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Effect of US-guided steroid injection in the sheath of the tibialis anterior tendon . (A) TA = tibialis anterior tendon, EHL = extensor hallucis longus tendon. Transversal scanning plane before steroid injection. Anechoic effusion, hyperechoic synovial hypertrophy and synovial hyperemia in the tendon sheath. (B) One week after injection there is complete regression of effusion, hypertrophy and hyperemia.
Source publication
The ankle region is frequently involved in juvenile idiopathic arthritis (JIA) but difficult to examine clinically due to its anatomical complexity. The aim of the study was to evaluate the role of ultrasonography (US) of the ankle and midfoot (ankle region) in JIA. Doppler-US detected synovial hypertrophy, effusion and hyperemia and US was used fo...
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Objective:
The objective of this study is to report the results of arthroscopic debridement of the subtalar joint in eight patients with Sinus Tarsi Syndrome (STS) refractory to conservative treatment.
Methods:
This is a retrospective study of eight patients with STS who underwent subtalar arthroscopy for debridement of the sinus tarsi between J...
Citations
... They allow precise localization of inflammation and accurate needle placement in clinically difficult-to-assess or hard-to-reach sites, such as wrists, TMJs, hip, small joints of hands and feet, ankles, and tendons. This maximizes treatment efficacy while minimizing local side effects, such as subcutaneous atrophy or localized skin hypopigmentation [75][76][77][78][79]. Due to limited and conflicting data, certain critical aspects require further investigation, particularly for specific sites such as the TMJs [80]. ...
In recent years, imaging has become increasingly important to confirm diagnosis, monitor disease activity, and predict disease course and outcome in children with juvenile idiopathic arthritis (JIA). Over the past few decades, great efforts have been made to improve the quality of diagnostic imaging and to reach a consensus on which methods and scoring systems to use. However, there are still some critical issues, and the diagnosis, course, and management of JIA are closely related to clinical assessment. This review discusses the main indications for conventional radiography (XR), musculoskeletal ultrasound (US), and magnetic resonance imaging (MRI), while trying to maintain a clinical perspective. The diagnostic-therapeutic timing at which one or the other method should be used, depending on the disease/patient phenotype, will be assessed, considering the main advantages and disadvantages of each imaging modality according to the currently available literature. Some brief clinical case scenarios on the most frequently and severely involved joints in JIA are also presented.
Graphical abstract
... Musculoskeletal ultrasonography (US) provides an objective assessment of inflammation in peripheral joints (3). US is a versatile, multiplanar, and inexpensive bedside imaging modality with high patient acceptability, and provides direct visualization for local steroid injections (4,5). ...
... Systematic literature review process. The study selection process is shown in a Preferred Reporting Items for Systematic reviews and Meta-Analysis flow diagram (14) Tables 1 and 2 (1)(2)(3)(4)(5)(15)(16)(17)(18)(19)(20)(21)(22)(23). The main objective in most studies was the assessment of synovitis, whereas tenosynovitis was the second objective. ...
... There were only 3 studies that included a control group (15,18,22). The ankle tendons were most studied (11 of 14 [78%]), particularly the posterior tibialis (1,2,4,(18)(19)(20)(21)(22)(23), while the biceps tendon was rarely investigated (20). ...
Objective
Synovitis and tenosynovitis are present in juvenile idiopathic arthritis (JIA), both as joint pain and/or inflammation, making them difficult to detect on physical examination. Although ultrasonography (US) allows for discrimination of the 2 entities, only definitions and scoring of synovitis in children have been established. This study was undertaken to produce consensus‐based US definitions of tenosynovitis in JIA.
Methods
A systematic literature search was performed. Selection criteria included studies focused on US definition and scoring systems for tenosynovitis in children, as well as US metric properties. Through a 2‐step Delphi process, a panel of international US experts developed definitions for tenosynovitis components (step 1) and validated them by testing their applicability on US images of tenosynovitis in several age groups (step 2). A 5‐point Likert scale was used to rate the level of agreement.
Results
A total of 14 studies were identified. Most used the US definitions developed for adults to define tenosynovitis in children. Construct validity was reported in 86% of articles using physical examination as a comparator. Few studies reported US reliability and responsiveness in JIA. In step 1, experts reached a strong group agreement (>86%) by applying adult definitions in children after one round. After 4 rounds of step 2, the final definitions were validated on all tendons and at all locations, except for biceps tenosynovitis in children <4 years old.
Conclusion
The study shows that the definition of tenosynovitis used in adults is applicable to children with minimal modifications agreed upon through a Delphi process. Further studies are required to confirm our results.
... This is the case for the midfoot, wrist, subtalar, and hip joints. Infiltration protocols have been established to improve the precision of IACIs in children [53][54][55]. ...
The interest and application of musculoskeletal ultrasound (MSUS) in juvenile idiopathic arthritis (JIA) are increasing. Numerous studies have shown that MSUS is more sensitive than clinical examination for detecting subclinical synovitis. MSUS is a well-accepted tool, easily accessible and non-irradiating. Therefore, it is a useful technique throughout JIA management. In the diagnostic work-up, MSUS allows for better characterizing the inflammatory involvement. It helps to define the disease extension, improving the classification of patients into JIA subtypes. Moreover, it is an essential tool for guiding intra-articular and peritendinous procedures. Finally, during the follow-up, in detecting subclinical disease activity, MSUS can be helpful in therapeutic decision-making. Because of several peculiarities related to the growing skeleton, the MSUS standards defined for adults do not apply to children. During the last decade, many teams have made large efforts to define normal and pathological US features in children in different age groups, which should be considered during the US examination. This review describes the specificities of MSUS in children, its applications in clinical practice, and its integration into the new JIA treat-to-target therapeutic approach.
... To the best of our knowledge, there is limited literature regarding diagnosis, clinical management, and therapeutic options for tenosynovitis in children, except for the use of glucocorticoids tendon sheath injections (CS-TSI) [1,5]. ...
... We conducted a retrospective cross-sectional study among patients with JIA cared for at the Rheumatology Service of the Institute for Maternal and Child Health IRCCS "Burlo Garofolo" of Trieste, Italy. Diagnosis of JIA was made according to the ILAR criteria [5], and all patients were aged less than 18 years at time of recruitment. ...
... Hendry et al. previously reported a poor agreement between clinical examination and musculoskeletal US in patients with JIA, especially for subclinical disease [11]. Pascoli et al. stated that clinical examination of the ankles in children with JIA is not sufficient on its own to assess all structures affected by inflammation; in their population, the US showed tenosynovitis in 13 ankles out of 31, although clinical examination was normal [5,12]. ...
Background:
The role of musculoskeletal ultrasound in JIA is still controversial, although there is growing evidence on its utility, especially in the diagnosis of tenosynovitis.
Methods:
We presented a retrospective cross-sectional study of a group of patients with JIA with ankle swelling followed in a Pediatric Rheumatology Service of a tertiary-level pediatric hospital in Northern Italy during the follow-up period between January 1st 2003 and December 31st 2019. Preliminary results have been presented at the EULAR Congress 2021. We enrolled only patients who underwent msk-US, and we identified those with a clinical and sonographic diagnosis of tenosynovitis. For each patient, we collected data on demographics, clinical characteristics, and therapeutic strategies during the follow-up.
Results:
On December 31st 2019, 56 swollen ankles of 48 patients were assessed with msk-US. Twenty-two ankles showed sonographic signs of joint synovitis, sixteen ankles presented signs of both joint synovitis and tenosynovitis, and fourteen ankles presented sonographic signs of tenosynovitis only. Overall, tenosynovitis was detected on 27 (56%) out of 48 children with at least a swollen ankle. In 13 patients out of 27 with tenosynovitis (48%), there was no joint synovitis of ankle or foot. Twenty-five patients with tenosynovitis (92%) achieved clinical and radiological remission: seven patients achieved remission of tenosynovitis with methotrexate only, and fifteen patients with biological drugs alone or in combination therapy.
Conclusions:
We observed that more than half of the patients with ankle swelling presented a tenosynovitis, and about 50% of them did not show sonographic signs of an active joint synovitis. Among patients with tenosynovitis, biological therapy alone or in association with DMARDs showed effectiveness in inducing disease remission.
... Therefore, it is particularly useful in patients with Juvenile Idiopathic Arthritis (JIA) [223]. Moreover, US can be used for guiding biopsies of tumors and cystic lesions and for supporting therapeutic strategies [224,225]. US is also becoming widely used for superficial tissue evaluation (skin and subdermis) in children with scleroderma and dermatomyositis. However, US is limited in the assessment of deeper lesions and the ones proximal to the airway, gastrointestinal tract, and skeletal structures [222]. ...
... US has a better sensitivity than clinical examination for the detection of inflammation in peripheral, particularly small joints [239][240][241][242][243][244][245][246]. US allows precise identification of the structures affected by the inflammatory process (joint, tendon, enthesis) with implication for JIA classification, extension, and treatment strategy (including US-guided local treatment) [225,237]. US is sensitive for tracking treatment-induced synovial changes [225]. Lanni et al. reported a strong sensitivity to change for grayscale and power Doppler US scores (standardized response mean 2.44 and 1.23), suggesting their potential use as outcome measures [247]. ...
... US allows precise identification of the structures affected by the inflammatory process (joint, tendon, enthesis) with implication for JIA classification, extension, and treatment strategy (including US-guided local treatment) [225,237]. US is sensitive for tracking treatment-induced synovial changes [225]. Lanni et al. reported a strong sensitivity to change for grayscale and power Doppler US scores (standardized response mean 2.44 and 1.23), suggesting their potential use as outcome measures [247]. ...
The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.
... Level of evidence: 3 Agree, n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100% Several studies reported complete or near-complete prolonged symptom relief after anesthetic-corticosteroid injections for tenosynovitis unresponsive to conservative management [36][37][38][39][40]. A study [39] using US guidance successfully demonstrated excellent improvement of the tendon sheath effusion and synovial hypertrophy around the anterior and posterior tibial tendon 4 weeks after injection. ...
... Level of evidence: 3 Agree, n = 53; disagree, n = 0; abstain, n = 0. Agreement = 100% Several studies reported complete or near-complete prolonged symptom relief after anesthetic-corticosteroid injections for tenosynovitis unresponsive to conservative management [36][37][38][39][40]. A study [39] using US guidance successfully demonstrated excellent improvement of the tendon sheath effusion and synovial hypertrophy around the anterior and posterior tibial tendon 4 weeks after injection. ...
Objectives
Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.
Methods
We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.
Results
A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.
Conclusion
According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.
Key Points
• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.
• Strong consensus was obtained for all statements.
• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.
... Furthermore, early occurrence of ankle arthritis has been correlated with unfavorable disease outcome (2,4). Ankle disease in JIA is frequently treated with the local injections of glucocorticoids, and systemic medications are often added in cases when the ankle remains inflamed or a multiplicity of its anatomical components are simultaneously affected (1,5,6). Precise identification of inflamed sites in the ankle is therefore crucial for a timely and effective treatment. ...
... The ankle is the second most frequently affected joint after the knee in children with JIA and is, together with the hip, the wrist, the cervical spine, and the temporomandibular joints, one of the most vulnerable sites of structural damage (1)(2)(3). Understanding the exact location of inflammation in the ankle compartments is crucial to optimize therapeutic decision-making and to pursue a successful local treatment with glucocorticoid injections (6). Achievement of complete control of inflammatory disease in the ankle helps to prevent the development of nonreversible joint damage and disability and may improve the disease outcome (4,30). ...
... In the current study, we compared the clinical evaluation and US assessment of the ankle in children with JIA who had clinically active disease in 1 or more of the 3 joint compartments that are part of the ankle region, the TT joint, the ST joint and the IT joint. The number of ankles evaluated in our study is larger than that of previous studies on ankles and US in JIA (6,7,(12)(13)(14). Unlike previous studies (13,14), we set cutoff values on both GSUS and PDUS to minimize a bias in the interpretation of US findings. ...
Objective
To compare the frequency of joint and tendon disease on ultrasound (US) and clinical examination, and to investigate agreement between US and clinical evaluation in ankles with clinically active juvenile idiopathic arthritis (JIA).
Methods
US and clinical evaluation were performed independently in the joint and tendon compartments of 105 ankles. Gray‐scale (GS) US and power Doppler (PD) US joint abnormalities were scored on a 4‐point semiquantitative scale. A joint with a GS score ≥2 and/or a PD score ≥1 was defined as active on US. Agreement was tested using kappa statistics.
Results
A total of 163 joints in 89 ankles had active synovitis on US. The tibiotalar (TT) joint was the most commonly affected joint on US and on clinical evaluation. The intertarsal (IT) joint and the subtalar (ST) joint were the second in frequency on US and on clinical evaluation, respectively. Tenosynovitis was found more commonly on US than on clinical evaluation (70.5% and 32.4%, respectively), and was more frequent in the medial and lateral than in the anterior tendon compartment. Isolated tenosynovitis was detected on US in 12 of 105 ankles. Agreement between US and clinical evaluation for detection of active synovitis and tenosynovitis was less than acceptable (κ <0.4). No correlation was found between any feature of active disease recorded on clinical evaluation (joint swelling, tenderness/pain on motion, and restricted motion) and active synovitis on US in the TT joint, ST joint, and IT joint.
Conclusion
Coupling clinical evaluation with US aids in correctly localizing pathology. US training of practitioners is recommended to manage ankle disease in JIA.
... A joint effusion was defined as anechoic material within the joint space or within the suprapatellar bursa (knee), or that displaced a fat pad in the tibiotalar and subtalar joints, as previously reported. 14,15 Grading of joint effusion was performed as previously published. 15,16 Synovial thickening was defined as hypoechoic material within the joint space that was not compressible. ...
Objective
To standardize and improve the accuracy of detection of arthritis by thermal imaging.
Methods
Children with clinically active arthritis in the knee or ankle, as well as healthy controls, were enrolled to the development cohort and another group of children with knee symptoms were enrolled to the validation cohort. Ultrasound was performed for the arthritis subgroup for the development cohort. Joint exam by certified rheumatologists was used as a reference for the validation cohort. Infrared thermal data were analyzed using a custom software. Temperature after within-limb calibration (TAWiC) was defined as the temperature differences between joint and ipsilateral midtibia. TAWiC of knees and ankles was evaluated using ANOVA across subgroups. Optimal thresholds were determined by receiver operating characteristic (ROC) analysis using Youden index.
Results
There were significant differences in mean and 95 th TAWiC of knee in anterior, medial, lateral views, and of ankles in anterior view, between inflamed and uninflamed counterparts (p<0.05). The area under the curve (AUC) was higher by 36% when using TAWiC Knee than those when using absolute temperature. Within validation cohort, the sensitivity of accurate detection of arthritis in knee using both mean and 95 th TAWiC from individual views or combined all 3 views ranged from 0.60 to 0.70 and the specificity was greater than 0.90 in all views.
Conclusion
Children with active arthritis or tenosynovitis in knees or ankles exhibited higher TAWiC than healthy joints. Our validation cohort study showed promise of the clinical utility of infrared thermal imaging for arthritis detection.
... Since US enables direct visualisation and quantification of synovitis, a potential indication for the use of this imaging modality in JIA is the evaluation of therapeutic efficacy. Previous studies have assessed the response to corticosteroid injections in the wrist and ankle regions (44,45), and in the knee and hip joints (46). In these studies short-term monitoring with US documented significant changes in joint inflammation with normalisation or partial regression of the baseline synovial abnormalities in the majority of the affected sites that were injected. ...
... Blinded injections are challenging in children, due to the small size of sites to inject and to the physiological abundant fat masking bony landmarks. Thus, by enabling clear visualisation of needle placement within the target (Fig. 5), US-guidance increases the chance of success of corticosteroid injections and minimises the risk of subcutaneous atrophy (44,45). Furthermore, the use of US during tendon sheath injections prevents accidental needle entry into the tendon fibres (65). ...
Juvenile idiopathic arthritis (JIA) is the most common chronic joint disease in paediatric rheumatology. Over the last two decades, ultrasound (US) has emerged as a tool with the potential to enhance disease assessment and management of JIA. This imaging modality is safe and well tolerated by children and can be easily applied bedside in the clinical setting. Owing to the lack of published studies regarding the validity and reproducibility of US in JIA and the difficulties in interpreting images of children, US was initially perceived like an art rather than a science. In recent years, a great deal of efforts has been made in order to fill the gap of scientific knowledge on US between paediatric and adult rheumatology. This has yielded significant breakthroughs, such as the achievement of valuable information about the anatomical peculiarities of the growing skeleton on US, including internationally agreed definitions on B-mode and Doppler US of components for the normal joints, and the development of a standardised scanning protocol for US examination suitable for use in children. The precise role of US in JIA, however, is yet to be fully defined. Although further research regarding the use of US in joint inflammatory pathology in paediatrics is required, this imaging modality may well possess the necessary properties to pursue the best practice in the care of children with JIA in the near future. The present review provides information on the recent advances that have made the application of US increasingly promising for the management of JIA.
... Regarding repeat injection, some studies have shown that subsequent injections are not as efficacious as the first (118). One study used imaging to determine the impact of synovial hypertrophy on ankle injections and found that those with milder hypertrophy were found to benefit the most from the injection (119). Other studies investigated relationships between inflammatory markers and efficacy and duration of the response to the injection; those positive for antinuclear antibodies did not have as good a response to the injection therapy (118). ...
