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Table 1 Ultrasound features used in differentiation of early inflammatory arthritis

From: The importance of ultrasound in identifying and differentiating patients with early inflammatory arthritis: a narrative review

Rheumatoid arthritis

Spondyloarthritis

Crystal arthropathies

Polymyalgia rheumatica

Septic arthritis

 • Joint effusion, synovial proliferation, synovial pannus, and hyperemia in typical RA distribution

 • Tenosynovial effusions, synovial hypertrophy, and hyperemia

 • Cortical bone erosions and cartilage lesions

 • Multijoint assessments confirming typical distribution of involvement

• Enthesitis characterized by tendon/ligament hypoechogenicity and thickening, calcification, bone erosions, intralesional focal calcification or fibrous tissue, and abnormal vascularization at enthesis insertion on power Doppler ultrasound

• Cortical bone erosions and enthesophytes (heterogeneous to RA)

• Synovitis and tenosynovitis

• Confounding factors: age, BMI

• Tophaceous deposits:

 • Cartilage: double contour sign (gout)

 • Periarticular: heterogeneous collection in soft tissue, “snowstorm” appearance sometimes with anechoic rim

 • Tendons and ligaments: intratendinous tophi and ovoid-shaped microdeposits with hyperechoic densities

• Cortical bone erosions

• CPPD deposits:

 • Hyaline cartilage: hyperechoic, within the layer of cartilage

 • Fibrocartilage: hyperechoic, rounded or amorphous deposits

• Basic calcium phosphate:

 • Hyperechoic foci with variable acoustic shadowing

 • Hyperemia on Doppler

• Bilateral subacromial/subdeltoid bursitis

• Biceps long-head tenosynovitis

• Trochanteric bursitis

• Synovitis

• Hip effusion

• Less common findings include enthesitis, glenohumeral effusions, flexor tenosynovitis, and peripheral synovitis

• Should not have hand- or wrist-joint synovitis

• Joint effusion, sometimes with hyperechogenicity and heterogeneity

• Increased peri-synovial vascularity with color Doppler

• Ultrasound can guide joint aspiration

• Clinical suspicion has the highest priority

  1. BMI body mass index, CPPD calcium pyrophosphate dehydrate, RA rheumatoid arthritis