Boutry et al.

M u s c u l o s ke l e t a l I m ag i n g P i c t o r i a l E s s ay
MRI and Sonography of
Rheumatoid Arthritis
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Early Rheumatoid Arthritis:

A Review of MRI and
Sonographic Findings
Nathalie Boutry1 OBJECTIVE. The introduction of antitumor necrosis factor agents has opened new pros-
Mlanie Morel1 pects in therapeutic management of patients with early rheumatoid arthritis, thereby creating new
Ren-Marc Flipo2 demands on radiologists to identify patients with aggressive disease at an early stage. As a result,
Xavier Demondion1,3 imaging techniques such as MRI and sonography have developed during the past few years.
Anne Cotten1 CONCLUSION. This article illustrates the imaging findings that may be encountered
with these techniques in patients with early rheumatoid arthritis.
Boutry N, Morel M, Flipo RM, Demondion X,
Cotten A heumatoid arthritis is characterized Positive Diagnosis of Early

Keywords: extremities, hand, MRI, musculoskeletal
imaging, power Doppler sonography, rheumatoid arthritis,
sonography, wrist
DOI:10.2214/AJR.07.2548
Received January 24, 2007; accepted after revision
June 19, 2007.
1Department of Musculoskeletal Radiology, Centre
Hospitalier Universitaire de Lille and Hpital Roger
Salengro, CHRU de Lille, Blvd. du Pr. J Leclercq, 59037 Lille,
France. Address correspondence to N. Boutry
(nboutry@chru-lille.fr).
2Department of Rheumatology, Centre Hospitalier
Universitaire de Lille and Hpital Roger Salengro,
Lille, France.
3Department of Anatomy, Centre Hospitalier Universitaire
de Lille and Hpital Roger Salengro, Lille, France.
AJR 2007; 189:15021509
0361803X/07/18961502
American Roentgen Ray Society
R by proliferative, hypervascularized
synovitis, resulting in bone erosion,
cartilage damage, joint destruction,
and long-term disability. Diagnosis is based on
clinical, laboratory, and radiographic findings.
Conventional radiography has been the mainstay
for diagnosis of joint damage and subsequent
follow-up. Radiography can provide only indi-
rect information on synovial inflammation, how-
ever, and the technique is insensitive to early
bone damage. Until recently, the absence of ef-
fective treatment to prevent joint destruction has
limited the need for more sensitive imaging tech-
niques. This situation changed after the develop-
ment of new therapeutics for rheumatoid arthri-
tis, such as the antitumor necrosis factor (TNF)
agents. Availability of these powerful and ex-
pensive drugs has created new demands on radi-
ologists to identify patients with aggressive rheu-
matoid arthritis at an early stage to affect the
therapeutic management of these patients.
MRI and sonography can be useful tools in
evaluating patients with early rheumatoid ar-
thritis. Both imaging techniques can detect
preerosive synovitis. They can also identify
early bone damage before it becomes apparent
on radiography. Furthermore, MRI can be used
to predict future bone damage. Because MRI
and sonography are rapidly becoming imaging
techniques for the evaluation of patients with
early rheumatoid arthritis, the purpose of this
article is to illustrate how these techniques can
be used in diagnosing early stage rheumatoid
arthritis, monitoring disease activity, and differ-
entiating early rheumatoid arthritis from other
inflammatory arthritides in some patients.
Rheumatoid Arthritis
The wrist and the metacarpophalangeal
(MCP) and metatarsophalangeal (MTP)
joints are among the first areas to be affected
in rheumatoid arthritis. The most sympto-
matic extremity, the dominant extremity, or
both may be studied with MRI and sonogra-
phy. Abnormalities in early rheumatoid ar-
thritis include synovitis, tenosynovitis, bone
erosions, bone marrow edema, and bursitis.
Synovitis
Proliferative synovitis (i.e., rheumatoid pan-
nus) is the earliest pathologic abnormality in
rheumatoid arthritis, and it is secondarily re-
sponsible for bone and cartilage damage. It is
usually, but not exclusively, bilateral. MRI re-
veals proliferative synovitis as thickening of
the synovial membrane that appears as quick
enhancement after the administration of gado-
linium [1]. This is well shown on fat-sup-
pressed gadolinium-enhanced T1-weighted
images (Fig. 1). Sonography shows abnormal
hypoechoic (relative to subdermal fat) intraar-
ticular tissue that is poorly compressible and
that exhibits Doppler signal with color or
power Doppler imaging [2] (Fig. 2).
A small amount of fluid may be associated
with synovitis. This fluid shows high signal in-
tensity on T2-weighted MR images and low
signal intensity on fat-suppressed gadolinium-
enhanced T1-weighted MR images. The fluid
appears anechoic on sonography, with no evi-
dence of flow on Doppler imaging, and can be
expelled from the region by compression with
the sonographic transducer. Both MRI and

1502 AJR:189, December 2007

 MRI and Sonography of Rheumatoid Arthritis
sonography are more sensitive than clinical as-
sessment for detecting synovial inflammation
[3], and they help distinguish between patients
with polyarthritis and those with oligoarthritis.
Conventional radiography, on the other
hand, is not helpful in the diagnosis of syno-
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vitis unless there is fusiform soft-tissue swell-
ing at the joints. This swelling is well seen at
the proximal interphalangeal joints and, to a
lesser extent, at the MCP joints.
Tenosynovitis
Tenosynovitis is a common finding in pa-
tients with early rheumatoid arthritis. Al-
though any tendon may be affected, the flexor
digitorum, extensor digitorum, and extensor
carpi ulnaris are frequently involved [4]. Teno-
synovitis is usually, but not exclusively, bilat-
eral. MRI reveals thickening of the synovial
sheath with marked enhancement on fat-sup-
pressed gadolinium-enhanced T1-weighted
images [4] (Fig. 3A). Sonography shows simi-
lar findings: hypoechoic thickening of the sy-
novial sheath with hyperemia on Doppler im-
aging [2] (Fig. 3B).
A small amount of fluid may be associated
with tenosynovitis. In some patients with
early rheumatoid arthritis, affected tendons
may appear heterogeneous (suggesting incip-
ient tendinitis) on both imaging techniques.
These tendinous changes are seen best on
sonography (Fig. 3B). Both MRI and sonog-
raphy outperform conventional radiography
in detecting tenosynovitis.
Bone Erosions
Bone erosions result from proliferative sy-
novitis. They are less frequently bilateral than
synovitis or tenosynovitis. The capitate, tri-
quetrum, and lunate bones (Fig. 4A); the radial
aspect of the second and third metacarpal
bones (Fig. 4B); and the lateral aspect of the
fifth metatarsal bone (Fig. 4C) are more fre-
quently involved with bone erosions [4, 5]. On
MRI, bone erosions appear as sharply margin-
ated areas of trabecular bone loss with a corti-
cal defect [1], often associated with synovitis.
These erosions are well seen after IV gadolin-
ium injection, especially with thin-partition 3D
gradient-echo sequences [4] (Fig. 4).
On sonography, bone erosions are seen as
intraarticular discontinuities of the bone sur-
face that are visible in two perpendicular
planes [2]. They are best detected at the ulnar
styloid process (Fig. 5A), the radial aspect of
the second MCP joint, the ulnar aspect of the
fifth MCP joint, and the lateral aspect of the
fifth MTP joint [4] (Fig. 5B). High signal on
AJR:189, December 2007
Doppler imaging suggests the presence of pro-
liferative, hypervascularized pannus tissue in
the erosion [2] (Fig. 5C). Compared with MRI,
however, sonography is limited in the evalua-
tion of the other MCP and MTP jointsbe-
cause of limitations of probe positioning, even
with a hockey stick transducerand the car-
pal bones. MRI is more sensitive than conven-
tional radiography for diagnosing bone ero-
sions [6]. The same is true of sonography for
the MCP and MTP joints [7, 8].
Bone Marrow Edema
Bone marrow edema may precede the de-
velopment of bone erosions and can be used
to predict medium-term functional disability
[9]. It is detectable with STIR T2-weighted or
fat-suppressed T2-weighted MRI sequences
(Fig. 6). Bone marrow edema appears as a le-
sion with ill-defined margins and high signal
intensity [1], typically located at the insertion
of the synovial membrane. It can occur alone,
or it may surround bone erosions [1]. In con-
trast to MRI, sonography provides no infor-
mation on bone marrow edema.
Bursitis
Bursitis is a common finding in patients
with early rheumatoid arthritis and may be
asymptomatic. It is located between or beneath
the metatarsal heads [4]. Intermetatarsal and
submetatarsal bursitis show significant en-
hancement on MRI after IV gadolinium injec-
tion due to inflammation (Fig. 7). On sonog-
raphy, intermetatarsal and submetatarsal
bursitis appear as heterogeneous (hypo- and
hyperechoic) collections that can be well- or
ill-defined (Fig. 8). Significant hyperemia of
the synovial lining is usually seen on Doppler
sonography (Fig. 8). Intermetatarsal bursitis
is more frequent in the second and third web
spaces [4], where it may be difficult to differ-
entiate from Mortons neuroma. However, lo-
cation at the plantar aspect of the foot on MRI
and identification of the entering and exiting
nerve on sonography are more suggestive of
interdigital nerve entrapment.
Disease Activity and
Damage Monitoring
MRI and sonography are both useful in as-
sessing early rheumatoid arthritis activity.
Modern drug therapies have reportedly de-
creased synovial proliferation and bone mar-
row edema and prevented the development of
bone erosions. MRI and sonography can both
quantify synovial inflammation. Treatment re-
sponse can be identified on MRI as a reduction
in synovial volume and a decrease in the rate of
synovial enhancement [10, 11] (Fig. 9). Simi-
larly, sonography shows a decrease in synovial
thickness and disappearance of the Doppler
signal in patients who respond to treatment
[12]. Microbubble sonographic contrast agents
may also improve the detection of synovial
vascularization, which is a marker of disease
activity [13], but they are not widely used in
daily practice.
More recently, methods of semiquantita-
tive scoring of early rheumatoid arthritis
changes (i.e., synovitis, bone erosions, and
bone edema) at the wrist and MCP joints have
been developed and standardized on MRI by
the OMERACT (Outcome Measures in Rheu-
matology Clinical Trials) [1] and EULAR
(European League Against Rheumatism) [1]
groups. These scoring systems may also be
useful in assessing rheumatoid arthritis activ-
ity and bone damage.
Differential Diagnosis
Diagnosis of early rheumatoid arthritis is of-
ten based primarily on inflammatory poly-
arthralgia of the hands. Clinicians sometimes
struggle to differentiate early rheumatoid ar-
thritis from psoriatic arthritis or systemic lupus
erythematosus, especially when conventional
radiography shows no abnormality.
In patients with psoriatic arthritis, MRI may
show extensive signal intensity changes in the
bone marrow on STIR T2-weighted, fat-sup-
pressed T2-weighted, or fat-suppressed gado-
linium-enhanced T1-weighted sequences [14].
These changes may sometimes be seen in the
soft tissues as well [14]. Bone marrow changes
due to psoriatic arthritis do not remain local-
ized in the joint capsule (in contrast to those
due to early rheumatoid arthritis) and can ex-
tend far beyond the joint capsule, probably re-
lated to inflammatory enthesitis (Fig. 10A).
Sonography cannot detect bone marrow
changes, but it may exhibit signs of peripheral
enthesitis affecting the lower limbs (especially
the Achilles tendon and the plantar fascia)
(Fig. 10B) and, in some cases, the fingers
(Fig. 10C). Enthesitis appears as a hypoechoic
thickening of the enthesis, associated with hy-
peremia on Doppler imaging (Fig. 10C).
In patients with systemic lupus erythema-
tosus, MRI may show abnormalities similar
to those of patients with early rheumatoid ar-
thritis (e.g., synovitis, tenosynovitis, and
bone erosions), and it might be impossible to
differentiate patients with early rheumatoid
arthritis from those with systemic lupus
erythematosus on MRI [15] (Fig. 11).
1503

Conclusion
MRI and sonography have opened new ho-
rizons in the detection of early joint damage,
assessment of synovial inflammation, and
therapeutic management of patients with rheu-
matoid arthritis. Radiologists should be famil-
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iar with the MRI and sonographic appearances
of early rheumatoid arthritis in the small sy-
novial joints of the appendicular skeleton. It is
still too early to indicate with certainty the role
of imaging in treatment decisions. No strategy
has yet been proposed in the literature. How-
ever, sonography is a quick and inexpensive
way to detect synovitis, whereas MRI allows a
more global approach to the small synovial
joints of the appendicular skeleton.
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Fig. 134-year-old woman with early rheumatoid arthritis and synovitis.
A and B, Transverse fat-suppressed gadolinium-enhanced T1-weighted spin-echo MR images show bilateral synovitis (arrows) in wrist (A) and metatarsophalangeal joints
(B). Note also bone marrow signal intensity changes (asterisks, B), which precede frank bone erosions, and flexor digitorum tenosynovitis (arrowhead, A).
1504
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AJR:189, December 2007
 MRI and Sonography of Rheumatoid Arthritis

Fig. 241-year-old man with early rheumatoid arthritis and synovitis. Dorsal
longitudinal color sonogram of wrist reveals hypoechoic distention of both
radiocarpal (single asterisk) and midcarpal (double asterisks) synovial recesses.
High signal in synovium on power Doppler imaging indicates hyperemia. R = radius,
L = lunate, C = capitate.
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A B
Fig. 329-year-old woman with early rheumatoid arthritis and tenosynovitis. R = radius, U = ulna, t = tendon.
A, Transverse fat-suppressed gadolinium-enhanced T1-weighted spin-echo MR image shows significant enhancement (arrows) around extensor carpi ulnaris tendon that
represents tenosynovitis. Note also mild enhancement in distal radioulnar joint, which is suggestive of synovitis.
B, Dorsal transverse sonogram of wrist shows hypoechoic thickening (asterisks) and hyperemia around extensor carpi ulnaris tendon on power Doppler imaging,
representing tenosynovitis. Note also heterogeneous appearance of tendon on sonography.

AJR:189, December 2007 1505

 Boutry et al.
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A B

Fig. 438-year-old woman with early rheumatoid arthritis and bone erosions.
A, Transverse fat-suppressed gadolinium-enhanced 3D gradient-echo MR image
reveals carpal bone erosions (capitate, triquetrum, pisiform) (arrows). Synovitis in
carpal joints and flexor and extensor tenosynovitis are also evident. (Reprinted with
permission from Boutry N, Larde A, Lapegue F, Solau-Gervais E, Flipo RM, Cotten A.
Magnetic resonance imaging appearance of the hands and feet in patients with early
rheumatoid arthritis. J Rheumatol 2003; 30:671679 [4])
B, Transverse fat-suppressed gadolinium-enhanced 3D gradient-echo MR image
shows bone erosion on radial aspect of third metacarpal bone (arrowhead). Note
also presence of significant bilateral synovitis in second and third
metacarpophalangeal joints and flexor digitorum tenosynovitis (arrows).
C, Transverse fat-suppressed gadolinium-enhanced 3D gradient-echo MR image
exhibits bone erosion on lateral aspect of fifth metatarsal bone (arrowhead), which
is associated with synovitis. Note also presence of inflammatory bursitis beneath
fifth metatarsal bone (asterisk). (Reprinted with permission from Boutry N, Larde A,
Lapegue F, Solau-Gervais E, Flipo RM, Cotten A. Magnetic resonance imaging
appearance of the hands and feet in patients with early rheumatoid arthritis. J
Rheumatol 2003; 30:671679 [4])
C

1506 AJR:189, December 2007

 MRI and Sonography of Rheumatoid Arthritis

Fig. 547-year-old woman with rheumatoid arthritis and bone erosions.

A, Transverse sonogram of wrist exhibits bone erosion of ulnar styloid process
(arrow). Latter is related to hypoechoic thickening around extensor carpi ulnaris
tendon, representing tenosynovitis (asterisks). U = ulna, t = tendon.
B, Coronal sonogram of forefoot shows bone erosion (arrow) on lateral aspect of fifth
metatarsal bone (M5) associated with synovitis (asterisks).
C, Coronal sonogram of hand shows hypervascular pannus filling bone erosion
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(arrows) on radial aspect of second metacarpal bone (M2) on power Doppler

imaging. Note also hyperemia in articular space.

B C

AJR:189, December 2007 1507

 Boutry et al.
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Fig. 633-year-old man with early rheumatoid arthritis and bone marrow edema. Fig. 751-year-old man with early rheumatoid arthritis and bursitis. Transverse fat-
Coronal STIR T2-weighted MR image reveals bone marrow edema in second suppressed gadolinium-enhanced 3D gradient-echo MR image shows
metacarpal bone (asterisk). Note also fluid in articular space. submetatarsal (asterisk) and intermetatarsal (boxes) bursitis. Note also presence of
bone erosion (arrow) associated with synovitis in third metatarsophalangeal joint.

Smax
Signal Intensity of Synovium

S3

S2

S1

0 t0 t1 t2 t3 t4 t5 t6
Time (s)

Fig. 828-year-old man with early rheumatoid arthritis and bursitis. Longitudinal
sonogram of web space reveals intermetatarsal bursitis (asterisks) as well-defined
heterogeneous collection with synovial hyperemia on power Doppler imaging.
(Courtesy of Morvan G, Paris, France)
Fig. 9Monitoring early rheumatoid arthritis activity. Schematic of quantitative
evaluation of rate of synovial enhancement before (solid line) and after (dotted line)
effective treatment. Data were derived from contrast-enhanced dynamic MRI scans.
Synovial enhancement is defined as SIt SI0 / t, where SIt is signal intensity
obtained t seconds after contrast injection, SI0 is signal intensity obtained in first
unenhanced image, and t is time taken to reach peak enhancement over initial
linear phase (dotted area). After treatment, synovitis and therefore synovial
enhancement are reduced.

1508 AJR:189, December 2007

 MRI and Sonography of Rheumatoid Arthritis
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A C
Fig. 1031-year-old man with psoriatic arthritis.
A, Coronal fat-suppressed T2-weighted MR image shows edematous signal intensity changes (asterisks) in bone marrow of first phalanx. Note also similar findings along
collateral ligaments (arrows) of adjacent proximal interphalangeal joint.
B, Longitudinal sonogram of foot using extended field of view reveals enthesitis of plantar fascia. Note significant hypoechoic thickening of fascia origin (double arrow); also
note bone erosions and spurs (arrowheads). More distally, plantar fascia shows normal sonographic appearance (arrows). C = calcaneus.
C, Coronal color sonogram of hand shows enthesitis of radial collateral ligament as hypoechoic thickening of ligament with mild hyperemia on power Doppler imaging. For
comparison, note normal fibrillar hyperechoic appearance of radial collateral ligament on normal side (arrows). P1 = proximal phalanx, P2 = middle phalanx.

Fig. 1127-year-old woman with systemic lupus erythematosus. Transverse fat-

suppressed gadolinium-enhanced T1-weighted spin-echo MR image shows bilateral
synovitis in metacarpophalangeal joints and tenosynovitis (arrows) in flexor and
extensor digitorum, as well as bone erosion on radial aspect of second metacarpal
bone (arrowhead). MRI findings are similar to those of early rheumatoid arthritis.

AJR:189, December 2007 1509