Joint Imaging in Rheumatology

Renu Saigal

here are various modalities of joint imaging e.g.

conventional radiography (CR), computed tomography
(CT), magnetic resonance imaging (MRI), bone scintigraphy,
positron emission tomography (PET), ultrasonography (US),
bone densitography. CR shows only bone lesions, while CT
demonstrate both bone and soft-tissue changes. MRI is
the best modality at showing soft tissue contrast than CT
scan and is multiplanar, but less sensitive in assessing bone
lesions than CT.
CONVENTIONAL RADIOGRAPHY
Not only does CR establish the presence of disease, but
serial films can be used to assess change or response to
therapy. Bone erosions, joint space narrowing, subluxation,
malalignment and ankylosis of the joints may be seen. Early
bone changes are not seen in plain x-rays.

Fig.1: RA : Erosions feet lateral aspect of the fifth

metatarsal head (curved white arrow), Erosions of the great
toe metatarsal head and medial cuneiform (black arrows).

Rheumatoid Arthritis (RA)

X-ray hands and feet PA view (Fig 1 & 2) will show changes
in metacarpophalangeal (MCP), proximal interphalangeal
(PIP), carpal joints of hands, and metatarsophalangeal (MTP)
and interphalangeal joints of feet. Distal interphalangeal
joints (DIP) are not involved in RA. Serial measurements
of radiological progression provide substantially more
information than a single X-ray.
Early changes:
1. Fusiform soft tissue swelling around joints
2. Periarticular osteopenia (PAO)
3. Joint space narrowing (JSN)
Delayed changes:
1. Periarticular erosions (Fig 2)
2. Cystic spaces

Fig.2: RA : Erosions hands (RA), JSN carpal CMC , PAO 1st,4th

&5th MCP

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3. Subluxations e.g. ulnar deviation and deformities

4. Ankylosis.
Erosions are diagnostic of RA, their presence early in the
disease suggests a poor prognosis. The erosions are located
at the so-called bare areas at the margins of the joint,
not covered by cartilage. Metacarpal and metatarsal heads
are frequently involved at an early stage. Early erosions in
the hands and wrist occur typically on the radial aspects of
the index and middle metacarpal heads, around the ulnar
styloid, and on the ulnar aspect of the head of the little
finger metacarpal. Deeper sub-articular cysts, or geodes,
may cause substantial bone resorption, either as the result
of intraosseous pannus or of synovial fluid entering bone via
a localized cortical defect.
In the feet erosions of bare areas on the heads of the
metatarsals may be seen. Subluxation of proximal phalanges
and hallux varus or valgus deformities of great toe may also
be seen. Feet involvement may be concurrent with hand
involvement or may be involved later. Earleist erosions are
seen on the lateral aspect of 5th metatarsal head (Fig.1).
Knee joints show pancompartmental JSN. Hip joints are
involved in about 21% of cases and it is bilateral. Diffuse
JSN and erosions of femoral head and acetabular surface can
lead to protrusion of femoral head and acetabulum into the
pelvis, called protrusio. Shoulder joints may show JSN of the
glenohumeral (best seen in Grashey view), acromiohumeral
and acromioclavicular joint. Healing of erosive damage is
rarely reported but can occur.1,2
Atlanto-axial joint subluxation due to progressive erosive
changes of odontoid process may occur, best seen in lateral,
flexed view where distance between anterior arch of C1 and
anterior aspect of dens of C2 increases (Normal - 3mm).
Spondyloarthropathy (SpA)
Axial skeleton like spine and sacroiliac joints (SI) are
characteristically involved in SpA. Subchondral bony
erosions occur on the iliac side of SI joints, followed by bony
proliferation and sclerosis. Changes occur in lower 1/3rd
of SI joints which is synovial . Joint space initially appear
to be widened , gradually whole of the SI joint is involved
which ultimately fuses (Fig.3,4,5,6). Sclerosis disappears
when fusion is complete.
Initially spine is involved in lumbosacral & thoracolumbar
segment, so x-ray of these regions AP and lateral view
should be done.

Fig.3: SpA : Grade 1. Sacroiliitis : Blurred joint margins

Fig.4: SpA -AS : Grade 2 Sacroiliitis : Early erosions &

Sclerosis at left Sacroiliac joint & early mild changes at
right

Fig.5: SpA: Bilateral grade 3 sacroiliitis with subchondral

sclerosis, erosions, and irregular widening of the joints

Fig.6: SpA.Grade 4Sacroiliitis - Complete ankylosis of SI joint

Following lesions are seen:

1. Enthesitis i.e. inflammation at sites of insertion of
ligaments, tendons and joint capsule into bone and
leads to new bone formation. CR of heel lateral view

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and pelvis may show retrocalcaneal and infracalcaneal

spurs (Fig.7) and whiskers around pelvis.
In spine this manifests as small erosion surrounded by
bony sclerosis at the vertebral corners seen as shiny
corners known as Romanus lesions.
2. Syndesmophytes - Ossification of outer annular fibers to
form marginal and symmetric bony outgrowths, which
can be differentiated with osteophytes as latter grows
outward or perpendicular to the vertebral body. Complete
fusion of the vertebral bodies by syndesmophytes may
occur producing bamboo spine(Fig.8 & 9).
3. Squaring of the vertebral bodies caused by corner
erosions and new bone formation leading to loss of
normal concavity of anterior border of vertebral body
(Fig.10). Shiny corner sign, squaring of vertebrae, and
syndesmophytes may antedate the development of
radiographic sacroiliitis in a small minority of patients3
They are commonly found at the thoracolumbar
junction4.
4. Erosions followed by ankylosis of costotransverse and
costovertebral joints may occur.
5. Andersson lesion: Fractures through ankylosed spine
becomes the single point of motion in the entire spine
resulting in non-union with pseudoarthrosis.
6. Peripheral arthropathy: Hips, knees and shoulders are
affected in 1/3rd patients. Hip joints show uniform JSN
and medial migration of femoral head.
Five subgroups of spondyloarthritis are distinguished:
Ankylosing spondylitis (AS)

Fig.8: SpA.CR showing ossification

of the anterior spinal ligament
and Syndesmophytes

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Reactive arthritis ( Reiter syndrome)

Psoriatic arthritis (PsA)
Arthritis associated with inflammatory bowel disease (eg,
Crohn disease or ulcerative colitis)
Undifferentiated spondyloarthritis
SI joint (asymmetric or symmetric) and spine involvement is
seen in 20-40% patients of ReA and PsA and syndesmophytes
are non-marginal, asymmetric and coarse(Fig.11). Bone
proliferation occurs in SpA especially in PsA and ReA
resulting in bony excrescences {Mouse ear (Fig.12)} and
periosteal new bone formation. Entire phalanx may become
"cloaked" in new bone "Ivory phalanx"(Fig.13), most frequent
in terminal phalanges of toes, especially first. Other
manifestations of PsA are pencil in cup deformity (Fig.14).

Fig.7: SpA: Fluffy whiskers retrocalcaneal and infra

calcaneal

Fig.9: SpA - Bamboo Spine

Fig 10.SpA: vertebral squaring thoracic

spine

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Fig.11: PsA : Jug Handle (Comma shaped)

Asymmetrical, thick, non-marginal Syndesmophyte
(parasyndesmophytes)

Fig.14: PsA . Pencil in cup appearance Erosion of one end of bone with expansion of the base
of the contiguous bone

Fig.12: PsA - Mouse ear appearance of terminal phalanx

of 2nd DIP, erosions base of 2nd 3rd and 5th proximal
phalanx

Fig.15: PsA : Arthritis Mutilans

Fig.16: PsA : Erosions DIP : No PAO unlike RA

Right Panel : Marked erosions PIP & Pencil in cup right
4th PIP

Fig.13: PsA-Ivory Phalanx & periosteal bony excrescense

There may be marked destructive changes with subluxation

(Arthritis mutilans 15 & 16 ) and involvement of DIP (Fig.16)
in PsA.

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Fig.17: Gout a) X-Ray hands (oblique view)bone erosions located in MCP joints and in PIP & DIP joints. (b) X-Ray foot (
dorsal-plantar projection) extensive bone erosions involving the first and fifth MTP joints, and PIP & DIP joints. Intratophus
calcifications in intraosseous tophi and in periarticular tophi. (c) X-Ray tarsal bones (oblique view) showing erosions in
the scaphoid and first metatarsal bone, with typical overhanging edges. Soft-tissue masses due to extensive tophaceous
deposition may also be observed.

Crystal Arthropathy
Gout: Characteristic radiological changes are:
Intra-articular or periarticular erosions which are aligned
with long axis of bone (Fig.17) and may have a rim of
sclerosis. Overhanging margins (Martels sign) is typical of
gout (Fig.18) and occurs as tophus wedges into joint. JSN
does not occur until late in the disease.
Calcium pyrophosphate dihydrate deposition (CPPD)
disease:Calcification in articular cartilage is linear and lies
in the mid-zone (Fig.19).
Hydroxyapatite deposition disease (HADD):
Calcium hydroxyapatite crystals are mostly idiopathic but
may be associated with renal failure or diabetes mellitus.
Supraspinatus tendon is the most common periarticular sites
of HADD (Fig.20).
Fig.18: Gouty erosions on the medial aspect of the
metatarsophalangeal and interphalangeal joints. At the base
of the distal phalanx a typical overhang is seen

Radiography in collagen vascular diseases: Systemic

Sclerosis (SSc): (Fig 21)

Fig.19: CPPD Disease : Knee joint AP & Lateral view : Meniscal calcification
extending into the posterior capsule. There is Popliteal artery calcification

Fig.20: HADD :Supraspinatus

calcification

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Fig 22. AS . CT SI Joints : Erosive bilateral sacroiliitis. Bony

spur formation seen on the left iliac side.
Fig.21: SSc - Destructive changes in the DIP joints soft-tissue
calcifications & resorption of the tip of the distal phalanx
of the left middle finger

CT Scan
The current use of CT is in the detection of change in
calcified tissues, as these are less well visualized at MRI.
CT scan detects calcifications in soft tissues (capsular and
ligamental). CT helps in detecting CPPD, diffuse idiopathic
skeletal hyperostosis (DISH) and Pagets disease. In SpA,
initial involvement of only one side of the sacroiliac joints
or new bone formation and/or destruction of the joint
cartilage with complete fusion are all accurately visualized
using CT (Fig.22) and apophyseal joints like costovertebral
and sternoclavicular joints which may be involved in SpA
are also well visualized in CT scan . HRCT increases the
accuracy of CT imaging, which helps in confirmation, and
exclusion of sacroiliitis.
CT scans may be :
High-resolution CT (HRCT);
Contrast-enhanced CT (CECT);
Helical (spiral) CT and dynamic CT;
Dual Energy CT.
Quantitative CT (QCT)
Dual-energy CT (DECT) imaging helps in computerised
quantification of tophus volume in peripheral joints. DECT
scans are performed using a renal stone colour-coding
protocol that specifically assesses the chemical composition
of the material (i.e. urate coloured in red, calcium coloured
in blue). DECT is the only imaging method described to date

Fig.23: GoutyTophi:DECTMultiple urate deposits (red)

that can confirm the diagnosis of chronic topheceaous gout

with high accuracy (Fig.23).
QCT can assess both bone volume and bone density in the
axial and appendicular skeletons and separately measures
cortical and trabecular bone. Irradiation dose is high which
precludes its use for assessment of normal persons in
research studies.

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Fig.24: MRI - RA T1-weighted (upper panels) and fatsuppressed T2-weighted (lower panels) images (a) baseline
(b) 3 months; (c) 6 months. (a) Baseline images show no
abnormality. (b) Three-month images show a focal defect
along the ulnar margin (arrow) containing low-signal
intensity on T1-weighted images and high-signal intensity
on T2-weighted images consistent with a small watercontaining cavity - an erosion.

Fig 25.MRI.RA.Synovial enhancement with GdDTPA. (a) Three-dimensional gradient-echo

image of a wrist following IV Gd-DTPA shows
extensive enhancing synovitis and distension
of the synovial cavity. (b) Repeat MRI with Gd
-DTPA following 3 months of DMARD therapy
shows marked reduction of enhancing tissue

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Magnetic Resonance Imaging (MRI)

MRI is ideal for imaging diarthrodial joints and can examine
all components of the joint simultaneously and therefore the
joint as a whole organ. MRI is safe during pregnancy as it does
not use ionizing radiations. It is higly sensitive to detect
bone erosions in the hands and wrists of RA patients(Fig.24).
MRI can visualize pre-erosive inflammatory changes, synovial
hyperplasia and joint effusions.Two MR sequences are
done T1 & T2. Presence of inflammation in the marrow
may be obscured by the signal from marrow fat. The short
tau inversion recovery (STIR) sequence is a T2-weighted
sequence that suppresses the fat signal so that the marrow
now appears dark, and any fluid within the marrow due to
active inflammation is relatively bright. Subchondral oedema
may be seen in posteroinferior part of the SI joint in very
early stages of sacroiliitis, therefore it is the investigation
of choice in early SpA. Later erosions develop leading to
loss of the marrow fat signal on T1WI (T1 weighted image)
together with loss of subarticular bone. Enhancement
of synovium in volume, the rate and magnitude after IV
gadolinium (Gd DTPA) have been shown to correlate with
the histological severity of inflammation in the synovium5
(Fig.25). Sacroiliitis, enthesitis and temporomandibular
joints may be better seen in MRI.
Romanus lesion is seen as increased marrow signal at

Fig.26: SpA .MRI -STIR image of

spine - Large white arrow: focal
discovertebral inflammation in
the center of the T12 inferior
endplate. Small white arrows:
Romanus lesions

Fig.27: MRI STIR image of spine :

Acute inflammation at costovertebral
joints Long white arrows: ribs.
Black arrows: transverse processes.
Short white arrow: vertebral side of
costovertebral joint

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anterior and posterior borders of vertebrae (Fig.26).Chronic

lesions like syndesmophytes are better seen in x-rays than
in MRI6.STIR images show inflammation at costovertebral
and costotransverse joints (Fig.27). Intra-articular foreign
bodies (e.g. thorns etc) causing monoarthritis, may also
be seen by MRI or US.
Scintigraphy
Tc-99m labelled diphosphonates is used IV and closely
sequenced images are acquired using gamma camera. This
modality is used to detect how many joints are affected and
which joints are most affected and any unsuspected site if
involved can be detected. Negative bone scan shows absence
of active arthritis. Bone scans can detect erosions in RA, can
localize pain and is helpful to localize bony metastases. It is
very useful in reflex sympathetic dystrophy syndrome (RSDS)
where intense periarticular activity in an involved extremity
on the delayed phase of the scan preceded by hyperemia in
a similar distribution on the immediate post-injection blood
flow and blood pool phases of the scan is seen (Fig.28).
In SpA sacroiliitis can be seen earlier before conventional
radiography. Quantitative scintigraphy is performed by using
the sacroiliac joint-sacrum-ratio (Normal ratio 1-1.5). But
specificity of bone scan is poor.
Ultrasound
US images are produced by the sequential emission and
reception of sound waves in the range of 2.0 to 12.0 MHz by
a piezoelectric crystal, grey scale and Doppler techniques
are used. It is safe as it does not use radiation and can
distinguish solid structures from those filled with liquid.
It is helpful in following conditions:
Diagnosing ruptured Baker's cyst.
Detection of a fluid collection in joints, bursae, tendon
sheaths and soft tissues. US detects minute amounts of
fluid (1-2 ml) in asymptomatic joints of healthy subjects.
In diagnosis of enthesitis and bursitis.
In detecting synovial thickening (Fig.29), proliferation
and villous formation.
US is capable of detecting up to seven times more
erosions than plain radiography in early RA (Fig.30).7
US localizes effusions and thus guide aspiration and
increases the rate of successful aspiration when
compared with conventional aspiration of the peripheral
joints by 3-fold 8. Therapeutic intra-articular and
intralesional injection therapy is also more successfully
done under US.
Power Doppler US (PDUS) can detect smaller degrees
of synovitis with a reported accuracy equal to that of

Fig.28: 3 Phase bone scan in acute RSDS. In phase three a

diffuse increase in tracer-uptake is found around the distal
joints of the disturbed extremity

Fig.29: US:-RA Synovial Prolieration in MCP joint *

Fig.30(A): US : MCP Normal Joint

Fig.30(B): US : Erosion * in RA

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dynamic MRI (Fig 31).9

In OA, US detects thinning of the cartilage layer and
presence of osteophytes.
In Gout US:
- Double contour sign (Fig.32)10 Hyperechoic nodules
(Fig.33)10, bone erosions and tophi can be seen by US.
- Power-Doppler signal is present in acutely inflamed
joints from gout patients (Fig.34)10, and the powerDoppler signal disappears with treatment11.
- Gouty synovitis is better detected with PDUS than
with clinical examination12.
PET scan
FDG (18 fluorodeoxyglucose) PET scan has been investigated
for assessing the metabolic activity of rheumatoid synovitis.
FDG is a radiopharmaceutical analog of glucose that is
taken up by metabolically active cells. PET-CT involves
the simultaneous acquisition of both metabolic (PET) and
anatomic (CT) information which is then combined for
presentation (Fig.35)13. PET/CT is able to detect active
inflammation in areas that are clinically asymptomatic.
Detecting active inflammation at the atlantoaxial joint
before clinical symptoms develop may be a determinant of
future instability14.
Dual Energy X-Ray absorptiometry scan (DEXA Scan)
DEXA has several advantages, such as fast scanning, high
accuracy, low cost, low radiation dose, and applicability to
clinically relevant sites of osteoporotic fracture. However,
DEXA provides two-dimensional imaging of 3-D objects, does
not distinguish between trabecular and cortical bone. Hip
DEXA is preferred for diagnosis and in patients > 65 years
old as osteophytes and vascular calcification interferes with
Bone mineral density (BMD) measurement at spine. Spine
DEXA is preferred for monitoring therapy of osteoporosis as
response is earlier at spine than at hip. BMD is compared
with the expected peak bone mass of young adults (T-score),
which shows whether patient is osteopenic or osteoporotic
(Fig 36).

Fig.31: PDUS in RA : Increased Vascularity shown by coloured

spots

Fig.32: Gout : Double contour sign: transversal ultrasound

imaging of the knee joint in the anterior intercondile area
The double contour image is shown as an anechoic line
paralleling bony contour femoral cartilage.( B-mode, linear
transducers with a frequency of 9 MHz. C) knee condyles.

Fig.33: Gout :Hyperechoic images: longitudinal US imaging

of the dorsal aspect of the first MTP The hyperechoic cloudy
area represents monosodium urate deposits within the
thickened synovial membrane (arrows). MH, metatarsal
head. (B-mode, linear transducers with a frequency of 9
MHz.)

Fig.34: Gout : PDUS: longitudinal view, dorsal aspect of

an asymptomatic first MTP joints. The Doppler signal may
be seen in hyperechoic synovial areas.(Transducer with a
frequency of 14 MHz in grey scale and colour Doppler with a
frequency of 7.5 MHz)

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Fig.35: Active synovitis in RA. The 3-dimensional projection

image (top) depicts a typical pattern of synovitis of the
right knee. Bottom panel : Corresponding transaxial slices
of the PET, CT, and fused PET/CT images (from left to right)
show that the increased FDG levels correspond to thickened
synovium (arrows).

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