The role of musculoskeletal ultrasonography in the early diagnosis and differentiation of rheumatoid arthritis, psoriatic arthritis and cutaneous psoriasis
Main Article Content
Abstract
Introduction. Inflammatory arthritis, including rheumatoid arthritis (RA) and psoriatic arthritis (PsA), presents with overlapping clinical manifestations, making early differentiation crucial for effective treatment. Musculoskeletal ultrasonography has emerged as a sensitive imaging tool for detecting early inflammatory and structural changes, aiding in precise diagnosis.
Objective. This study aims to identify specific musculoskeletal ultrasonography parameters distinguishing RA, PsA, and psoriasis (PsO), facilitating early diagnosis and optimizing therapeutic strategies.
Methods. A cross-sectional study was conducted on 274 patients diagnosed with inflammatory musculoskeletal diseases, categorized into three groups: 127 PsA, 91 RA, and 56 PsO patients. All participants underwent clinical and ultrasonographic assessment, evaluating synovial hypertrophy, joint effusions, tenosynovitis, enthesitis, and bone erosions using Gray Scale and Power Doppler techniques. Statistical analysis was performed using SPSS 26.0.
Results. Musculoskeletal ultrasonography revealed significant differences between PsA, RA, and PsO. Synovial hypertrophy and bone erosions were predominant in RA (75.67%) and PsA (48.48%), with tenosynovitis affecting flexor tendons in PsA and extensor tendons in RA. Subclinical enthesitis was present in 72.72% of PsA patients and 45% of PsO patients, while radiocarpal joint effusions were more common in RA (59%). PsO patients exhibited mild, subclinical changes, with 40% showing early synovio-entheseal inflammation.
Conclusions. Musculoskeletal ultrasonography is a valuable tool for the early differentiation of inflammatory arthritis types, allowing detection of subclinical enthesitis and tenosynovitis in PsA, as well as progressive synovial hypertrophy and erosions in RA. Periodic musculoskeletal ultrasonography monitoring in PsO patients may help predict PsA onset, improving early intervention strategies.
Keywords:
musculoskeletal ultrasonography, rheumatoid arthritis, psoriatic arthritis, enthesitis, early diagnosis
Article Details
How to Cite
RUSSU, Eugeniu et al.
The role of musculoskeletal ultrasonography in the early diagnosis and differentiation of rheumatoid arthritis, psoriatic arthritis and cutaneous psoriasis.
Medical Research Archives, [S.l.], v. 13, n. 4, apr. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6488>. Date accessed: 15 may 2025.
doi: https://doi.org/10.18103/mra.v13i4.6488.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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18. Kay J, Upchurch KS. ACR/EULAR 2010 rheumatoid arthritis classification criteria. Rheumatology (Oxford). 2012 Dec;51 Suppl 6:vi5-9. doi: 10.1093/rheumatology/kes279. PMID: 23221588.
19. Ben Abdelghani, K., Boussaa, H., Miladi, S., Zakraoui, L., Fazaa, A., Laatar, A. Value of Hands Ultrasonography in the Differential Diagnosis Between Psoriatic Arthritis and Rheumatoid Arthritis. J. Ultrasound Med. 2023, 42, 1987–1995. doi.org/10.1002/jum.16215.
20. Aydin, S.Z., Mathew, A.J., Koppikar, S., Eder, L., Østergaard, M. Imaging in the diagnosis and management of peripheral psoriatic arthritis. Best Pract. Res. Clin. Rheumatol. 2020, 34, 101594. doi.org/10.1016/j.berh.2020.101594.
21. Sapundzhieva, T., Sapundzhiev, L., Karalilova, R., Batalov, A. A Seven-Joint Ultrasound Score for Differentiating Between Rheumatoid and Psoriatic Arthritis. Curr. Rheumatol. Rev. 2022, 18, 329–337. doi.org/10.2174/1573397118666220215093323.
22. Ramadan, A., Tharwat, S., Abdelkhalek, A., E Eltoraby, E. Ultrasound detected synovitis, tenosynovitis and erosions in hand and wrist joints: A comparative study between rheumatoid and psoriatic arthritis. Rheumatology 2021, 59, 313–322. doi.org/10.5114/reum.2021.110550.
23. Smerilli, G., Di Matteo, A., Cipolletta, E., Grassi, W., Filippucci, E. Enthesitis in Psoriatic Arthritis, the Sonographic Perspective. Curr. Rheumatol. Rep. 2021, 23, 75. doi.org/10.1007/s11926-021-01039-1.
24. Smerilli, G., Cipolletta, E., Castaniti, G.M.D., Di Matteo, A., Di Carlo, M., Moscioni, E., Francioso, F., Mirza, R.M., Grassi, W., Filippucci, E. Doppler Signal and Bone Erosions at the Enthesis Are Independently Associated with Ultrasound Joint Erosive Damage in Psoriatic Arthritis. J. Rheumatol. 2023, 50, 70–75. doi.org/10.3899/jrheum.210974.
25. Gessl, I., A Hana, C., Deimel, T., Durechova, M., Hucke, M., Konzett, V., Popescu, M., Studenic, P., Supp, G., Zauner, M., et al. Tenderness and radiographic progression in rheumatoid arthritis and psoriatic arthritis. Ann. Rheum. Dis. 2023, 82, 344–350. https://doi.org/10.3899/jrheum.210974 doi.org/10.1136/ard-2022-222787.
26. Naredo, E., Janta, I., Baniandrés-Rodríguez, O., Valor, L., Hinojosa, M., Bello, N., Serrano, B., Garrido, J. To what extend is nail ultrasound discriminative between psoriasis, psoriatic arthritis and healthy subjects? Rheumatol. Int. 2019, 39, 697–705. https://doi.org/10.1007/s00296-018-4222-y.
27. Polachek, A., Furer, V., Zureik, M., Nevo, S., Mendel, L., Levartovsky, D., Wollman, J., Aloush, V., Tzemah, R., Elalouf, O., et al. Ultrasound, magnetic resonance imaging and radiography of the finger joints in psoriatic arthritis patients. Rheumatology 2022, 61, 563–571. doi.org/10.1093/rheumatology/keab272.
28. Ogdie, A. The preclinical phase of PsA: A challenge for the epidemiologist. Ann. Rheum. Dis. 2017, 76, 1481–1483. doi.org/10.1136/annrheumdis-2017-211109.
29. Chen, Z.-T., Chen, R.-F., Li, X.-L., Wang, Q., Ren, W.-W., Shan, D.-D., Zhao, Y.-J., Sun, L.-P., Xu, H.-X., Shi, Y.-L., et al. The role of ultrasound in screening subclinical psoriatic arthritis in patients with moderate to severe psoriasis. Eur. Radiol. 2023, 33, 3943–3953. doi.org/10.1007/s00330-023-09493-4.
30. Naredo, E., Moller, I., de Miguel, E., Batlle-Gualda, E., Acebes, C., Brito, E., Mayordomo, L., Moragues, C., Uson, J., de Agustin, J.J., et al. High prevalence of ultrasonographic synovitis and enthesopathy in patients with psoriasis without psoriatic arthritis: A prospective case-control study. Rheumatology 2011, 50, 1838–1848. doi.org/10.1093/rheumatology/ker078.
31. Ruyssen-Witrand, A., Jamard, B., Cantagrel, A., Nigon, D., Loeuille, D., Degboe, Y., Constantin, A. Relationships between ultrasound enthesitis, disease activity and axial radiographic structural changes in patients with early spondyloarthritis: Data from DESIR cohort. RMD Open 2017, 3, e000482. doi.org/10.1136/rmdopen-2017-000482.
32. Lackner, A., Heber, D., Bosch, P., Adelsmayr, G., Duftner, C., Ficjan, A., Gretler, J., Hermann, J., Husic, R., Graninger, W.B., et al. Ultrasound verified enthesophytes are associated with radiographic progression at entheses in psoriatic arthritis. Rheumatology 2020, 59, 2893–2897. doi.org/10.1093/rheumatology/keaa028.
2. Tom Stephanie, Zhong Yujie, Cook Richard, Zehra Aydin Sibel, Kaeley Gurjit, Eder Lihi. Development of a Preliminary Ultrasonographic Enthesitis Score in Psoriatic Arthritis — GRAPPA Ultrasound Working Group. The Journal of Rheumatology, Apr 2019, 46 (4) 384-390; doi:10.3899/jrheum.171465.
3. Di Matteo A., Mankia K., Azukizawa M., Wakefield R.J. The Role of Musculoskeletal Ultrasound in the Rheumatoid Arthritis Continuum. Curr Rheumatol Rep. 2020 Jun 19;22(8):41. doi:10.1007/s11926-020-00911-w. PMID: 32562012; PMCID: PMC7305070.
4. Dubash S.R., De Marco G., Wakefield R.J., Tan A.L., McGonagle D., Marzo-Ortega H. Ultrasound Imaging in Psoriatic Arthritis: What Have We Learnt in the Last Five Years? Front Med (Lausanne). 2020 Aug 25; 7:487. doi:10.3389/fmed.2020.00487. PMID: 32984374; PMCID: PMC7477070.
5. Filer A., Cader M., Abhishek A., et al. Ultrasound defined tenosynovitis improves the prediction of rheumatoid arthritis and persistent disease in patients with very early synovitis. Annals of the Rheumatic Diseases, 2013; 71:506-507.
6. Gudu T., Ng B., Jethwa H., Graham C., Kudva V., Rammanohar J., Zhang C., Sapsford M., Jadon D.R. Improving Imaging Modalities in Early Psoriatic Arthritis: The Role of Ultrasound in Early Diagnosis of Psoriatic Arthritis. Front Med (Lausanne). 2022 Jan 7;8:804695. doi: 10.3389/fmed.2021.804695. PMID: 35071281; PMCID: PMC8776996.
7. Gutierrez M., Filippucci E., Salaffi F., Di Geso L., Grassi W. Differential diagnosis between rheumatoid arthritis and psoriatic arthritis: the value of ultrasound findings at metacarpophalangeal joints level. Ann Rheum Dis. 2011 Jun;70(6):1111-4. doi:10.1136/ard.2010.147272. Epub 2011 Mar 15. PMID: 21406459.
8. Kaeley, G.S., Bakewell, C. & Deodhar, A. The importance of ultrasound in identifying and differentiating patients with early inflammatory arthritis: a narrative review. Arthritis Res Ther 22, 1, 2020. doi.org/10.1186/s13075-019-2050-4.
9. Kamp Felbo S., Wiell C., Ǿstergaard M., et al. Do tender joints in psoriatic arthritis reflect inflammation on ultrasound? Annals of the Rheumatic Diseases, 2020;79:1842-1843.
10. Merola J.F., Espinoza L.R., Fleischmann R. Distinguishing rheumatoid arthritis from psoriatic arthritis. RMD Open 2018;4:e000656. doi:10.1136/rmdopen-2018-000656.
11. Tang Y., Cheng S., Yang Y., Xiang X., Wang L., Zhang L., Qiu L. Ultrasound assessment in psoriatic arthritis (PsA) and psoriasis vulgaris (non-PsA): which sites are most commonly involved and what features are more important in PsA? Quant Imaging Med Surg 2020;10(1):86-95. doi:10.21037/qims.2019.08.09.
12. Chiara C. Rizzo. Ultrasound in rheumatoid arthritis. Medical Ultrasonography 15(3):199 Romanian Society of Ultrasonography in Medicine and Biology 2013-9 2066-8643. doi:10.11152/mu.2013.2066.153.cr1fc2.
13. Zabotti A., De Marco G., Gossec L., et al. EULAR points to consider for the definition of clinical and imaging features suspicious for progression from psoriasis to psoriatic arthritis. Annals of the Rheumatic Diseases, 2023;82:1162-1170.
14. Tang Y., Yang Y., Xiang X., Wang L., Zhang L., Qiu L. Power Doppler Ultrasound Evaluation of Peripheral Joint, Entheses, Tendon, and Bursa Abnormalities in Psoriatic Patients: A Clinical Study. J Rheumatol. 2018 Jun;45(6):811-817. doi:10.3899/jrheum.170765. Epub 2018 Apr 15. PMID: 29657139.
15. Boussaid, S., Ben Aissa, R., Rekik, S., Rahmouni, S., Jammali, S., Zouaoui, K., Sahli, H., Elleuch, M. Ultrasonography Enthesitis and Synovitis Screening in Psoriatic Patients: A Case Control Study. Mediterr. J. Rheumatol. 2023, 34, 495–505. doi.org/10.31138/mjr.180923.ues.
16. Balulu, G., Furer, V., Wollman, J., Levartovsky, D., Aloush, V., Elalouf, O., Sarbagil-Maman, H., Mendel, L., Borok, S., Paran, D., et al. The association between sonographic enthesitis with sonographic synovitis and tenosynovitis in psoriatic arthritis patients. Rheumatology 2024, 63, 190–197. doi.org/10.1093/rheumatology/kead202.
17. Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H; CASPAR Study Group. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006 Aug;54(8):2665-73. doi: 10.1002/art.21972. PMID: 16871531.
18. Kay J, Upchurch KS. ACR/EULAR 2010 rheumatoid arthritis classification criteria. Rheumatology (Oxford). 2012 Dec;51 Suppl 6:vi5-9. doi: 10.1093/rheumatology/kes279. PMID: 23221588.
19. Ben Abdelghani, K., Boussaa, H., Miladi, S., Zakraoui, L., Fazaa, A., Laatar, A. Value of Hands Ultrasonography in the Differential Diagnosis Between Psoriatic Arthritis and Rheumatoid Arthritis. J. Ultrasound Med. 2023, 42, 1987–1995. doi.org/10.1002/jum.16215.
20. Aydin, S.Z., Mathew, A.J., Koppikar, S., Eder, L., Østergaard, M. Imaging in the diagnosis and management of peripheral psoriatic arthritis. Best Pract. Res. Clin. Rheumatol. 2020, 34, 101594. doi.org/10.1016/j.berh.2020.101594.
21. Sapundzhieva, T., Sapundzhiev, L., Karalilova, R., Batalov, A. A Seven-Joint Ultrasound Score for Differentiating Between Rheumatoid and Psoriatic Arthritis. Curr. Rheumatol. Rev. 2022, 18, 329–337. doi.org/10.2174/1573397118666220215093323.
22. Ramadan, A., Tharwat, S., Abdelkhalek, A., E Eltoraby, E. Ultrasound detected synovitis, tenosynovitis and erosions in hand and wrist joints: A comparative study between rheumatoid and psoriatic arthritis. Rheumatology 2021, 59, 313–322. doi.org/10.5114/reum.2021.110550.
23. Smerilli, G., Di Matteo, A., Cipolletta, E., Grassi, W., Filippucci, E. Enthesitis in Psoriatic Arthritis, the Sonographic Perspective. Curr. Rheumatol. Rep. 2021, 23, 75. doi.org/10.1007/s11926-021-01039-1.
24. Smerilli, G., Cipolletta, E., Castaniti, G.M.D., Di Matteo, A., Di Carlo, M., Moscioni, E., Francioso, F., Mirza, R.M., Grassi, W., Filippucci, E. Doppler Signal and Bone Erosions at the Enthesis Are Independently Associated with Ultrasound Joint Erosive Damage in Psoriatic Arthritis. J. Rheumatol. 2023, 50, 70–75. doi.org/10.3899/jrheum.210974.
25. Gessl, I., A Hana, C., Deimel, T., Durechova, M., Hucke, M., Konzett, V., Popescu, M., Studenic, P., Supp, G., Zauner, M., et al. Tenderness and radiographic progression in rheumatoid arthritis and psoriatic arthritis. Ann. Rheum. Dis. 2023, 82, 344–350. https://doi.org/10.3899/jrheum.210974 doi.org/10.1136/ard-2022-222787.
26. Naredo, E., Janta, I., Baniandrés-Rodríguez, O., Valor, L., Hinojosa, M., Bello, N., Serrano, B., Garrido, J. To what extend is nail ultrasound discriminative between psoriasis, psoriatic arthritis and healthy subjects? Rheumatol. Int. 2019, 39, 697–705. https://doi.org/10.1007/s00296-018-4222-y.
27. Polachek, A., Furer, V., Zureik, M., Nevo, S., Mendel, L., Levartovsky, D., Wollman, J., Aloush, V., Tzemah, R., Elalouf, O., et al. Ultrasound, magnetic resonance imaging and radiography of the finger joints in psoriatic arthritis patients. Rheumatology 2022, 61, 563–571. doi.org/10.1093/rheumatology/keab272.
28. Ogdie, A. The preclinical phase of PsA: A challenge for the epidemiologist. Ann. Rheum. Dis. 2017, 76, 1481–1483. doi.org/10.1136/annrheumdis-2017-211109.
29. Chen, Z.-T., Chen, R.-F., Li, X.-L., Wang, Q., Ren, W.-W., Shan, D.-D., Zhao, Y.-J., Sun, L.-P., Xu, H.-X., Shi, Y.-L., et al. The role of ultrasound in screening subclinical psoriatic arthritis in patients with moderate to severe psoriasis. Eur. Radiol. 2023, 33, 3943–3953. doi.org/10.1007/s00330-023-09493-4.
30. Naredo, E., Moller, I., de Miguel, E., Batlle-Gualda, E., Acebes, C., Brito, E., Mayordomo, L., Moragues, C., Uson, J., de Agustin, J.J., et al. High prevalence of ultrasonographic synovitis and enthesopathy in patients with psoriasis without psoriatic arthritis: A prospective case-control study. Rheumatology 2011, 50, 1838–1848. doi.org/10.1093/rheumatology/ker078.
31. Ruyssen-Witrand, A., Jamard, B., Cantagrel, A., Nigon, D., Loeuille, D., Degboe, Y., Constantin, A. Relationships between ultrasound enthesitis, disease activity and axial radiographic structural changes in patients with early spondyloarthritis: Data from DESIR cohort. RMD Open 2017, 3, e000482. doi.org/10.1136/rmdopen-2017-000482.
32. Lackner, A., Heber, D., Bosch, P., Adelsmayr, G., Duftner, C., Ficjan, A., Gretler, J., Hermann, J., Husic, R., Graninger, W.B., et al. Ultrasound verified enthesophytes are associated with radiographic progression at entheses in psoriatic arthritis. Rheumatology 2020, 59, 2893–2897. doi.org/10.1093/rheumatology/keaa028.