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Insertional Achilles tendinopathy is an umbrella medical term referring to pain and swelling on the posterior aspect of the calcaneus. High-resolution ultrasound imaging is commonly used in daily practice to assess the pathological changes of the Achilles tendon, cortical bone of the calcaneus, and soft tissues located inside the retrocalcaneal space to optimize the management of relevant patients. To the best of our knowledge, a standardized ultrasound protocol to evaluate the retrocalcaneal bursal complex is lacking in the pertinent literature. In this sense, our step-by-step sonographic approach is intended to be an easy and ready-to-use guide for sonographers/physicians in daily practice to assess this anatomical complex in patients with Achilles tendinopathy. Needless to say, the peculiar histological features of this V-shaped synovial/fibrocartilaginous bursa surrounding the posteroinferior wedge of the Kager's fat pad and the retrocalcaneal space make the examination challenging., (© 2024 The Author(s). Journal of Ultrasound in Medicine published by Wiley Periodicals LLC on behalf of American Institute of Ultrasound in Medicine.)

Background: The present study aims to investigate the feasibility of labeling ligaments using ultrasound-guided injections. On formalin-fixed cadavers, the anterolateral ligament was selected and targeted for demonstration. The development of portable ultrasound machines and the ability to connect them to tablets via Bluetooth or WLAN makes it an accessible tool to implement into the anatomical dissection courses in order to associate medical imaging (MRI and ultrasound), anatomical structures and their subsequent dissection., Methods: 8 formalin fixed human cadavers were used for the ultrasound-guided injections of 1 mL of blue latex into the anterolateral ligament. 8 cadavers were not injected with latex for comparative purposes. The injections were performed by an experienced ultra-sonographer. After approximately 10 months, five dissections were carried out by students during the dissection course and three specimens were dissected by anatomists., Results: The anterolateral ligament was successfully marked and demonstrated in 7 out of 8 cases. In 4 out of 5 cases, the dissection was primarily conducted by students, while in 3 out of 3 cases, it was performed by anatomists. The accuracy was 80 % and 100 %, respectively., Conclusion: The present study demonstrated that labeling obscure ligaments, such as the anterolateral ligament, using ultrasound guidance is feasible on formalin-fixed cadavers. It also showed that students can successfully perform the dissections as the structure is highlighted and that the time between injection and dissection (approximately 10 months) has little impact on the outcome. The use of ultrasound in dissection courses should be further encouraged., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Authors. Published by Elsevier GmbH.. All rights reserved.)

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., (© 2024. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

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., Competing Interests: Declaration of Competing Interest None. Written permission was obtained from the patients., (Copyright © 2024 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

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., (© 2023. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Background: Muscle injuries are common in football. Imaging diagnostics have a major role in establishing a diagnosis. The main diagnostic procedures are MRI and ultrasound. Both diagnostics have advantages and disadvantages, which should be balanced against each other., New Ultrasonic Techniques: The role of MRI as the gold standard is increasingly being replaced by high-resolution ultrasound techniques, and MRI imaging is not always useful. To detect complications in the early stages it is advised to perform regular ultrasound-imaging check-ups. The healing process can be monitored, and it offers additional options for ultrasound-guided interventions such as hematoma punctures and targeted infiltrations., Advantages and Disadvantages: However, ultrasound imaging is highly user dependent. Experienced operators can eliminate this disadvantage, which makes ultrasound a superior imaging system in many areas, especially for dynamic examinations. Nevertheless, MRI imaging remains a necessary imaging method in certain areas., (© 2024. The Author(s).)

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., (© 2024. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

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.

Background: A common approach to define sonoanatomy is a reciprocal exchange of macroscopic and microscopic information in ultrasound imaging. High-resolution ultrasound has been long established and is crucial as an inexpensive and adaptable tool, not just in clinical settings but also while teaching anatomy. Early application of ultrasonography provides medical students with a couple of benefits: they acquire an improved understanding of anatomy and learn how to use it., Methods: A comprehensive literature review has been carried out, with relevant studies discovered in the following databases: MEDLINE, EMBASE, CENTRAL, BIOSIS Previews and Web of Science Core Collection. Gray literature was also considered in two different ways: (1) Regarding grey literature databases: National Gray Literature Collection. (2) For PhD theses and dissertations, the databases EThOS and Open Access Theses and Dissertations were screened for relevant studies by combining the keywords used in the search string. The reference lists of all relevant papers were scanned. Search process was performed on January 3rd, 2023. The search string was developed with the aid of and finally checked by a professional librarian. Only ultrasound studies on human cadavers were included, not animals or phantoms. If the studied subject was a joint, the article was included. Only B-Mode ultrasound was included, whereas Elastosonography, Doppler sonography and quantitative approaches including among others sound speed, backscatter attenuation were excluded. Intravascular, intraosseous, intraarticular, and three-dimensional or four-dimensional ultrasonography were also eliminated from the analysis. All appropriate information comprising articles, PhD theses, dissertations and chapters in textbooks were considered. There were solely English and German studies covered. There was no additional restriction on the publishing year. The included studies' general characteristics and ultrasound techniques were taken from them and examined. Using VOS viewer, a keyword analysis was also carried out., Results: 142 of the 8899 results that were returned by the search satisfied the requirements. With a quarter of the included studies, the knee joint was the most extensively studied joint, followed by the elbow joint (10.6%) and the shoulder joint (9.2%). The methodological analysis includes 125 studies. Both the sample size and the ultrasonographer's qualifications were diverse. The probe position and the ultrasound method were precisely documented so that a reader could duplicate them in about three-quarters of the included studies (72.8%)., Conclusion: The current study, in our perspective, is the first scoping review to screen ultrasound studies on human cadaver joints. A heterogeneous field was shown by the methodological investigation. We suggest using a uniform method for conducting and presenting ultrasound examinations in future studies., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests. Competing interests The authors declare that they have no competing interests., (Copyright © 2023 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Objective: The prevalence of crystal arthropathies in the general population is rising. The purpose of this pictorial study is to describe the sonographic elements of the most prevalent crystal arthropathies by emphasizing particular sonographic findings using illustrative images and cases while considering technical details and common pitfalls., Methods: Using established recommendations, specialists in the fields of sonography and crystal arthropathies agreed by consensus on the unique ultrasound signs associated with each of the conditions., Results: Gout, calcium pyrophosphate deposition arthropathy, and hydroxyapatite arthropathy are the three most prevalent crystal arthropathies. Today's high-resolution sonography enables reliable evaluation of the underlying crystal deposits, post-inflammatory changes, and a precise description of joint inflammation., Conclusions: High-prevalence crystal arthropathies are reliably detectable by ultrasound with current ultrasound equipment. It is necessary to have extensive ultrasound training, know specific sonographic findings, and understand all possible differential diagnoses for disorders affecting the musculoskeletal system.

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., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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.

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.

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., Competing Interests: Conflict of interest None. No funding was received., (Copyright © 2022 Elsevier GmbH. All rights reserved.)

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.

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 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.

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., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

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., Competing Interests: Competing interests: CDejaco has received consulting/speaker’s fees from Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, all unrelated to this manuscript. PMM has received consulting/speaker’s fees from Abbvie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this manuscript, and is supported by the National Institute for Health Research (NIHR), University College London Hospitals (UCLH), Biomedical Research Centre (BRC). FC has received consulting/speaker’s fees from Abbvie and Celgene, all unrelated to this manuscript. LT has received speakers fee from Novartis, UCB, Roche and Pfizer. GT has received research grants from Iqone and received consulting/speaker’s fees from Menarini, all unrelated to this manuscript. LMS has received consulting/speaker’s fees from Janssen-Cilag, Novartis, Pfizer, Abiogen, Samsung Medison, Esaote, all unrelated to this manuscript. FP has received research grants from Novartis and UCB and received consulting/speaker’s fees from Abbvie, AMGEN, BMS, Hexal, Janssen, MSD, Novartis, Pfizer, Roche and UCB, all unrelated to this manuscript. CP has received honoraria and/or research and development grants from: Abbott/AbbVie, Astellas, Astra-Zeneca/MedImmune, BMS, CelGene, Grunenthal, GSK, Janssen/J&J, MSD, Pfizer, Sanofi, Roche/Genentech/Chugai, UCB. HBH has received fees for speaking and/or consulting from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis. WH has received fees for speaking and/or consulting from AbbVie, Alpinion, Canon, Celgene, Chugai, Janssen-Cilag, Pfizer, Roche. CDuftner has received consulting/speaker’s fees from Abbvie, BMS, Eli Lilly, Janssen, Novartis, Pfizer, Roche and UCB, all unrelated to this manuscript. PVB has received consulting/speaker’s fees from Abbvie, BMS, Celgene,Celltrion, Eli Lilly, IBSA, Janssen-Cilag, MSD, Novartis, Pfizer, Professional Publishing Hungary, Richter, Roche, Sandoz, Springer Nature, UCB, all unrelated to this manuscript. XB has received consulting/speaker’s fees or grant support from Abbvie, Amgen, BMS, Chugai, Galapagos, Gilead, Hexal, Lilly, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, all unrelated to this manuscript., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

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., Competing Interests: Authors do not report any financial or personal connections with other persons or organisations which might negatively affect the contents of this publication and/or claim authorship rights to this publication., (2022 Polish Ultrasound Society. Published by Medical Communications Sp. z o.o. All rights reserved.)

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 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.

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.

Background: Viral infections may trigger autoimmunity in genetically predisposed individuals. Immunizations mimic viral infections immunologically, but only in rare instances vaccinations coincide with the onset of autoimmunity. Inadvertent vaccine injection into periarticular shoulder tissue can cause inflammatory tissue damage ('shoulder injury related to vaccine administration, SIRVA). Thus, this accident provides a model to study if vaccine-induced pathogen-specific immunity accompanied by a robust inflammatory insult may trigger autoimmunity in specific genetic backgrounds., Methods: We studied 16 otherwise healthy adults with suspected SIRVA occurring following a single work-related influenza immunization campaign in 2017. We performed ultrasound, immunophenotypic analyses, HLA typing, and influenza- and self-reactivity functional immunoassays. Vaccine-related bone toxicity and T cell/osteoclast interactions were assessed in vitro., Findings: Twelve of the 16 subjects had evidence of inflammatory tissue damage on imaging, including bone erosions in six. Tissue damage was associated with a robust peripheral blood T and B cell activation signature and extracellular matrix-reactive autoantibodies. All subjects with erosions were HLA-DRB1*04 positive and showed extracellular matrix-reactive HLA-DRB1*04 restricted T cell responses targeting heparan sulfate proteoglycan (HSPG). Antigen-specific T cells potently activated osteoclasts via RANK/RANK-L, and the osteoclast activation marker Trap5b was high in sera of patients with an erosive shoulder injury. In vitro, the vaccine component alpha-tocopheryl succinate recapitulated bone toxicity and stimulated osteoclasts. Auto-reactivity was transient, with no evidence of progression to rheumatoid arthritis or overt autoimmune disease., Conclusion: Vaccine misapplication, potentially a genetic predisposition, and vaccine components contribute to SIRVA. The association with autoimmunity risk allele HLA-DRB1*04 needs to be further investigated. Despite transient autoimmunity, SIRVA was not associated with progression to autoimmune disease during two years of follow-up., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

CME Sonography 101: Ultrasound of the Musculoskeletal System - Update 2021 Abstract. Ultrasound technologies in medicine (and in many other areas of life) continuously undergo enormous technological advances. There is increasing automation in medicine, and this is also true for diagnostic imaging. This article describes the current state of the art in musculoskeletal ultrasound and takes a look into the near future.

CME Sonography 101/Answers: Ultrasound of the Musculoskeletal System - Update 2021 Abstract. Ultrasound technologies in medicine (and in many other areas of life) continuously undergo enormous technological advances. There is increasing automation in medicine, and this is also true for diagnostic imaging. This article describes the current state of the art in musculoskeletal ultrasound and takes a look into the near future.

CME Sonography 100/Answers: Emergency Ultrasound of the Soft Tissues and the Musculoskeletal System Abstract. The term "emergency sonography" refers to a focused sonography in emergency situations, also called emergency "Point of Care Ultrasound (POCUS)". The attending physician applies it specifically and directly on the patient. As an indispensable part of the physical examination, emergency ultrasound helps to answer simple clinical questions. The corresponding answers provide essential elements for diagnostic and therapeutic decision-making. However, the emergency ultrasound also increases the safety and efficiency of interventions on the musculoskeletal system and soft tissues. In this article we will discuss common clinical emergency situations in a focused way, and we will not address the regional anesthesiological and analgesia-related applications that are also important in this context.

CME Sonography 100: Emergency Ultrasound of the Soft Tissues and the Musculoskeletal System Abstract. The term "emergency sonography" refers to a focused sonography in emergency situations, also called emergency "Point of Care Ultrasound (POCUS)". The attending physician applies it specifically and directly to the patient. As an indispensable part of the physical examination, emergency ultrasound helps to answer simple clinical questions. The corresponding answers provide essential elements for diagnostic and therapeutic decision-making. Furthermore, the emergency ultrasound increases the safety and efficiency of interventions on the musculoskeletal system and soft tissues. In this article we will discuss common clinical emergency situations in a focused way, but we will not address the regional anesthesiologic and analgesia-related applications that are also important in this context.

Knuckle pads are benign subcutaneous and usually hyperkeratotic fibromas for which no specific treatments exist. Unspecific treatments are, most of the time, ineffective and a wait-and-see policy is often recommended to patients. However, especially in adolescents, knuckle pads are often poorly tolerated for cosmetic reasons, potentially causing embarrassment and social anxiety. Here we present the case of a young adult successfully treated with a combination of high-dose salicylic acid and urea topical keratolytics. In addition, we provide ideal diagnostic images obtained via high-resolution ultrasonography and histological features that can be used by medical practitioners to better distinguish knuckle pads from other proximal interphalangeal/ metacarpophalangeal joint diseases as also from other diseases inducing swelling of periarticular soft tissues., Competing Interests: Conflict of interest: The authors declare no potential conflict of interest., (Copyright: the Author(s).)

CME Sonography 97/Answers: Ultrasound Pathologies of the Hip Abstract. Abstract: Hip pain has a broad differential diagnosis. A clinical examination is not enough to determine the underlying cause. In most cases, sonography helps to narrow the differential diagnosis or to make a specific diagnosis. Furthermore, ultrasound allows a targeted and anatomically precise diagnostic aspiration or therapeutic infiltration. Examples are used to illustrate different pathologies by region.

CME Sonography 97: Ultrasound Pathologies of the Hip Abstract. Hip pain has a broad differential diagnosis. A clinical examination is not enough to determine the underlying cause. In most cases, sonography helps to narrow the differential diagnosis or to make a specific diagnosis. Furthermore, ultrasound allows a targeted and anatomically precise diagnostic aspiration or therapeutic infiltration. Examples are used to illustrate different pathologies by region.

CME Rheumatology 23: Rheumatoid Arthritis Following COVID-19/SARS-CoV-2 Infection Abstract. Individuals with rheumatic diseases, especially those on immuno-modulating treatment, have an increased risk of infection. On the other hand, it is known that viral infections may be a cause for acute arthralgias and of arthritis. We present in the following a case of ACPA-positive and RF-positive rheumatoid arthritis after an acute COVID-19/SARS-CoV-2 infection and discuss the possible association with the infection.

CME Rheumatology 22/Answers: Rheumatological Cases Abstract. With the help of various cases, frequent and less frequent causes of painful or swollen joints are illustrated. Usually, the medical history and precise clinical examination already leads us in the right diagnostic direction. The further clarifications such as laboratory analyses or imaging procedures are used in a targeted manner, taking into account the clinic.

CME Rheumatology 23/Answers: Rheumatoid Arthritis Following COVID-19/SARS-CoV-2 Infection Abstract. Individuals with rheumatic diseases, especially those on immuno-modulating treatment, have an increased risk of infection. On the other hand, it is known that viral infections may be a cause for acute arthralgias and of arthritis. We present in the following a case of ACPA-positive and RF-positive rheumatoid arthritis after an acute COVID-19/SARS-CoV-2 infection and discuss the possible association with the infection.

CME Rheumatology 22: Rheumatological Cases Abstract. With the help of various cases, frequent and less frequent causes of painful or swollen joints are illustrated. Usually, the medical history and precise clinical examination already leads us in the right diagnostic direction. The further clarifications such as laboratory analyses or imaging procedures are used in a targeted manner, taking into account the clinic.

CME Rheumatology 24: 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.

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.

The most common etiology of carpal tunnel syndrome (CTS) is idiopathic. However, secondary causes of CTS should be considered when symptoms are unilateral, or electrodiagnostic studies are discrepant with the clinical presentation. Imaging of the carpal tunnel should be performed when secondary causes of CTS are suspected. An ultrasound evaluation of the carpal tunnel can assess for pathologic changes of the median nerve, detect secondary causes of CTS, and aid in surgical planning., (© 2020 American Institute of Ultrasound in Medicine.)

Aims: RheumaTool is a clinical decision support system designed to support the diagnostic process in rheumatology by presenting a differential diagnosis list after the input of clinical information. The objective of this study was to evaluate the performance of RheumaTool in detecting the correct diagnosis in referrals to a rheumatology clinic., Methods: In this retrospective chart analysis, data were gathered from patients with musculoskeletal complaints and an uncertain diagnosis who were referred to a Swiss tertiary rheumatology outpatient clinic. Data were entered into RheumaTool in a standardised fashion, while the principal diagnoses in the medical reports were blinded. RheumaTool&rsquo;s output was compared to the correct diagnoses, established either by widely accepted diagnostic criteria or through the expert consensus of independent rheumatologists. Diagnostic precision, the primary endpoint, was defined as the proportion of correctly diagnosed cases among all cases., Results: One hundred and sixty cases with 46 different diseases were included in this analysis. RheumaTool correctly diagnosed 40% (95% confidence interval 32.4&ndash;48.1) of all cases. In 63.8% (95% confidence interval 55.7&ndash;71.1), the correct diagnosis was present in a differential diagnosis list consisting of a median of two diagnoses., Conclusion: In this first validation, RheumaTool provides a useful list of differential diagnoses. However, there is not sufficient diagnostic reliability for unfiltered data entry, especially in patients with multiple concomitant musculoskeletal disorders. This must be taken into account when using RheumaTool.

CME Sonography 95: Sonographic Differential Diagnosis of Anterior Shoulder Pain Abstract. Anterior shoulder pain is common, and, compared to high-resolution dynamic sonography, the clinical examination is usually not precise enough for the exact classification of the cause of the pain. In this review we discuss possible causes of anterior shoulder pain with special emphasis on the ultrasound diagnosis of causes of subcoracoidal impingement and of anterior snapping syndrome. We use high-resolution ultrasound images to illustrate various possible underlying pathologies in anterior shoulder pain.

CME Sonography 93: Ultrasound of the Enthesis - Not Every "Enthesitis" Signals a Spondyloarthritis Abstract. In this CME we will focus on the ultrasound anatomy of the enthesis. In addition, we describe the terms enthesopathy and enthesitis and discuss related differential diagnostic considerations. It is important to know all the diseases that can manifest themselves at the enthesis, so that diagnoses can be made, and patients classified correctly. At this point it is worth mentioning that the findings of enthesitis do not necessarily need to be associated with spondylarthritis.

CME Sonography 93/Answers: Ultrasound of the Enthesis - Not Every Enthesitis Signals a Spondyloarthritis Abstract. In this CME we will focus on the ultrasound anatomy of the enthesis. It is important to know all the diseases that can manifest themselves at the enthesis, so that diagnoses can be made, and patients classified correctly. At this point it is worth mentioning that the findings of enthesitis do not necessarily need to be associated with spondylarthritis.

Ultrasound of the Knee (Adapted According to SGUM Guidelines) Abstract. This review paper explains the simplified ultrasound anatomy of the knee. The adapted basic standard planes are described in detail according to SGUM guidelines and illustrated with a selection of high-resolution ultrasound images. A profound knowledge of the sonographic anatomy is essential for the detection of pathologies.

Ultrasound of the Hip (Adapted According to SGUM Guidelines) Abstract. This review paper explains the simplified ultrasound anatomy of the hip. The adapted basic standard planes are described in detail according to SGUM guidelines and illustrated with a selection of high-resolution ultrasound images. A profound knowledge of the sonographic anatomy is essential for the detection of pathologies.

CME-Rheuma 21: Precision Medicine - Synovial Biopsy in Rheumatology Abstract. Synovial biopsy is increasingly performed in the medicine of the musculoskeletal system. On the one hand it allows the in-depth diagnosis of unclear arthritides. On the other hand, there is an increasing body of publications showing that histology, immunohistochemistry and RNA analysis of synovial tissue may lead to subclassifications within rheumatoid arthritis. This in turn may have predictive value for the treatment response. We herein give a short overview of the joint biopsy technique, the basic evaluation of biopsy samples and the prospects of synovial biopsy.

Objectives: To evaluate grey scale US (GSUS) and power Doppler US synovitis (PDUS), separately or in combination (CombUS), to predict joint damage progression in RA., Methods: In this cohort study nested in the Swiss RA register, all patients with sequential hand radiographs at their first US assessment were included. We analysed the summations of semi-quantitative GSUS, PDUS and CombUS assessments of both wrists and 16 finger joints (maximum 54 points) at their upper limit of normal, their 50th, 75th or 87.5th percentiles for the progression of joint damage (ΔXray). We adjusted for clinical disease activity measures at baseline, the use of biological DMARDs and other confounders., Results: After a median of 35 months, 69 of 250 patients with CombUS (28%), 73 of 259 patients with PDUS (28%) and 75 of 287 patients with available GSUS data (26%) demonstrated joint damage progression. PDUS beyond upper limit of normal (1/54), GSUS and CombUS each at their 50th (9/54 and 10/54) and their 75th percentiles (14/54 and 15/54) were significantly associated with ΔXray in crude and adjusted models. In subgroup analyses, GSUS beyond 14/54 and CombUS higher than 15/54 remained significantly associated with ΔXray in patients on biological DMARDs, while clinical disease activity measures had no significant prognostic power in this subgroup., Conclusion: Higher levels of GSUS and CombUS are associated with the development of erosions. GSUS appears to be an essential component of synovitis assessment and an independent predictor of joint damage progression in patients on biological DMARDs., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Rheumatology.)