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 Table of Contents  
Year : 2018  |  Volume : 13  |  Issue : 5  |  Page : 72-74

High-Resolution musculoskeletal ultrasound in India: The present perspective and the future

1 Director, Dr ML Aggarwal Imaging Centre, New Delhi, India
2 Senior Consultant, Department of Rhuematology, BLK Hospital, New Delhi, India

Date of Web Publication1-Aug-2018

Correspondence Address:
Dr. Raghav Aggarwal
Dr ML Aggarwal Imaging Centre, A1/150, Safdarjung Enclave, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-3698.238196

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High-resolution musculoskeletal ultrasound (HRMSK US) has evolved tremendously from being performed in dark lit scanning rooms to being done at a remote setting, being one of its kind of modalities where live streaming is making remote diagnosis possible; like self-scanning by an astronaut in outer space, or, an on field assessment of an acute injury in a high-stake football match , or a hand-held device used for scanning at a remote location, with the images streamed over the net for interpretation. It began as gray scale imaging; however, as power Doppler came into practice, it gave a leap to the use of ultrasound in inflammatory arthritis. Three-dimensional power Doppler, beam steering, sonoelastography, contrast ultrasound, and fusion imaging are the new weapons in the armamentarium of MSK US. The role of MSK US ranges from detecting various changes in rheumatological diseases; be it active synovitis, bony erosions, enthesitis, assessment of crystal deposition, salivary gland changes, and vessel changes, aiding in diagnosis, especially in children. HRMSK US has an established role as a diagnostic tool, both as a primary modality and as an adjunct to other modalities in orthopedic practice and sports medicine also, and has evolved as a primary therapeutic tool in these fields, be it pinpoint-guided steroid injections, platelet-rich plasma injections, and barbotage of calcium deposition in situations such as calcific tendinitis. Even with all these advantages, it is still sparingly used in the practice of rheumatology in India. The authors believe that it is likely to be more widely used in the future given the enormous scope of its applications.

Keywords: Contrast, doppler, inflammatory arthritis, musculoskeletal ultrasound, prp injections, rhuematology, sports medicine

How to cite this article:
Aggarwal R, Aggarwal VK. High-Resolution musculoskeletal ultrasound in India: The present perspective and the future. Indian J Rheumatol 2018;13, Suppl S1:72-4

How to cite this URL:
Aggarwal R, Aggarwal VK. High-Resolution musculoskeletal ultrasound in India: The present perspective and the future. Indian J Rheumatol [serial online] 2018 [cited 2021 Oct 16];13, Suppl S1:72-4. Available from:

  Introduction Top

The first use of ultrasound in musculoskeletal disorders started with reports in the mid-seventies on gray scale imaging.[1],[2] Ultrasound has now moved out of the scanning room, to the football fields for the assessment of injuries as an on field modality, to being used by the National Aeronautics and Space Agency, USA, by their scientists in space doing a self-scanning, to self-scanning by patients or technologists by hand-held units in a remote setting and streaming of data to a remote console, for interpretation by a specialist! However, the legal restrictions in our country do not allow such widespread use of this technology presently.

The availability and low cost of ultrasound, its reproducibility, patient acceptability, nonionizing nature, and its ability to scan multiple joints in the same sitting give it an undeniable edge over other diagnostic modalities. The major advantage of ultrasound is its ability for multiplanar imaging along with the inherently dynamic nature of the ultrasound scan. High-resolution musculoskeletal ultrasound (HRMSK US) adds complementary information to most of the available diagnostic techniques, and in our experience, it has always added a new dimension to the available imaging information, each and every time we have used it!

HRMSK US in Rheumatology Practice

Over the years, the refinement of gray scale and the incorporation of power Doppler in the 1990s gave a new dimension to its usefulness and subsequently paved the way for modern rheumatological practice.[3] Power Doppler signals in the synovial tissue were consistent with active pannus in synovitis and have been used over the years as a sign of disease activity in rheumatoid arthritis (RA).[4],[5],[6]

Algorithms for ultrasound have been designed for the diagnosis, management, and follow-up of RA, with protocols to be followed at the time of making of diagnosis, to assessment of disease progression and response to therapy, to assessment of remissions and flares, to escalation protocols, to shifting from conventional disease-modifying anti-rheumatic drugs (DMARDs) to biological DMARDS, and the tapering and fine-tuning of treatment.[7] MSK US is useful in the diagnostic workup in differentiating various arthritis, namely spondyloarthritides (with predominant enthesitis) from crystal deposition disease (gout and pseudogout) and RA to degenerative joint disease, assessment of temporal arteritis, and Sicca syndrome, and very beautifully differentiates these, in a single sitting.[8]

The usefulness of MSK US in assessing remission and flareups in rheumatological processes has been validated in different studies; however, the role in the assessment of response to biological DMARDs needs further studies, in a larger cohort, for their use in the future on a regular basis.[9] The role of HRMSK US in pediatric rheumatological practice and pediatric trauma and orthopedic practice is unparalleled. There is a lot of scope in further developing pediatric application of various ultrasound techniques in the future!

HRMSK US –Diagnostics to Therapeutics

HRMSK US has evolved over the years from a breakthrough imaging technique in dynamic imaging of musculoskeletal pathologies to a standalone diagnostic modality. It is also an adjunct to other diagnostic modalities such as conventional radiography, computerized tomography (CT), and magnetic resonance imaging (MRI) in the imaging of inflammatory arthritis, in the assessment of musculoskeletal trauma, and in diagnosis of pathologies. It is a sometimes the only tool for guided therapeutics in sports medicine, rheumatological practice, and orthopaedics, whether it be guided glucocorticoid injections, platelet-rich plasma therapy, barbotage, etc., and follow-up of post procedure, even in the presence of scenarios such as a prosthesis in situ. Having a higher temporal resolution than even MRI, HRMSK US depicts finer anatomical details of anatomy and pathology and pinpoint accuracy for needle placements. It is likely that HRMSK US shall become an integral part of all rheumatology units, orthopedic units, and sports medicine units of the future in India and the world over. However, even with these advantages, HRMSK US is grossly underutilized, primarily because of lack of awareness, initiative, and training. Starting from forming validation of protocol of examination, and striving toward a more widespread availability of technique and expertise, it would pave a solid way for its future use, applications, and advancements.

Imaging of peripheral nerves dynamically has been revolutionized by HR US. Therapeutics for nerve entrapments, etc., can also be done in the same sitting as the diagnostic, whether it be ultrasound-guided corticosteroid injections or hydrodissection!

Sono Elastography

Sonoelastography (SEL) is an ultrasound-based technique, whereby the degree of distortion which occurs under external force, which causes strain, and a color map is generated, with a quantitative and qualitative mapping of the relative hardness of the tissues. SEL was used in the past for assessment of various pathologies of the liver, thyroid prostate, breast, etc. It developed as a diagnostic tool in musculoskeletal disorders, with roles in assessment of tendon Achilles pathologies, tennis elbow, rotator cuff disease, pulley ligaments of the fingers, etc., whereby it could differentiate a hemorrhagic tendon from a degenerative or a partially torn tendon or edema, all which may give a similar hypoechoic appearance on gray scale high-resolution scanning. There are exciting innovations such as image fusion of elastography with CT and MRI and three-dimensional (3D) elastography, the frontiers of which are being explored! Quantitative shear-wave elastography has been used to assess muscles at rest and exercise, mechanism and pathologies of muscle injuries, and healing, especially in athletes. With the incorporation of shear-wave elastography into present-day high-resolution probes, it has become possible to study elastography of the synovium in RA [10],[11] in which the synovium in patients with RA is softer than in controls [Figure 1]. Although elastography is exciting, it is not without its limitations, such as lack of standardization.[10] Hopefully, the future would resolve these dilemmas!
Figure 1: On the left: gray scale synovial hypertrophy; on the left: elastogram showing synovium as soft

Click here to view

Contrast Enhanced Ultrasound

Contrast-enhanced ultrasound can detect accurately the slow flow of angiogenesis, RA, and tumors, as these are helpful in RA to assess active proliferative synovium/pannus, to assess disease activity and response to therapy, and to differentiate fibrotic synovial thickening from active pannus[Figure 2]. It holds a promise in the future for being a gold standard for disease activity, as it has a direct ability to assess active angiogenesis. 3D power Doppler studies [12] and their use in an objective assessment in diagnostics and therapeutic response in inflammatory arthritis and the use of techniques of elastography, image fusion, and microbubble ultrasound contrast in HRMSK US are being used for differentiating fibrotic synovium from active synovitis [10],[11] [Figure 2]. These are newer tools which require validation. Quantitative power Doppler has been used to prognosticate patients for radiological progression,[12] using 3D power Doppler volume and 2D vascularity scores.[13] In turn, this may help decide of early use of targeted therapies. Image fusion between CT, MRI, and ultrasound has overcome the major limitation of ultrasound, i.e., user dependence, and this is useful in scenarios such as facet joint injections and sacroiliac joint injections. This may also be a good teaching tool in the future.
Figure 2: Contrast ultrasound showing contrast enhancement, suggestive of active synovitis

Click here to view

  Conclusion Top

The advancements in technology, in the form of new equipment and hardware, and special probes such as high-frequency linear matrix probes, hockey stick probes, 3D volume high-resolution probes, being available now, new postprocessing algorithms, and high-resolution power Doppler 3D, contrast-enhanced studies, along with advancements in one's skill and knowledge, could pave the way further in defining the role of HR US. The requirement of high-end equipment, along with specialized, structured training in the future, would pave the way for the widespread use of this technique and technology, in day-to-day practice. There is a learning curve, as is there in any technology, but we have to start somewhere. Although the ultrasound lacks the ability to peep inside a joint, with the requirement of an echo-window, to the inability to assess bone edema, the present advantages make ultrasound an indispensable tool for the rheumatologist, orthopedic surgeon, and sports medicine consultant of future India and will be one of the most versatile weapon in the armamentarium of the future radiologist and clinician!

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Conflicts of interest

There are no conflicts of interest.

  References Top

McDonald DG, Leopold GR. Ultrasound B-scanning in the differentiation of baker's cyst and thrombophlebitis. Br J Radiol 1972;45:729-32.  Back to cited text no. 1
Cooperberg PL, Tsang I, Truelove L, Knickerbocker WJ. Gray scale ultrasound in the evaluation of rheumatoid arthritis of the knee. Radiology 1978;126:759-63.  Back to cited text no. 2
Newman JS, Adler RS, Bude RO, Rubin JM. Detection of soft-tissue hyperemia: Value of power Doppler sonography. AJR Am J Roentgenol 1994;163:385-9.  Back to cited text no. 3
Naredo E, Rodríguez M, Campos C, Rodríguez-Heredia JM, Medina JA, Giner E, et al. Validity, reproducibility, and responsiveness of a twelve-joint simplified power Doppler ultrasonographic assessment of joint inflammation in rheumatoid arthritis. Arthritis Rheum 2008;59:515-22.  Back to cited text no. 4
Ellegaard K, Torp-Pedersen S, Terslev L, Danneskiold-Samsøe B, Henriksen M, Bliddal H, et al. Ultrasound colour Doppler measurements in a single joint as measure of disease activity in patients with rheumatoid arthritis – Assessment of concurrent validity. Rheumatology (Oxford) 2009;48:254-7.  Back to cited text no. 5
Hammer HB, Sveinsson M, Kongtorp AK, Kvien TK. A 78-joints ultrasonographic assessment is associated with clinical assessments and is highly responsive to improvement in a longitudinal study of patients with rheumatoid arthritis starting adalimumab treatment. Ann Rheum Dis 2010;69:1349-51.  Back to cited text no. 6
D'Agostino MA, Terslev L, Wakefield R, Østergaard M, Balint P, Naredo E, et al. Novel algorithms for the pragmatic use of ultrasound in the management of patients with rheumatoid arthritis: From diagnosis to remission. Ann Rheum Dis 2016;75:1902-8.  Back to cited text no. 7
Taljanovic MS, Melville DM, Gimber LH, Scalcione LR, Miller MD, Kwoh CK, et al. High-resolution US of rheumatologic diseases. Radiographics 2015;35:2026-48.  Back to cited text no. 8
Haavardsholm EA, Aga AB, Olsen IC, Lillegraven S, Hammer HB, Uhlig T, et al. Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial. BMJ 2016;354:i4205.  Back to cited text no. 9
Abd ellah MM, Bamidele JO, Debbage P, Taljanovic M, Jaschke W, Klauser AS. Future of musculoskeletal ultrasound. Curr Radiol Rep 2015;3:21.  Back to cited text no. 10
Sammel AM, Spies MC, DeCarle R, Rayment M, Joshua F. Shear-wave elastographic ultrasound of metacarpophalangeal synovium in rheumatoid arthritis – A pilot study. Australas J Ultrasound Med 2017;20:58-65.  Back to cited text no. 11
Sreerangaiah D, Grayer M, Fisher BA, Ho M, Abraham S, Taylor PC, et al. Quantitative power Doppler ultrasound measures of peripheral joint synovitis in poor prognosis early rheumatoid arthritis predict radiographic progression. Rheumatology (Oxford) 2016;55:89-93.  Back to cited text no. 12
Strunk J, Strube K, Müller-Ladner U, Lange U. Three dimensional power Doppler ultrasonography confirms early reduction of synovial perfusion after intra-articular steroid injection. Ann Rheum Dis 2006;65:411-2.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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