clinical topic updates

Optimal Use of Imaging in Rheumatoid Arthritis

by Eric M. Ruderman, MD


The fields of rheumatology and radiology are changing rapidly. Potential roles for imaging in rheumatoid arthritis (RA) include assisting in early detection and/or diagnosis, prognosticating future RA aggressiveness, and assessing disease activity in real time. While there are good data for some of these applications, others require more research.

Expert Commentary

Eric M. Ruderman, MD

Professor of Medicine
Associate Chief for Clinical Affairs
Division of Rheumatology
Northwestern University Feinberg School of Medicine
Chicago, IL

“There are numerous potential opportunities for using MRI and ultrasound. These modalities are certainly helpful in identifying inflammatory arthritis in patients when the diagnosis is clinically uncertain, but the value of imaging in ongoing patient management is less clear.”

Eric M. Ruderman, MD

There are many more options for imaging than ever before; in some cases, there are good data on the value of its use, but more data are needed in other areas. Early in the course of the disease, functional issues are often driven by inflammation, but, as time goes on, particularly in untreated or undertreated patients with RA, it is the damage itself that begins to drive the functional deficits. And even if you reduce the inflammation, you are left with those challenges. Thus, one of the main purposes of imaging is to ensure that we pick up on the signs that structural damage is starting to occur so that we can intervene in this process. By initiating aggressive therapy early, structural and functional abnormalities can often be avoided.

There are numerous potential opportunities for using magnetic resonance imaging (MRI) and ultrasound. These modalities are certainly helpful in identifying inflammatory arthritis in patients when the diagnosis is clinically uncertain, but the value of imaging in ongoing patient management is less clear. The advantages of MRI and ultrasound are that you can identify structural changes earlier than on x-ray and you can detect inflammatory changes that would not be seen on x-ray. There is much research on the use of MRI to identify synovitis and early changes that may not be detected on x-ray. However, the challenge is that not all of these early changes proceed to radiographic abnormalities. Additionally, it is unknown to what extent the detection of subclinical changes is helpful in our current approach. That is, in the treat-to-target paradigm, the assessment of disease activity is largely clinical—not imaging based—and recent studies have found that the addition of MRI or ultrasound does not add much value in achieving therapeutic targets. Another question is whether following imaging parameters over time is useful. In the era of biologics, there is little progression of radiographic damage, so the value of serial imaging is diminished. The other challenge is that, even if some progression is detected, it is unclear which treatment we could switch that patient to that would be better. Another possible use of ultrasound is for identifying patients who are candidates for treatment tapering or discontinuation. You might be more comfortable about withdrawing or tapering therapy in a patient with RA who is not only in remission clinically, but on ultrasound as well. A final area in research is the use of imaging to more rapidly identify response—or nonresponse—to therapy, possibly by identifying patients who have rapid resolution of findings vs those who have persistent findings on ultrasound. There are not a lot of data in this area, but it is important and it certainly has a theoretical rationale.


Baker JF, Conaghan PG, Gandjbakhch F. Update on magnetic resonance imaging and ultrasound in rheumatoid arthritis. Clin Exp Rheumatol. 2018;36 Suppl 114(5):16-23.

Boer AC, Boeters DM, van der Helm-van Mil AHM. The use of MRI-detected synovitis to determine the number of involved joints for the 2010 ACR/EULAR classification criteria for rheumatoid arthritis - is it of additional benefit? Ann Rheum Dis. 2018;77(8):1125-1129.

Caporali R, Smolen JS. Back to the future: forget ultrasound and focus on clinical assessment in rheumatoid arthritis management. Ann Rheum Dis. 2018;77(1):18-20.

Dakkak YJ, Boeters DM, Boer AC, Reijnierse M, van der Helm-van Mil AHM. What is the additional value of MRI of the foot to the hand in undifferentiated arthritis to predict rheumatoid arthritis development? Arthritis Res Ther. 2019;21(1):56.

Fujimori M, Kamishima T, Kato M, et al. Composite assessment of power Doppler ultrasonography and MRI in rheumatoid arthritis: a pilot study of predictive value in radiographic progression after one year. Br J Radiol. 2018;91(1086):20170748.

Niemantsverdriet E, van der Helm-van Mil AHM. Imaging detected tenosynovitis of metacarpophalangeal and wrist joints: an increasingly recognised characteristic of rheumatoid arthritis. Clin Exp Rheumatol. 2018;36 Suppl 114(5):131-138.

Østergaard M, Boesen M. Imaging in rheumatoid arthritis: the role of magnetic resonance imaging and computed tomography. Radiol Med. 2019 Mar 18. doi: 10.1007/s11547-019-01014-y. [Epub ahead of print]

Takase-Minegishi K, Horita N, Kobayashi K, et al. Diagnostic test accuracy of ultrasound for synovitis in rheumatoid arthritis: systematic review and meta-analysis. Rheumatology (Oxford). 2018;57(1):49-58.

van den Berg R, Ohrndorf S, Kortekaas MC, van der Helm-van Mil AHM. What is the value of musculoskeletal ultrasound in patients presenting with arthralgia to predict inflammatory arthritis development? A systematic literature review. Arthritis Res Ther. 2018;20(1):228.

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