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com
Extended report
1
Academic Unit of
Musculoskeletal Disease, Chapel
Allerton Hospital, Leeds, UK;
2 clinical examination (CE) and ultrasound (US) with high
Department of Radiology,
Leeds Teaching Hospitals NHS
Trust, Chapel Allerton Hospital,
Leeds, UK; 3 York Hospital NHS
Trust, York, UK; 4 Bradford
Hospitals NHS Trust, St Luke’s
Hospital, Bradford, UK; 5 School
of Health and Social Care and
HealthQWest, Glasgow
Caledonian University,
Glasgow, UK
Correspondence to:
Dr R J Wakefield, Academic Unit
of Musculoskeletal Disease,
Chapel Allerton Hospital,
Chapeltown Road, Leeds, LS7
4SA, UK; medrjw@leeds.ac.uk
Accepted 28 January 2008
Published Online First
7 February 2008
1678
The optimal assessment of the rheumatoid arthritis
hindfoot: a comparative study of clinical examination,
ultrasound and high field MRI
R J Wakefield,1 J E Freeston,1 P O’Connor,2 N Reay,1 A Budgen,3 E M A Hensor,1
P S Helliwell,4 P Emery,1 J Woodburn5
ABSTRACT
Objectives: The aim of this pilot study was to compare
field MRI (as the reference standard) for the detection of
rearfoot and midtarsal joint synovitis and secondly
tenosynovitis of the ankle tendons in patients with
established rheumatoid arthritis (RA).
Methods: Patients with RA (as determined by the
modified American College of Rheumatology (ACR)
criteria) with symptoms of midfoot and rearfoot disease
were recruited. Demographic data were collected. All
underwent CE, US and high field MRI (with intravenous
gadolinium contrast) of their right foot. Percentage exact
agreement (PEA), sensitivity and specificity were calcu-
lated for CE and US when compared to MRI. Inter-reader
reliability for CE and US was also assessed.
Results: Compared to the gold standard of MRI, for CE
(joint synovitis) the ranges for sensitivity, specificity and
PEA were 55–83%, 23–46% and 46–60%, and for US
were 64–89%, 60–80% and 64–78%, respectively.
Compared to the gold standard of MRI, for CE
(tenosynovitis) the ranges for sensitivity, specificity and
PEA were 0–100%, 20–91% and 55–91%, and for US
were 0–67%, 86–100% and 59–86%, respectively.
Conclusion: CE was sensitive but US more specific in
identifying hindfoot pathology in RA when compared to
the reference standard of MRI. There was poor
interobserver variability between ultrasonographers sug-
gesting a need for standardisation of acquisition and
interpretation of US images of the hindfoot.
Foot disease in rheumatoid arthritis (RA) is a
common problem, with at least 90% of patients
affected during the course of the disease.1
Involvement usually begins in the forefoot and
later progresses to involve the midfoot and rear-
foot.2 3 Chronic inflammatory changes in the joints
and local tendons are known to result in important
and irreversible structural changes such as flatten-
ing of the medial longitudinal arch, valgus defor-
mity of the calcaneus and tibialis posterior tendon
dysfunction.4 5
Clinical decisions are often based on clinical
examination (CE) of the ankle alone (ie the
presence of tender and swollen joints) but CE can
be adversely affected by factors such as deformity,
overlying structures, obesity and peripheral
oedema. Radiography has limited value in detect-
ing soft tissue changes and lacks tissue specificity.
An earlier and more accurate method of identifying
and therefore treating joint inflammation would be
a clinical advantage.
Recently interest has therefore been directed
towards the use of new imaging techniques such as
MRI and ultrasound (US) in order to potentially
improve our assessment of inflammatory disease of
the foot.6 7 US and MRI have both previously been
shown to be more sensitive than CE for detecting
synovitis in the forefeet in RA8–11 but few data exist
for the rearfoot.12 CE has been shown to correlate
poorly with metatarsophalangeal (MTP) and tibio-
talar joint effusion detected by US.13 Maillefert et al
compared CE and high field MRI with respect to
synovitis and tenosynovitis in the hindfoot in a
mixed inflammatory arthritis cohort and also
showed a poor correlation between imaging and
CE.14 Lehtinen et al15 demonstrated that in painful
RA ankles with normal x rays, US and low field
MRI were superior to CE for the detection of
synovitis and tenosynovitis, with high concor-
dance between the imaging modalities but poor
correlation with CE.
The aim of this pilot study was to compare CE
and US with high field MRI (as the reference
standard) for the detection of (1) synovitis of the
rearfoot and midtarsal joints, and (2) tenosynovitis
of the ankle tendons in patients with established RA.
PATIENTS AND METHODS
Patient selection
Patients with RA (according to the 1987 modified
American College of Rheumatology (ACR) cri-
teria)16 with symptoms of midfoot and rearfoot
disease were recruited consecutively over a 3-
month period from the rheumatology outpatient
departments of two West Yorkshire, UK hospitals.
Local ethics committee approval was obtained. All
patients had had foot symptoms for less than 1-
month duration. Demographic and disease data
were also collected.
Clinical assessment
Clinical examination was performed by a podia-
trist (JW) for the presence or absence of swelling in
the right tibiotalar (TTJ), subtalar (STJ), talonavi-
cular (TNJ) and calcaneocuboid (CCJ) joints. The
following tendons were examined for the presence
of tenosynovitis: tibialis anterior (TA) and poster-
ior (TP), peroneus longus (PL) and brevis (PB)
(assessed together), flexor digitorum longus (FDL),
flexor hallucis longus (FHL), extensor digitorum
longus (EDL) and extensor hallucis longus (EHL).
An overall grade for the severity of the combined
foot deformities was assigned (grade 1 = mild,
Ann Rheum Dis 2008;67:1678–1682. doi:10.1136/ard.2007.079947
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Extended report

Figure 1 Sagittal T1 weighted fat

saturated post intravenous gadolinium
injection MRI and ultrasound IUS)
(longitudinal plane) showing synovitis of
the subtalar joint (medial aspect).
Synovitis is highlighted by arrows on the
MRI image and * on the US image.
T = talus, C = calcaneus.

grade 2 = moderate, grade 3 = severe), as described previously by made with the opposite side. A second experienced sonographer
our group.17 A second examiner (AB) examined the same joint (POC) also examined the same joint and tendon areas in the
and tendon areas in five randomly selected subjects in order to same five randomly selected subjects (as for clinical examina-
assess interobserver reliability. tion) in order to assess interobserver reliability.

US assessment MRI assessment

US was performed by an experienced sonographer (RJW) using
an ATL HDI (Advanced Technologies Laboratories, High
Definition Imaging, Bothel, Washington, USA) 3000 machine
employing a 10–5 MHz linear array ‘‘hockey stick’’ transducer.
Examinations were performed on the same joints and tendons
as clinical examination, although peroneus longus and brevis
were assessed individually. In addition, the STJ was examined
from the medial and lateral aspects. The presence or absence of
synovitis and tenosynovitis was recorded where appropriate.
Synovitis was defined as an abnormal hypoechoic area within
the joint and tenosynovitis as an abnormal hypoechoic area
around the tendon within the tendon sheath compatible with
the Outcome Measures in Rheumatoid Arthritis Clinical Trials
(OMERACT) ultrasound group definitions.18 Comparison was
MRI of the ankle to the midtarsal joints of the right foot was
performed using a Gyroscan ACS-NT 1.5 Tesla scanner (Philips,
Best, The Netherlands) with gadolinium contrast enhancement.
The MR imaging parameters were as follows: a 3D T1-weighted
gradient-echo sagittal pulse sequence with repetition time
22 ms, echo time 9.2 ms and flip angle 55u; a 2566256
acquisition matrix; 150–190 mm field of view; 50–60 1.5 mm
thick contiguous slices with pixel size 0.78 mm and an
acquisition time of 212 s. Sequences were obtained before and
after gadolinium contrast injection. The orientation of the right
foot in the scanner was standardised using a bespoke non-
metallic pronation-supination jig (as previously described by our
group).17 To maximise the MRI signal, two elements of a
commercial body coil were placed medially and laterally over

Figure 2 Sagittal T1 weighted fat

saturated post intravenous gadolinium
injection MRI and ultrasound (US)
(anterior longitudinal paramidline plane)
showing synovitis of the talonavicular
joint. Synovitis is highlighted by arrows
on the MRI image and * on the US image.
T = talus, N = navicular, O = osteophyte.

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Extended report

Table 1 Comparison between clinical examination (CE) and MRI for synovitis and tenosynovitis of the
hindfoot
Comparison data Inter-reader reliability data
Reader 1 Reader 2
Area assessed MRI (n) CE (n) PEA Sensitivity Specificity (n) (n) PEA PABAK

Synovitis:
TTJ 11 17 54.5 81.8 27.3 3 3 60.0 0.20
STJ 12 17 59.1 83.3 30.0 3 2 40.0 20.20
TNJ 9 17 45.5 77.8 23.1 4 2 60.0 0.20
CCJ 11 12 50.0 54.5 45.5 4 0 20.0 20.60
Tenosynovitis:
TA 1 4 77.3 0.0 81.0 1 1 60.0 0.20
TP 12 19 59.1 91.7 20.0 4 3 80.0 0.60
FDL 6 5 68.2 33.3 81.3 1 1 60.0 0.20
FHL 5 5 72.7 40.0 82.4 1 2 40.0 20.20
Peroneal* 11 13 54.5 63.6 45.5 4 3 80.0 0.60
EDL 2 3 77.3 0.0 85.0 2 1 80.0 0.60
EHL 1 3 90.9 100.0 90.5 2 0 60.0 0.20
*Peroneus longus and brevis tendons were assessed together.
CCJ, calcaneocuboid; EDL, extensor digitorum longus; EHL, extensor hallucis longus; FDL, flexor digitorum longus; FHL, flexor
hallucis longus; PABAK, prevalence and bias-adjusted k; PEA, percentage exact agreement; STJ, subtalar; TA, tibialis anterior;
TNJ, talonavicular; TP, tibialis posterior; TTJ, tibiotalar.

the ankle regions inside the jig. The MRI images were assessed
by a musculoskeletal radiologist (POC) for the presence or
absence of synovitis at the TTJ, STJ, TNJ and CCJ joints and for
presence or absence of tenosynovitis of the TP, TA, FDL, FHL,
EDL and EHL tendons.
Statistical analysis
Using MRI as the reference standard, percentage exact agree-
ment (PEA), sensitivity, and specificity of CE and US for each
joint and tendon area were calculated. Subanalysis was also
performed on the data divided into feet with a mild deformity
and those with a moderate/severe deformity (as described
above). PEA and prevalence and bias-adjusted k (PABAK)
values19 were calculated for the inter-reader reliability analyses.
RESULTS
A total of 22 patients (14 female, 8 male) were assessed. The
mean age was 52 years (range 33–70) and mean disease
duration was 6.8 years (range 1–20). All patients were on
stable doses of non-steroidal anti-inflammatory drugs
(NSAIDs). The following number of patients were on
disease-modifying antirheumatic drug (DMARD) therapy: 10
taking methotrexate monotherapy, 1 sulfasalazine, 1 hydro-
xychloroquine, 1 gold and 6 on combination methotrexate
and anti-tumour necrosis factor (TNF)a therapy. All patients
reported symptoms of pain in the subtalar/midtarsal region
with varying combinations of stiffness and instability. With
respect to foot deformity grading, 8 patients had mild, 11
moderate and 3 severe deformity.
Frequency of pathology on MRI
In the 22 patients, synovitis was noted in the following joints:
TTJ in 11 patients, STJ in 12, TNJ in 9 and CCJ 11. The
commonest tendons involved were TP and peroneal tendons
involved in 12 and 11 patients respectively. The least common
tendons to be affected were TA and the extensor tendons.
When dividing the patients into those with mild and those with
moderate/severe foot deformity, an increase in all joint synovitis
and TP tenosynovitis was seen in the latter group with all three
modalities (data not shown).

Figure 3 Sagittal T1 weighted fat

saturated post intravenous gadolinium
injection MRI and ultrasound (US)
(anterior longitudinal midline plane)
showing synovitis of the tibiotalar joint.
Tib = Tibia, Tal = talus, Cal = calcaneus.
Synovitis is highlighted by an arrow on
the MRI image and * on the US image.

1680 Ann Rheum Dis 2008;67:1678–1682. doi:10.1136/ard.2007.079947

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Extended report

Table 2 Comparison between MRI and ultrasound (US) for synovitis and tenosynovitis of the hindfoot
Comparison data Inter-reader reliability data (n = 5*)
Reader 1 Reader 2
Area assessed MRI (n) US (n) PEA Sensitivity Specificity (n) (n) PEA PABAK

Synovitis:
TTJ 11 10 68.2 63.6 72.7 1 1 100.0 1.00
STJ med 12 8 63.6 50.0 80.0 2 1 80.0 0.60
STJ lat 12 14 72.7 83.3 60.0 4 4 100.0 1.00
TNJ 9 12 77.3 88.9 69.2 3 5 60.0 0.20
CCJ 11 11 72.7 72.7 72.7 2 1 80.0 0.60
Tenosynovitis:
TA 1 3 81.8 0.0 85.7 0 0 100.0 1.00
TP 12 9 77.3 66.7 90.0 2 2 100.0 1.00
FDL 6 3 86.4 50.0 100.0 0 0 100.0 1.00
FHL 5 0 77.3 0.0 100.0 0 0 100.0 1.00
PL 7 3 72.7 28.6 93.3 0 1 80.0 0.60
PB 11 4 59.1 27.3 90.9 0 1 80.0 0.60
EDL 2 1 86.4 0.0 95.0 0 0 100.0 1.00
EHL 1 3 81.8 0.0 85.7 0 0 100.0 1.00
*Except for TTJ where n = 4.
CCJ, calcaneocuboid; EDL, extensor digitorum longus; EHL, extensor hallucis longus; FDL, flexor digitorum longus; FHL, flexor
hallucis longus; PABAK, prevalence and bias-adjusted k; PB, peroneus brevis; PEA, percentage exact agreement; PL, peroneus
longus; STJ, subtalar; TA, tibialis anterior; TNJ, talonavicular; TP, tibialis posterior; TTJ, tibiotalar.

CE compared to MRI (table 1) Tendons

Joints
CE detected synovitis in 63 joints compared to 43 with MRI.
There was poor correlation between CE and MRI as demon-
strated by low PEA (range 45.5–59.1). The sensitivities of CE
were generally high except at the CCJ (range 54.5–81.8) but
with poor specificity (range 23.1–45.5).
Tendons
CE detected tenosynovitis at 53 sites compared to 38 with MRI.
PEA values were generally higher than for synovitis except for
the peroneal tendons (range 54.5–90.9). The sensitivities of CE
were variable, ranging from 0–100%. Sensitivity was highest at
the TP and EHL and the lowest at EDL and TA. Specificities
were generally higher than for joints, ranging from 20–90.5. The
highest values were seen for EHL and EDL and the lowest for TP
and the peroneal tendons.
US compared to MRI (table 2, figs 2 and 3)
Joints
US and MRI detected synovitis in 55 joints each. PEA values
ranged from 63.6–77.3. Sensitivities ranged from 50–88.9, the
lowest being medial STJ and the highest TNJ. Specificities
ranged from 60–80, the lowest being lateral STJ and the highest
medial STJ.
Tendons
US detected tenosynovitis in 31 tendons compared to 56 on
MRI. PEA values ranged from 59.1–86.4 at the peroneal brevis
and FDL respectively. Sensitivities ranged from 0–66.7 (lowest
TA/EDL and EHL and highest TP) and specificities from 85.7–
100 (lowest TA and highest FDL/FHL).
Interobserver reliability for CE (table 1)
Joints
Reader 1 identified synovitis in 14 joints whereas reader 2
identified 7. PEA ranged from 20–60, the lowest value being for
CCJ and the highest for TTJ. PABAK ranged from 20.6–0.2 (the
lowest for CCJ and the highest for TTJ and TNJ).
In all, 15 tendons were found to be affected by tenosynovitis by
reader 1 and 11 by reader 2. PEA ranged from 0.4–0.8, the lowest
being for FHL and the highest for TP, EDL and peroneal
tendons. PABAK ranged from 20.2–0.6, the lowest for FHL and
the highest TP, EDL and peroneal tendons.
Interobserver reliability for US (table 2)
Joints
Readers 1 and 2 both identified synovitis in 12 joints each, with
PEA results ranging from 60–100, the lowest value for TNJ.
PABAK ranged from 0.2–1, the lowest value again being for
TNJ.
Tendons
Reader 1 identified tenosynovitis in two tendons compared to
five by reader 2. PEA ranged from 80–100, the lowest value for
the peroneal tendons. PABAK ranged from 0.6–1, the lowest
being for the peroneal tendons.
DISCUSSION
In patients with established RA with symptomatic foot disease,
CE correlated poorly with MRI for the detection of synovitis
and tenosynovitis. Although CE was sensitive for detecting
pathology, it crucially lacked specificity especially for synovitis.
By contrast, US had better correlation with MRI and was more
specific for pathology (especially tenosynovitis) but lacked
sensitivity. These data highlight the difficulty of using CE
alone to assess the rheumatoid foot as findings may be
unreliable. In particular, CE, unlike imaging, can be confounded
by external factors such as obesity and subcutaneous oedema.
This study was the first to our knowledge to employ high field
MRI in a formal comparison of three assessment modalities (CE,
MRI and US) in the rheumatoid foot. This was also the first
study that assessed any differences in CE and US results related
to the degree of foot deformity.
These data are similar to those found by Lehtinen et al15
although their results were qualitative and no formal statistical
comparison was made between the three assessment modalities.

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Extended report
In addition, low field 0.1T MRI rather than high field was used
although the authors did use intravenous gadolinium contrast,
which would improve sensitivity and specificity for synovitis.
Maillefert et al14 found a poor correlation between high field
MRI and CE with k values of 0.1 for synovitis and 0.27 for
tenosynovitis. The authors studied a mixed inflammatory
disease cohort including only nine patients with RA so it is
difficult to extrapolate further on their detailed results for
different joints and tendons. Scheel et al20 compared US with
high field MRI in only four patients with inflammatory arthritis
demonstrating poor interobserver agreement (k 0.28) for US
when compared to MRI; however, this figure was for a
combination of ankle and toe joints. Premkumar et al21
examined the TP and FDL tendons in 31 patients with high
field MRI and US (using colour Doppler), showing that US had
a high sensitivity (80%) and specificity (90%) for diagnosing
tendinopathy compared to MRI. None of these studies,
however, assessed intraobserver variation.
There may be a number of different reasons why CE appeared
poor in some cases. First, anatomical structures lie close together
or may be overlying making it difficult to differentiate between
adjacent structures; for example, the STJ and TP tendon.
Second, the amount of inflammatory tissue present may be
small, making it harder to detect particularly in areas predis-
posed to osteophytes such as the midtarsal region. Third, joints
such as the TTJ and STJ lie relatively deep to the skin, making
assessment by palpation more difficult. However, in this study
we used an experienced podiatrist in order to maximise CE
findings. It could be argued, however, that podiatrists are most
effective at assessing deformity and have less experience at
detecting synovitis.
The limitations of this study included the small number of
patients studied, which limits the ability to extrapolate from
these results to wider clinical practice. Only five patients were
used in the assessment of interobserver variation, which may
account for the low PABAK values seen for some joint and
tendon areas. US showed a marked interobserver variation
despite readers being experienced. This may be artefactual
because of small numbers or because there is a lack of
standardisation of image acquisition/interpretation.
Dichotomous scoring was used for the MRI and US images
but a more quantitative assessment may have allowed us to
identify a threshold above which CE proved to be much more
specific in its identification of pathology. Radiographs were not
performed and bone damage was not evaluated. Technical
limitations included examining the TTJ only from the anterior
aspect on US as per EULAR guidelines whereas MRI is
tomographic and thus gives a potentially more accurate
assessment. Due to the perceived low sensitivity of the power
Doppler tool on the US machine used for this study, we were
not able to employ this assessment in our US examination,
which may have increased specificity but decreased sensitivity.
In conclusion, CE was sensitive but US more specific in
identifying hindfoot pathology in RA when compared to the
reference standard of MRI. Even though the foot is not part of
the typical disease activity clinical assessment (such as the
1682
DAS28), foot problems are an important cause of disability in
RA and imaging offers a means to further investigate and direct
therapy (such as corticosteroid injections). This study has
highlighted the poor interobserver variability between ultra-
sonographers suggesting a need for standardisation of acquisi-
tion and interpretation of US images of the hindfoot.
Competing interests: None.
Ethics approval: Local ethics committee approval was obtained.
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Ann Rheum Dis 2008;67:1678–1682. doi:10.1136/ard.2007.079947
 Downloaded from http://ard.bmj.com/ on April 5, 2015 - Published by group.bmj.com

The optimal assessment of the rheumatoid

arthritis hindfoot: a comparative study of
clinical examination, ultrasound and high
field MRI
R J Wakefield, J E Freeston, P O'Connor, N Reay, A Budgen, E M A
Hensor, P S Helliwell, P Emery and J Woodburn

Ann Rheum Dis 2008 67: 1678-1682 originally published online February
7, 2008
doi: 10.1136/ard.2007.079947

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