Best Practice & Research Clinical Rheumatology 26 (2012) 805822

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Best Practice & Research Clinical

Rheumatology
journal homepage: www.elsevierhealth.com/berh

MRI and ultrasonography for diagnosis and monitoring of

psoriatic arthritis
Laura C. Coates, MBChB, PhD, MRCP a, b, *, Richard Hodgson, BM, PhD a, b,
Philip G. Conaghan, MBBS, PhD, FRCP, FRACP a, b, Jane E. Freeston,
MA, MD, MRCP a, b
a
b

Division of Rheumatic and Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, UK
NIHR Leeds Musculoskeletal Biomedical Research Unit, UK

Keywords:
Psoriatic arthritis
Magnetic resonance imaging
Ultrasound
Diagnosis
Outcome measures
Monitoring
Imaging

Imaging techniques such as magnetic resonance imaging (MRI)

and ultrasound (US) have been increasingly used in psoriatic
arthritis (PsA) providing additional clues to the pathogenesis of
this peripheral, axial and dermatologic disease. This has improved
our understanding of the disease and can be used to aid diagnosis
and then to follow outcomes of treatment. Both imaging modalities have highlighted the differing involvement of PsA when
compared with rheumatoid arthritis (RA) with a signicant burden
of entheseal disease, exor tenosynovitis (occurring alone or as
part of dactylitis) and other extra-capsular inammatory changes.
MRI scanning has also highlighted the link between the nail and
the distal interphalangeal (DIP) joint conrming previous clinical
observations. Imaging studies in psoriasis patients have discovered
a high level of subclinical inammatory change but the clinical
importance of such ndings has not yet been dened.
The potential use of MRI and US to monitor treatment outcomes
has encouraged research in this eld. In MRI, the PsA MRI Score
(PsAMRIS) has been developed with promising initial validation. In
US, work is ongoing with the OMERACT group to dene key
pathologies and to develop scoring systems. A few scoring systems
are available for enthesitis scoring using US which are further
being developed and rened.
Further improvements in technologies in both of these elds offer
exciting possibilities for future research. New MRI techniques offer
the chance to image previously dark structures such as tendons
which is key in spondyloarthritides (SpA). Sonoelastography may

* Corresponding author. Division of Rheumatic and Musculoskeletal Disease, Leeds Institute of Molecular Medicine,
University of Leeds, UK.
E-mail address: L.C.Coates@leeds.ac.uk (L.C. Coates).
1521-6942/$ see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.berh.2012.09.004

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also improve our understanding of tendon involvement in SpA.

Whole-body multi-joint MRI allows a snapshot of inammation
in PsA including joints, entheses and spinal involvement. Threedimensional US should improve reliability and comparability of
US scoring reducing inter-operator variability. The latest machines
offer real-time fusion imaging employing US machines with an inbuilt virtual navigator system linked to previous MRI acquisitions.
All of these new techniques should aid our understanding of PsA
and our ability to objectively measure response to therapy.
2012 Elsevier Ltd. All rights reserved.

Psoriatic arthritis (PsA) is considered as part of the umbrella group of the seronegative spondyloarthritides (SpA), including PsA, ankylosing spondylitis (AS), reactive arthritis, inammatory bowel
disease-related arthritis and undifferentiated SpA. AS is considered as the prototype SpA with typical
features such as sacroiliitis, a high prevalence of human leucocyte antigen B27 (HLA-B27) and only
minimal clinical variation. A proportion of patients with AS do have peripheral arthritis but this is much
lower than that seen in PsA [1]. However, PsA shows signicant clinical heterogeneity with potential
involvement of both the peripheral and the axial skeleton. In addition to arthritis, inammatory changes
are seen in many other tissues resulting in enthesitis and dactylitis which are considered hallmarks of
PsA. The phenotype of PsA varies signicantly and includes RA-like polyarticular disease, oligo or
monoarthritis typically of large joints and those with predominant axial or entheseal disease. This
heterogeneity must be taken into account when reviewing imaging literature in this eld.
Magnetic resonance imaging (MRI) and ultrasound (US) have helped in the identication of the
different pathologies found within PsA joints and can be used in diagnosis to help differentiate
between PsA and other inammatory arthropathies. Both techniques are also increasingly being used
to monitor disease both in clinical practice and in research studies with the use of specic scoring
techniques. This chapter aims to summarise recent MRI and US research in PsA, discussing the use of
these modalities in identifying pathology, aiding diagnosis and following disease progression.
Magnetic resonance imaging
The potential for imaging studies to contribute to the understanding of the pathogenesis of PsA is
well recognised [2]. However, there has been very little work done using modern imaging such as MRI
and ultrasound in PsA, especially in early disease, to improve our insight into the disease. High-eld
MRI with contrast enhancement is arguably the gold standard for simultaneously imaging soft
tissue and bony pathology in PsA. MRI is the most sensitive imaging modality for the assessment of
structures critical in the evolution of inammatory disease [3]. MRI allows visualisation of the area of
interest in three planes and provides detail of both the bone and surrounding soft tissue. Studies in
other inammatory arthritides such as rheumatoid arthritis (RA) have conrmed the superiority of MRI
when compared with plain lm radiography for assessing structural damage. Unlike radiography or
computed tomography (CT), there is also no ionising radiation exposure for the patient. The sensitivity
of MRI as an outcome measure in RA allows the detection of differences between treatment groups
earlier than conventional radiography, and smaller degrees of change may also be observable [4]. As
a result, MRI is being increasingly used in clinical studies, in terms of both identifying features for
diagnosis and monitoring disease progression over time [5].
The majority of MRI studies to date, particularly those comparing PsA to other inammatory arthritides
such as RA, have scanned the hand and wrist using conventional 1.5-T magnets with a surface coil. There are
some studies in PsA which have looked specically at large joints such as the knee or ankle. Conventional
MRI can only be used to scan one joint region of interest at a time and this is a limitation when assessing PsA,
which is very heterogeneous in terms of phenotype and joints involved. Conclusions that can be drawn
from MRI studies about the pattern of disease in PsA are limited when only certain phenotypes, such as
RA-like polyarticular disease, are included and when they are based on imaging of just one joint area.

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Current role of MRI: pathology

MRI allows visualisation of the diverse pathological tissues in PsA. These differing features can be
used to aid diagnosis of PsA.
Synovitis
Despite the fact that synovial tissue samples have suggested a difference in the histopathology of
PsA and RA tissue [6], joint synovitis in PsA and RA is indistinguishable on static or dynamic MRI
scanning when matched for disease activity [7]. Other features such as enthesitis, dactylitis and
spondylitis can be used to differentiate the two conditions [8]. A small study comparing 10 patients
with PsA and 10 with RA investigated the appearances of metacarpo-phalangeal (MCP) synovitis using
a 1.5-T MRI scanner. Patients included in this study were selected for MCP synovitis although the
majority had oligoarticular PsA (n 8). This highlighted similar post-contrast appearances of synovitis,
although a little higher grade in RA patients [9]. Predominant extracapsular enhancement was
described as being more striking in the PsA patients but was not a common enough feature (PsA
patients n 3 vs. RA patients n 2, p 0.252) to differentiate between diseases [9]. A slightly larger
study of post-contrast 1.5-T hand MRIs comparing PsA (n 18) and RA (n 21) also found similar
proportions with synovitis but a different distribution. MRI-identied pathology including synovitis
was more commonly seen in the proximal inter-phalangeal (PIP) joints in PsA, whereas synovitis in the
wrist, mid-carpal and MCP joints was more common in RA [10]. This study was a retrospective analysis
of MRI scans performed as part of clinical practice and therefore is likely to have selected patients with
hand involvement. Many patients with PsA, particularly those with large joint oligoarthritis, are not
likely to have synovitis in the small joints of the hands. These ndings therefore may not be generalisable to all PsA patients.
Bone erosions and bone marrow oedema
Bone erosions appear similar to those seen in RA and do not have disease-specic appearances on
MRI [11]. In both diseases, a break in the bone surface can be visualised on MRI [12]. This may be lled
with inammatory tissue or with brous tissue. It has been shown in a variety of inammatory
arthritides, including PsA, that even large erosions seen on MRI may not be identied using conventional radiography [13]. There is evidence that erosions progress at a slower rate in PsA than in early RA
[14], but obviously this is dependent on the cohort of patients studied as radiographic progression in
PsA is very variable.
The appearance of bone oedema across the inammatory arthritides is similar on MRI. Images show
an increased signal within the bone on short-tau inversion recovery (STIR) imaging, T2-weighted lms
with fat saturation and enhancement on post-contrast T1-weighted images [12]. In RA, bone marrow
oedema on MRI has been shown to correlate with osteitis on histology of peripheral joints [15]
However, in PsA, MRI bone marrow oedema has not been validated against histopathological change
at the peripheral joints, although this has been examined at the sacroiliac joints of SpA patients [16].
Bone marrow oedema is commonly described as an MRI feature of PsA. Using non-contrastenhanced MRI scanning, Giovagnoni and colleagues noted signal change in subchondral bone (bone
oedema) in 43% of their PsA patients [17]. Godfrin et al. showed that bone marrow oedema at entheses
on MRI correlated with hot spots on radionuclide scanning [18]. Bone oedema identied in the spine
and peripheral joints (knee, hip and hands) has been shown to improve in PsA with anti-tumour
necrosis factor (TNF) therapy [19,20] also suggesting that bone oedema represents tissue inammation. Similar to synovitis, the differences seen between RA and PsA for bone oedema and erosion relate
to the sites of involvement rather than a different appearance of the pathology.
In PsA, evidence linking bone erosion to preceding joint inammation is not as clear as in RA. A
cross-sectional MRI study of 28 patients with erosive PsA did show that bone marrow oedema PsA MRI
(PsAMRIS) scores were signicantly higher in the arthritis mutilans type than in other non-mutilans
PsA, and these patients also had high radiographic scores for joint damage using the modied
Sharpvan der Heijde method [21]. However, no longitudinal studies have conrmed a denite link

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between bone marrow oedema and bone erosion to date. This study also highlighted an unusual
pattern of diaphyseal bone oedema in four of the 28 patients which may be specic to PsA. This was
seen in one patient with arthritis mutilans and three patients with a non-mutilans pattern of PsA.
Enthesitis
Inammation in tendons and ligaments can be viewed on MRI as swelling of an involved tendon and
increased signal on T2-weighted images. In addition, enthesitis is represented by increased signal on
STIR images at the tendon/ligament insertion and associated signal change in the underlying bone.
McGonagle et al. studied enthesitis in knee arthritis associated with new-onset SpA (including PsA)
and RA [22]. Extracapsular oedema was seen adjacent to the enthesis at the patellar tendon, iliotibial
band and the posterior capsule of the knee in all 10 of the SpA group but only 4/10 in the RA group. Six
of the SpA patients also showed bone marrow oedema which was maximal at the site of entheseal
insertions [22]. The same group also imaged calcaneal enthesopathy showing a similar increased perientheseal signal and bone marrow oedema [23].
Extracapsular inammation
When considering extra-capsular anatomy, the features of PsA on MRI imaging are signicantly
different from RA and more closely resemble changes seen in other SpAs. Jevtic and co-workers [24]
rst described the extensive extra-capsular inammation seen on contrast-enhanced MRI scans in
PsA. In their series of 16 PsA patients, half demonstrated changes similar to those seen in RA with active
synovitis and pannus where inammatory changes were always located within the joint capsule.
However, the other half of the patients showed inammation also involving neighbouring structures
including thickened collateral ligaments and periarticular soft tissue. In one joint, predominant
extracapsular inammation was seen without signicant associated synovitis, thus raising the possibility that the joint capsule and synovium is not always the primary target in PsA [24]. However,
although these features were interesting, they were not uniform across the PsA cohort with around half
having intracapsular disease and no extracapsular inammation. This research suggested that there
may be heterogeneity in PsA where some patients have a predominantly synovial disease as in RA and
some show an extracapsular focus for their inammation, consistent with the proposal that PsA, like
SpA, is an entheseal-driven disease. It is also possible that some cases of sero-negative RA may have
been included if patients had co-existent psoriasis and fullled the Moll and Wright criteria.
Giovagnoni et al. also showed extensive inammation in the periarticular tissue beyond the joint
capsule and involving the surrounding subcutaneous tissue in patients with PsA. In patients with RA,
the inammation was conned to the joint capsule in most cases and where periarticular oedema was
seen in RA patients, it did not extend to the subcutaneous tissue [17]. A review by Spira et al. conrmed
the typical pattern of PsA with early extracapsular enhancement associated with diffuse soft-tissue
oedema spreading to the sub-cutis [25].
McGonagle et al. studied knee synovitis in patients with a recent onset (mean duration 10 weeks) of
knee effusion [22]. Ten patients with RA and 10 patients with SpA (including three with PsA) were
included. Focal soft-tissue oedema and bone marrow oedema adjacent to the entheseal insertions were
more common in SpA, despite little clinical evidence of enthesitis. This MRI pattern of inammation is
similar to that seen in peripheral enthesitis suggesting the possibility of a common pathogenesis.
Dactylitis
Dactylitis, one of the hallmark clinical features of PsA, occurs in 16%48% of PsA and can be seen in
many PsA phenotypes. It is often painful, but a chronic, non-tender dactylitic swelling can also occur.
The pathogenesis of dactylitis is still not fully understood with abnormalities seen in many of the
tissues on imaging.
The majority of imaging work on dactylitis has been performed by Olivieri et al. This group
specically imaged 12 dactylitic ngers using MRI and US, showing that all dactylitic ngers had
a moderate to severe exor tenosynovitis but no peritendinous oedema was identied. They initially
concluded that dactylitis was due to exor tenosynovitis and that the peritendinous soft tissue was not

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involved [26]. However, subsequent work by the same group showed that peritendinous inammation
and oedema were present in a proportion of dactylitic digits in addition to the exor tenosynovitis
[2729]. They have suggested that peritendinous oedema could have been caused by increased
capillary permeability secondary to exor tenosynovitis, but this remains hypothetical.
Jevtics earlier MRI study included two cases with clinical dactylitis, which was associated with
a much greater degree of extra-capsular inammation in the soft tissues around dactylitic digits. In
these cases, there was extensive soft-tissue involvement but no associated tenosynovitis [24]. Only
coronal sequences were performed in this study which could mean that tenosynovitis was missed. A
more recent study by Healy et al., imaging 19 dactylitic digits, found soft-tissue oedema and synovitis
to be the most frequent abnormalities in 69% of digits. However, in keeping with previous studies,
a wide range of other abnormalities were frequently found including exor tenosynovitis and bone
oedema the latter in several patterns ranging from discrete periarticular involvement to abnormalities in the metaphysis of the phalanx [30]. Spira et al. reviewed the imaging ndings of PsA and
highlighted the key pathology of tenosynovitis with additional synovitis or soft-tissue oedema in
dactylitis and that exor tenosynovitis was far more common than extensor involvement [25].
Relationship between the DIP joint and nail disease
Distal interphalangeal (DIP) joint involvement, although not exclusive to PsA, is certainly one of the
characteristic features of this disorder. Nail involvement is more common in PsA than uncomplicated
psoriasis and DIP joint involvement is often seen with co-existent nail disease [31,32]. Investigating the
pathogenesis underlying this link between arthritis and nail disease is likely to help us gain a better
understanding of the disease.
Histological work has shown that the extensor tendon attaches to the base of the terminal phalanx
and then extends distally to connect with the nail root. This can now be visualised on MRI using highresolution techniques. MRI studies have conrmed the intimate relationship between the nail bed, the
distal phalanx, the DIP joint and the insertion of the extensor tendon [3336].
Scarpa et al. imaged 23 patients with PsA using a 1.5-T MRI and surface coil, 12 with clinical
onychopathy and 11 without. They showed that nail thickening on MRI was extremely common in
patients with PsA, even when clinical evidence of onychopathy was lacking, and that all of these
patients also showed MRI involvement at the distal phalanx. In the majority of patients without clinical
onychopathy, the changes were conned to the nail and distal phalanx with little evidence of DIP joint
disease. However, involvement of the DIP joint was much more common in those with clinical
onychopathy (58% of cases) [34].
The Leeds group compared 20 patients with DIP joint involvement, half with osteoarthritis (OA) and
half with PsA patients. Again, they used a 1.5-T MRI scanner, but this study used a new 23-mm highresolution microscopy coil which produced superior image quality of just one joint. They demonstrated
that PsA patients have signicantly more entheseal and ligament enhancement, extracapsular changes
and diffuse bone oedema [36]. Although there was a difference seen at the group level, it was not
possible to differentiate between OA and PsA in individual patients using the MRI ndings. This
inammatory response seemed to be focussed around the ligament origins/insertions with virtual
normality of ligaments up to the enthesis. Bone oedema was seen diffusely throughout the distal
phalanx in 80% of PsA digits but was seen maximally at the insertion of the collateral ligament enthesis
[36]. The inammation seen was extensive enough in most cases to involve the nail bed, distal phalanx
and DIP joint [35] providing an explanation for the common association of nail and DIP joint
involvement. It seems likely that inammation in this region is transmitted via the entheses, which
extend up to the nail bed and envelop the DIP joint, but these studies did not identify where the
primary site of pathology lies. Both Scarpa and the Leeds group suggested that inammation was likely
to start in the nail and spreads proximally to the distal phalanx and then to the DIP joint. This seemed
credible given the usual scenario in this disease, where disease of the skin (and nails) usually precedes
joint disease.
More recently, a longitudinal study of PsA DIP joints has claried the relationship further. Dalbeth
and colleagues performed longitudinal scanning over a 1-year period. At baseline, 34 patients were
assessed clinically using the psoriatic nail severity score (PNSS) and had a 1.5-T MRI of their dominant

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hand. There was an association between clinical nail disease and MRI evidence of both bone erosion
and bone proliferation at the DIP joint. Twenty patients attended for a repeat PNSS score at 12 months,
giving follow-up data on 80 nails. Nails that had developed new onycholysis or hyperkeratosis during
the study period were more likely to have had distal phalanx bone marrow oedema at baseline,
suggesting that the inammation may have originated in the bone [37] and spread to the nail bed.
Subclinical disease in psoriasis
The majority of studies investigating subclinical joint disease in psoriasis have used ultrasound, but
a small study from Italy has investigated MRI in this setting. Patients with active skin psoriasis but with
no signs or symptoms of PsA (n 25) had a non-contrast-enhanced scan of their hand using a 1-T MRI
with surface coil. They found that 17 patients had one or more signs of arthritis on MRI with capsular
distension (n 11), periarticular oedema (n 9) and erosions at the MCP and interphalangeal (IP)
joints (n 7) [38]. By comparison, only one control patient had a bone cyst and they had no other
features of PsA. It seems that MRI can be used to visualise signs of subclinical arthropathy, but the
clinical signicance of these ndings has not been investigated.
Axial disease
MRI has also improved our ability to detect axial disease in PsA. Traditionally, the diagnosis of
sacroiliitis in all forms of SpA, including PsA, has relied on radiological evidence of disease. However, it
can take between 1 and 9 years from the onset of inammatory back pain for radiological sacroiliitis to
develop [39]. In the early 1990s, MRI began to be investigated as a tool to detect sacroiliitis [4042].
Since then, MRI bone oedema has been demonstrated in all forms of SpA, affecting the sacroiliac (SI)
joints and the cervical, thoracic and lumbar spine. Bone oedema adjacent to the SI joints has also been
proven to correlate with histopathological evidence of inammatory disease [16]. MRI is now accepted
as a diagnostic tool for axial disease in SpA including PsA and has been used as an outcome measure to
evaluate treatment with TNF blockers [20]. Further information on the use of MRI in axial SpA can be
found in Chapter 6.
Monitoring treatment outcomes
While MRI has often been applied as a research tool to investigate the pathogenesis of arthritis, it
has less commonly been used as an outcome measure for disease activity and joint damage. However,
increasingly studies are looking for objective methods of measuring disease activity and MRI is able to
visualise all structures in and around the joint as well as inammatory change involving synovium,
entheses and bone.
The Outcome Measures in Rheumatology Clinical Trials (OMERACT) MRI in inammatory arthritis
group have developed a scoring system for PsA MRI (PsAMRIS) [43], following on from the development of the RA MRI score (RAMRIS) [12]. The rst step was a literature review of PsA MRI studies to
identify typical pathologies that would need inclusion into a scoring system [8]. The RA version of the
scoring system scores the wrist joints and the metocarpophalangeal (MCP) joints of ngers 25. There
was a concern about excluding the proximal interphalangeal (PIP) and DIP joints in a potential PsA
scoring system, given the increased involvement typically in the DIP joints. Therefore, the joints scored
in the PsAMRIS are MCP, PIP and DIP of ngers 25. These joint regions were divided by the midpoints
of the phalangeal bones and were then subdivided at the joint space line to give three joint regions and
six sub-regions [43]. Given that synovitis, bone erosions and bone oedema appear similar to that of RA,
the semi-quantitative scoring system used in the RAMRIS was adopted [43]. In addition to this, other
key features were dened and added to the scoring system. Tenosynovitis is assessed in each joint
region in each of the four exor tendons on a scale of 03 depending on the thickness of enhancing or
bright signal within the tendon. Periarticular inammation is scored as present or absent adjacent to
each joint region on the dorsal and palmar aspect of the nger. Bone proliferation, dened as
abnormal bone formation in the periarticular region, such as at the entheses (enthesophytes) and

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across the joint (ankylosis) [43], is also scored as present or absent in each joint region. The joint
regions and scoring system are outlined in Fig. 1.
The score is time-consuming to perform and has not yet been used in any clinical trials, although it
has been tested in multiple validation exercises. The rst cross-sectional exercise showed good to
moderate inter-reader reliability for bone erosion and bone oedema, but low inter-reader reliability for
the other features [44]. Difculty assessing PIP and DIP joints was reported by the readers as the image
resolution was poor at the extremes of the eld of view. Following on from this exercise, further
denitions were created to improve inter-reader reliability in scoring [43].
A second cross-sectional validation exercise used a further 10 MRI scans of patients with PsA and
two healthy controls. These were scored by eight readers and found an improved intra-class coefcient
(ICC) of 0.840.91 except for the scoring of periarticular inammation which was low [44]. This
provides evidence for increased reliability following clear denitions of pathologies and removal of
some features.
A longitudinal exercise was then performed by eight readers to assess responsiveness. They scored
paired scans taken prior to treatment and at 6 weeks following treatment with anti-TNF therapy
(adalimumab). This conrmed good reliability and sensitivity to change in synovitis, tenosynovitis and
periarticular inammation [44]. However, given that the scans were only 6 weeks apart, there was not
enough change in the bony features to accurately assess responsiveness for these features. Another
study, performed by the OMERACT MRI group, analysed 12 paired MRI scans taken 1-year apart in
patients with PsA treated with either standard DMARDs (n 4) or anti-TNF therapy (n 8). The interand intra-reader reliability of PsAMRIS status and change scores were good to very good with the

D2
D
D1
P2
P
P1

M2
M
M1

MRI Feature
Synovitis
Erosions
Bone oedema
Tenosynovitis
Peri-articular inflammation
Bone proliferation

Scoring range
0-3
0-10
0-3
0-3
0/1
0/1

Site of scoring
M, P, D
M1, M2, P1, P2, D1, D2
M1, M2, P1, P2, D1, D2
M, P, D
M, P, D (palmar and dorsal)
M, P, D

D=DIP joint region, P=PIP joint region, M=MCP joint region

Fig. 1. PsAMRIS scoring system.

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exception of bony changes (proliferation or erosion) which showed very little change even with the
extended trial period. The scoring system was found to be moderately responsive to change when
considering standardised response means (SRMs) again with poorer results for bone changes which
were not commonly seen over the 12-month period [45].
Recent and upcoming techniques in MRI
Low-eld MRI scanners
Although well investigated for use in RA, low-eld (<or to one Tesla (1 T)) MRI scanners have not
been researched signicantly in PsA. The use of low-eld MRI machines in rheumatology is now
expanding as they are practical for use in the outpatient department and are more comfortable for
patients. All of the validation studies investigating their use against a gold standard of high-eld MRI
have been in patients with RA. They have been shown in these patients to be equivalent to high-eld
MRI in sensitivity and specicity for detecting bone erosions and synovitis [46]. However, they are
signicantly less sensitive when identifying bone marrow oedema [46] and this is of concern when
considering their use in the imaging of seronegative conditions.
Cimmino et al. compared imaging ndings in patients with PsA and RA using a 0.2-T extremity MRI
of the wrist [7,47] and the results of this study are discussed below. Scarpa et al. used low-eld MRI to
scan 26 PsA patients, looking at nail and DIP joint disease [48], and found results in keeping with their
previous study using high-eld MRI [34]. However, there have been no studies directly comparing
high-eld and low-eld magnetic resonance (MR) images in PsA to formally validate extremity MRI in
this disease.
Dynamic contrast-enhanced MRI
Further work is also underway exploring the use of MRI in assessing synovial inammation and
vascularity in PsA, using dynamic contrast enhancement (DCE) [49]. This technique can be used to
measure synovial rates of enhancement that can be displayed graphically, plotting relative signal
enhancement over time to give a value for maximum enhancement (ME) and initial rate of
enhancement (IRE), which is measured from onset to maximum enhancement. It has been used in
clinical trials to compare patients results before and after therapy [50], but is not fully validated for
clinical use.
Schraml et al. used DCE MRI of the hands to see if it was possible to differentiate between PsA (n 17)
and erosive osteoarthritis (n 9) in a 3-T scanner. They found high synovial contrast uptake in both groups
with similar curves of enhancement (including ME and IRE) seen in the early phase, but in the late phase
(15 min after contrast enhancement) there was a statistically signicant difference between the two
groups. PsA patients had lower levels of signal intensity in the late phase [51]. The authors hypothesised
that this could be related to the different vascular abnormalities with a lower rate of contrast diffusion
seen in the thickened tortuous vessels seen in PsA, but this theory is unproven. Interestingly, the same
group also evaluated 3T DCE-MRI to compare PsA (n 14) with RA (n 31) with similar results. Again,
PsA patients had lower levels of contrast uptake in the late phase with similar enhancement curves seen in
the early phase [52]. In contrast, Cimmino et al. compared PsA (n 7) and RA (n 10) patients using DCE
in a 0.2-T extremity MRI of the wrist. Patients with RA had a higher volume of inammation at nearly all
sites, but interestingly PsA patients had higher IRE and ME results, suggesting a greater degree of
inammation at the wrist joint [47]. Thus, there are disparities between results in these comparative
studies. One possible explanation for this variability, commented on by others, is that dynamic contrast
enhancement (CE) measurements are highly dependent on positioning of the region of interest (ROI) [53].
Similar methods could also be applied to uptake of contrast into bone. It could provide information
about the vascularity of the inamed bone and is likely to be more sensitive to change than semiquantitative scoring. DCE-MRI of bone marrow may therefore allow early detection of osteitis and
quantication of inammatory activity at these sites [54].
Ultra-short echo time imaging
Ultra-short echo time (UTE) MRI scanning is a novel MR technique that allows improved detection
of signal from tendons, brocartilage and cortical bone, resulting in better visualisation. Tendons and

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brocartilage have a very short echo time and therefore are low signal intensity on MRI scanning,
which makes it difcult to identify their detailed structure. UTE identies the signal from tendons and
brocartilage captured earlier than standard MRI sequences. These tissues can be imaged directly,
allowing them to be differentiated from each other. The optimisation of the images can be improved
using subtraction, T1 weighting, fat suppression, magnetisation transfer and the use of intravenous
contrast. Abnormalities in enhancement reecting increased vascularity due to inammation are likely
to precede structural changes. Thus, UTE imaging may allow the detection of early changes at the
enthesis, localisation of changes to the brocartilage or tendon and visualisation of vascular, oedematous and structural changes. Vascularity may be sensitive to changes in treatment, as it is in the
inamed synovium of RA.
Sequences for imaging the Achilles tendon have been tested and optimised using healthy volunteers
and have also been tested in patients with PsA and clinical enthesitis at the Achilles tendon (see Fig. 2)
[55]. Quantitative assessment of the bound proton fraction was reduced in a symptomatic patient with
PsA suggesting this as a possible future technique to measure pathological change at the enthesitis. An
independent group in California has also investigated the UTE technique showing that it correlated
with clinical assessment of enthesitis in PsA patients [56].
Whole-body multi-joint MRI
Whole-body multi-joint MRI (WBMJ-MRI) allows multiple joints and entheses to be visualised in
a single examination. Imaging of the spine and large joints has been successfully used in AS [5761] and
has also been applied to PsA [62]. More recently, it has been combined with techniques for imaging the
small joints similar to those previously used in RA [63]. Weckbach et al. studied 30 patients with PsA
using STIR and T1w gradient echo images with and without intravenous contrast; the whole spine,
sacroiliac joints, shoulders, hips, knees, ankles, feet and hands were included [64]. Good image quality
of the axial skeleton was obtained in 87% of cases and of hands and feet in 53%. In at least 80% of cases,
MRI showed more extensive abnormalities than clinical examination, resulting in a change in
management in 73%. The most common ndings were enthesitis of the hips and spine. Synovitis
(hands, feet, hips, shoulders and knees), bone marrow oedema (sacroiliac joints, spine and pubic

Fig. 2. Short echo time gradient echo MR image from a patient with longstanding symptomatic PsA showing increased signal and
thickening of the Achilles tendon.

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symphysis) and erosions (hands and shoulders) were also commonly detected. Three patients who
received follow-up imaging showed a response to treatment. These results suggest that WBMJ-MRI is
useful for detecting sub-clinical disease in patients with PsA and may be useful for detecting the full
extent of disease and determining management.
Future role of MRI in diagnosis and monitoring
MRI has signicant potential to improve our understanding of the pathogenesis of PsA, particularly
in view of its ability to image both soft tissues and bone. The process underlying the development of
this disease (as for example proposed by the primary entheseal hypothesis) could be elucidated and
further MRI assessment of dactylitis may help us understand the basis of this pathognomonic feature.
New techniques such as UTE MRI allow visualisation of previously dark structures such as the tendon
and will also improve our understanding of pathogenesis.
The development of the PsAMRIS scoring system has created a new outcome measure for clinical
trials. PsAMRIS is now being used in randomised controlled trials and will provide an objective
measure of disease activity. It may be able to identify responses earlier than clinical assessments which
would allow quicker evaluation of new therapies. Beyond semi-quantitative scoring, increasing work in
DCE-MRI is developing a truly quantitative measure of synovitis and bone marrow oedema that can be
used as an outcome measure.
Development of WBMJ-MRI will allow a snapshot of the total inammatory burden of PsA to be
measured relatively quickly. This provides an objective measure of arthritis, enthesitis and axial disease
in one assessment, with the potential for repeat measures over time after effective intervention, and is
particularly useful in PsA as the disease is highly heterogeneous.
Ultrasound
Musculoskeletal US typically employs B mode/grey scale (GS) assessment as a structural indicator
(of, for example, synovial hypertrophy, effusion and tendinopathy) and power Doppler (PD) as
a sensitive measure of vascular ow (indicating inammation). US has been used in PsA to examine
a variety of pathologies, such as enthesitis/enthesopathy, joint synovitis and effusion, bone changes,
tenosynovitis and dactylitis. The focus has been largely on the peripheral joints and entheses, although
interest in axial disease and sacroiliitis has been increasing.
The reproducibility of US ndings is an important area to highlight as this is a potential weakness of
US compared to techniques such as MRI. Studies have therefore attempted both to quantify the degree
of agreement between and within sonographers and to minimise intra and inter-reader variation by
pre-study training, often using static images to reach consensus on scoring of pathology. Filipucci et al.
showed moderate to excellent inter- and intra-observer agreement for soft-tissue inammation (k 0.7,
0.8 respectively) and damage (k 0.7, 0.9) [65]. In the study by De Miguel et al. involving six participants,
inter-observer reliability had an ICC of 0.6, supporting the ndings of the Italian study [66]. These
studies highlight difculties encountered in reaching agreement on bone irregularity (as it is difcult to
decide what constitutes a pathological change) and entheseal hypo-echogenicity (because of the
potential for anisotropy, creating the false appearance of hypo-echogenicity due to the imaged
structure not being perpendicular to the ultrasound probes footprint).
Current role of US: pathogenesis
Synovitis and bone abnormalities
Technically, peripheral joint assessment using US in PsA is identical to that for RA, employing GS and
PD modalities. There are, however, differences in pathology identied by US. Fournies group showed
that while the synovial membrane of joints and tendon sheaths could be involved in both conditions,
extra-synovial abnormalities were only seen in PsA patients. These included abnormalities denoting
enthesitis, thickening of soft tissues and Doppler signal from the base of the nail indicating periungual
psoriatic involvement [67].

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815

Bone abnormalities that can be identied using US include erosions, enthesophytes and new bone
formation/periosteal reaction. These are discussed in more detail below. The important point to
highlight is that US cannot identify osteitis (seen as bone marrow oedema on MRI) and as such has
a reduced sensitivity/specicity for active enthesitis compared to MRI.

Enthesitis and enthesopathy

Entheseal abnormalities are frequently imaged using US, as this modality offers the ability to
compare to the opposite side as well as the ability to image multiple sites at one sitting. The OMERACT
Ultrasound group has produced a preliminary denition of enthesopathy as (an) abnormal hypoechoic
region with loss of normal brillar architecture and/or thickened tendon or ligament at its bony
attachment, seen in 2 perpendicular planes that may exhibit Doppler signal and/or bony changes
including enthesophytes, erosions or irregularity [68]. US ndings in enthesopathy are often split into
features of soft-tissue inammation and features of tissue damage, to reect the reversible and irreversible pathological components, as shown in Fig. 3 (taken from Filippucci et al. Ref. [65]). Examples of
pathological changes on US are shown in Fig. 4A and B.
A signicant proportion of SpA patients (including PsA) has been found to have sub-clinical
enthesitis using US [6971]. Scarpa et al. examined early PsA subjects with articular and/or entheseal symptoms of <12 weeks duration and showed that bone scintigraphy identied 3 times as many
affected areas as clinical examination (using tender/swollen joint counts and Maastricht ankylosing
spondylitis enthesitis score (MASES) for tender entheses [72]). US was only used, however, to conrm
affected sites identied by scintigraphy rather than assessing a standard set of entheses [71]. Other
studies have used established SpA cohorts where PsA patients have constituted only a small number
being studied. Balint et al. [69], for example, had seven patients with PsA in a cohort of 35 SpA patients
with a mean disease duration of 24.9 years. They showed that 22% of entheses assessed were abnormal
on clinical examination and 56% were abnormal on grey scale ultrasound (GS US). Of note, PD was not
used; thus specicity for active inammation was likely to have been reduced. DAgostino used power
Doppler ultrasound (PDUS) to assess multiple entheseal sites (greater trochanter, pubis, patella,
Achilles tendon, plantar fascia, medial and lateral epicondyles) and showed that entheseal involvement
on US of at least one of these sites is seen in 98% of patients with SpA including PsA but is far less
common in controls with mechanical back pain (44%) or RA (60%). The most common sites of
involvement in PsA were in the lower limb (Achilles tendon, patellar tendon, plantar fascia and greater
trochanter) [73]. Falsetti et al. looked specically at the calcaneal enthesis using US and plain

Fig. 3. Features of enthesitis seen on ultrasound scanning (taken from (Filippucci et al.) Ref. [65]).

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L.C. Coates et al. / Best Practice & Research Clinical Rheumatology 26 (2012) 805822

Fig. 4. Examples of pathological changes on ultrasound. 4A: Power Doppler ultrasound image (longitudinal view) showing active
inammation of the Achilles tendon adjacent to calcaneal insertion, shown as presence of power Doppler signal (indicated by white
arrow). 4B: Grey scale ultrasound image (longitudinal view) showing erosion of the calcaneum at the Achilles enthesis (indicated by
white arrow).

radiography and compared patients with PsA, RA and OA. There was no signicant difference found
between the PsA and RA groups but there was a trend towards more Achilles enthesitis and plantar
fasciitis in PsA and more erosive disease in patients with RA [74].
Freeston et al. [75] assessed 42 patients with new-onset PsA (median disease duration 11.1 months)
and 10 control subjects with clinical examination and GS/PD US of a standard set of entheses and found
the prevalence of sub-clinical enthesitis in this early PsA cohort was low. The few sub-clinically
inamed entheses were in the lower limb, where mechanical stress is likely to be more signicant.
Apart from the inability to identify osteitis, it can be difcult to differentiate inammatory disease
from mechanical/degenerative change (e.g., enthesophyte and tendon thickening) using US. There is
a general lack of standardisation of image acquisition and scoring. For PD, there are fewer vessels in
inamed entheses compared with synovium, so can be harder to visualise and Doppler artefacts can
occur at the enthesis due to reective cortical bone.
Tenosynovitis and dactylitis
Dactylitic digits have also been imaged using US, showing subcutaneous soft-tissue enlargement,
exor tenosynovitis and adjacent synovitis. However, studies have differed signicantly in the
frequency of soft-tissue involvement and synovitis identied [26,67,76]. Kane et al. found subcutaneous soft-tissue enlargement in all affected digits (25 dactylitic ngers and toes), with exor tenosynovitis seen in 96% of cases and articular synovitis in around half of the digits [76]. Olivieri et al.
found that all 12 dactylitic ngers showed uid collections surrounding the tendons in keeping with
exor tenosynovitis but no involvement of the peritendinous soft tissues or the synovial joints [26]. The
authors have conceded, however, that the lack of soft-tissue involvement on US may have been due to

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817

limitations in the technology at that time (26 and Olivieri personal communication). Fournie examined
25 psoriatic ngers, showing extra-synovial changes in 84%, of which 60% also had synovial changes.
The authors described the extra-synovial changes as including subcutaneous soft-tissue thickening of
the nger pad or entire nger (pseudotenosynovitis) [67].
Sub-clinical disease in psoriasis
US of entheses has also been investigated in patients with skin psoriasis only. Gisondi and
colleagues performed a casecontrol study comparing 30 patients with skin psoriasis and controls with
other dermatological diagnoses. They used the Glasgow Ultrasound Enthesitis Score (GUESS) and
found a much higher GUESS score for those with psoriasis compared with controls (7.9 vs. 2.9,
p < 0.0001) indicating a higher prevalence of entheseal abnormalities even though these patients were
asymptomatic for musculoskeletal disease [77]. These ndings have been supported by more recent
studies such as that by Naredo et al. This Spanish group has shown that US synovitis and enthesopathy
were signicantly more frequent in psoriatic patients (n 162) compared to age-matched controls
(n 60) [78]. Synovitis was seen in 3.2% of joints in psoriasis patients but only 1.3% of joints of controls
(p < 0.0005) while enthesitis was seen in 11.6% of entheses in the psoriasis group but only 5.3% of those
in the control group (p < 0.0005).
Axial disease
The majority of published data on the use of US in axial disease has focussed on the sacroiliac joint
(SIJ) and has used AS cohorts. These have used colour and duplex Doppler US, showing lower resistive
indices in cases of active inammation [79]. Klauser et al. used microbubble contrast-enhanced colour
Doppler US showing a sensitivity of 94% and specicity of 86% for the diagnosis of active sacroiliitis,
veried by MRI [80]. In SpA, US detected joint effusion has been identied in 39% of SIJs in comparison
with 2% controls [81]. The presence of inammatory back pain was signicantly associated with SIJ
effusion on US but there was no direct comparison with MRI. There are, however, some pitfalls associated with using US for SIJ assessment. Increased SIJ perfusion can be seen in some osteoarthritis and
control subjects [82]. The need for an acoustic window means that US can only visualise the posterior
part of the joint and US is less sensitive for erosion detection than CT.
Monitoring treatment outcomes
The use of US as an objective outcome measure has been expanding. US allows real-time image
acquisition of multiple joints to assess both bony changes (erosion) and inammation. Denitions of
pathologies (bone erosion, synovial uid, synovial hypertrophy, tenosynovitis and enthesopathy) seen
on US have been agreed by the OMERACT US group [68]. The majority of studies using US have used
these denitions and borrowed scoring systems from the RA literature. There are several different
versions, all based on a semi-quantitative 03 scoring system where 0 normal, 1 mild,
2 moderate and 3 severe pathology. Erosions can be scored using a binary present/absent system,
a 03 semi-quantitative score [83] or a numeric count. The OMERACT US group has not yet published
any consensus scoring systems for different types of pathology, although the RA-GLOSS (Global
synovitis scoring system) is in development.
Several US enthesitis assessment tools have been developed in SpA cohorts such as the GUESS tool
which examines ve lower limb sites (Achilles, quadriceps, superior and inferior patellar tendons and
plantar fascia) [69] and the MASEI (Madrid Sonographic Enthesis Index) which assesses six sites (ve as
before plus the triceps tendon) [66]. Using these tools, US has been shown to be more sensitive than
clinical examination for detecting enthesitis in established SpA cohorts [69].
One of the key questions raised by the use of US as an outcome measure is the question of how many
joints should be scanned. Obviously, scanning many joints provides additional information, but US is
still relatively time-consuming and feasibility is a key issue. Work has begun in RA to identify reduced
joint combinations that can still accurately identify pathology and both 7 and 12 joint scores have been

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proposed [84,85]. Similar work in PsA has yet to be done, and this is likely to be more challenging given
the heterogeneity of clinical presentation in PsA.
There is a small amount of published data looking at the sensitivity of US for the assessment of
change (in joint inammation/damage) over time. These have derived from small longitudinal treatment studies of peripheral joint disease in PsA [86] and SpA [87]. However, these did not include any
formal analysis of the smallest detectable difference and should be regarded as preliminary.
Recent and upcoming techniques in US
Three-dimensional (3D) volumetric ultrasonography is a relatively new tool in musculoskeletal
imaging. Compared to conventional two-dimensional (2D) US, 3D offers virtual operator independence
(due to transducer automated sweeping), reduced examination time as well as acquisition of innite
3D data sets [81]. Several studies have conrmed good inter-reader reliability using this technique
when examining RA hand and wrist joints [88,89], as well as improvement with therapy [90]. In SpA,
Iagnocco et al. have shown similar ndings for Achilles tendon involvement between 2D and 3D
ultrasound [91] but there are no specic PsA studies to date.
Sonoelastography offers the ability to identify changes in tissue elasticity and has been widely used
in non-musculoskeletal applications. It has recently been studied in a rheumatological context with
particular interest in identifying tendinopathy. Klausers group has examined patients with chronic
Achilles tendinopathy and compared ndings with controls, showing that only in Achilles tendons with
distinct softening is clinical examination comparable to US ndings [92]. They hypothesise that mild
softening might be explained by very early changes in tissue elasticity in the case of Achilles tendinopathy, which should be assessed in follow-up studies.
Ultrasonography and magnetic resonance real-time fusion imaging have recently been developed,
employing US machines with an in-built virtual navigator system. This allows an MRI acquisition of, for
example, the hand and wrist, to be uploaded onto the US machine and viewed simultaneously with
anatomically matched US images. This allows US investigation of pathological sites identied on MRI,
as well as the provision of MRI reference points for subsequent US examinations. Iagnocco et al. studied
nine patients (six with OA and three with RA), showing a striking concordance in the visualisation of
the bony prole with evidence of pronounced osteophytes in OA and bone erosions in RA. This tool has
great potential when applied to disease and therapy monitoring, enabling more reproducible and
potentially more responsive US assessment [93].
Future role of US in diagnosis and monitoring
There is potential for incorporation of US measures into PsA diagnostic criteria as this could lead to
earlier detection of pathology and improved sensitivity. US is an important tool in helping determine
the clinical signicance of sub-clinical disease in the different PsA sub-types, at both the joint and
enthesis levels. Such information will be valuable for identifying those who will benet from early,
aggressive therapy. As a prognostic tool, US also has much to offer, with studies needed to examine its
ability to predict disease severity, disease-modifying anti-rheumatic drug (DMARD) and biologic
requirements in patients with early disease. Development of representative anatomical sites for rapid
patient assessment using US (e.g., for clinical trial therapeutic monitoring) is also an area that requires
investment if we are to use our time wisely and efciently.
Summary
The use of MRI and US in PsA is becoming much more commonplace in both clinical and research
elds. Both imaging techniques are being used in early diagnosis and identication of disease, including
identifying pre-clinical changes in patients who only have skin psoriasis. They are also increasingly
becoming accepted in monitoring disease outcome and identifying responses to treatment. OMERACT
groups are leading the development of validated scoring systems that can be used as outcome measures
in observational studies and clinical trials. Future research into imaging in PsA has the potential to help
us to understand more about its development and pathogenesis. Use of these imaging modalities is also

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819

likely to become more commonplace in clinical practice to allow early identication of disease,
assessment of prognosis and to then guide therapeutic decisions for individual patients.

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