnosed with psoriatic arthritis (within five years), confirmed by a rheumatologist
• Patients with psoriasis confirmed by a dermatologist, but without psoriatic arthritis or musculoskeletal symptoms
• Patients with noninflammatory rheumatic conditions to serve as controls

The study will use ultrasound to examine tendon structures bilaterally in the subjects' shoulders, elbows, knees, ankles and feet. The images are sent to a central location, where blinded ultrasound experts compare and contrast them.

"Achilles tendinitis is a common mechanical condition. However, psoriatic arthritis enthesitis can occur at the same location," Dr. Kohler says. "But there are areas within the tendon and the entheseal complex where inflammation may differ. And so we're trying to determine how to distinguish that."

Their findings will be used to develop a scoring system that clinicians can use along with an ultrasound to diagnose psoriatic arthritis and differentiate between mechanical and inflammatory processes.

Musculoskeletal Ultrasound Helps Patients with Immunotherapy-Related Adverse Events

The Rheumatology Musculoskeletal Ultrasound Program is also using its advanced technology to help patients with cancer. Dr. Kohler's group is evaluating patients who develop therapy-related inflammatory arthritis while on checkpoint inhibitor therapy in partnership with the Severe Immunotherapy Complications group at the Mass General Cancer Center.

"Checkpoint inhibitor therapies have been revolutionary for cancer treatment, but they can be associated with side effects such as musculoskeletal symptoms that are manageable if identified and treated appropriately," she says. "And we can offer medications and ultrasound-guided joint aspirations and injections for pain relief so they'll be able to continue their much-needed cancer-treating infusions."

Differentiating Gout From Other Types of Joint Pain to Guide Treatment

Dr. Kohler's program also partners with the Gout and Crystal Arthropathy Center at Mass General for clinical care and research. Ultrasound has several uses in patients with gout or pseudo-gout, such as to:

• Diagnose patients during the intra-critical period, before and in between painful flare-ups
• Differentiate what kind of crystal arthritis a patient has in order to guide more effective treatment selection
• Eliminate unnecessary needle sticks from joint fluid aspirations
• Enhance the ability to target treatment injections with better accuracy and less pain

Together, the programs are collecting data from the Mass General database on cohorts with gout or pseudo-gout to understand how diet affects flares.

"Gout and pseudo-gout can lead to chronic inflammation and cause joint deformities and bone damage, but a lot of times this diagnosis goes unrecognized," Dr. Kohler says. "A patient may have had one or two attacks but not realize that there's some subclinical inflammation that's contributing to joint damage. Musculoskeletal ultrasound can reveal the diagnosis and guide treatment decisions."

Musculoskeletal Ultrasound "Changes the Clinical Picture"

Dr. Kohler continues to seek new partnerships to use ultrasound to improve prognoses and quality of life for patients with musculoskeletal conditions.

"This is going to change the clinical picture for patients," Dr. Kohler says. "With earlier diagnosis, patients can get on medications earlier to prevent disease progression, bony damage and disability."

Learn more about the Musculosketal Ultrasound Program

Refer a patient to the Rheumatology Unit