Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Technology Insight: the role of color and power Doppler ultrasonography in rheumatology

Nature Clinical Practice Rheumatology volume 3, pages 35–42 (2007)Cite this article

Abstract

An increasing number of rheumatologists have access to ultrasound equipment that provide both color and power Doppler modes, which can be used to investigate musculoskeletal and vascular pathologies. Musculoskeletal Doppler ultrasonography can be used to estimate levels of inflammation, to document the anti-inflammatory effect of agents such as corticosteroids and tumor necrosis factor inhibitors, to differentiate between inflammatory and degenerative disease, and to distinguish between normal and inflamed joints in cases of minor synovial swelling. Vascular Doppler ultrasonography can be used to determine organ involvement in small-vessel vasculitides, to delineate aneurysms in vasculitides of medium-sized arteries, and to assess the characteristic findings in large-vessel vasculitis. Numerous studies, including a meta-analysis, have been published on the use of temporal-artery ultrasonography for the diagnosis of giant cell arteritis. Duplex ultrasonography is a sensitive approach for detecting characteristic edematous wall swellings in active temporal arteritis and for assessing vasculitis of the axillary arteries (large-vessel giant cell arteritis) in patients with suspected temporal arteritis, polymyalgia rheumatica, or fever of unknown origin. Duplex ultrasonography can also be used to assess vasculitis of subclavian and carotid arteries in younger patients with Takayasu's arteritis and acute finger artery occlusions in patients with small-vessel vasculitides.

Key Points

  • Doppler ultrasonography provides clinically important information in rheumatology

  • Doppler ultrasonography of joints and tendons allows for assessment of inflammation, documentation of the effect of anti-inflammatory agents, and differentiation of inflammatory disease from degenerative disease

  • Semiquantitative evaluation of color signals is most commonly used: Grade 0, no color signal; grade 1, single vessel signals; grade 2, confluent vessel signals; grade 3, more than 50% of the area of the synovium is covered with color signals

  • In small-vessel vasculitides, ultrasonography assesses pathologies that are secondary to vasculitis; in medium-sized-artery vasculitides, aneurysms can be detected; in large-vessel vasculitides, ultrasonography delineates characteristic, homogeneous, circumferential wall swellings

  • In temporal arteritis, further characteristic signs of inflammation are stenosis and acute occlusion

  • In patients with temporal arteritis, polymyalgia rheumatica, or fever of unknown origin, it is recommended that the axillary arteries are investigated with Doppler ultrasonography, as large-vessel giant cell arteritis is more common than previously thought

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Dorsal longitudinal scan of a wrist with synovitis and high inflammatory activity.
Figure 2: Colour Doppler images.
Figure 3: Duplex ultrasound of the right axillary artery in large-vessel giant cell arteritis.

Similar content being viewed by others

References

  1. Schmidt WA (2004) Doppler sonography in rheumatology. Best Pract Res Clin Rheumatol 18: 827–846

    Article  Google Scholar 

  2. Newman JS et al. (1994) Detection of soft-tissue hyperemia: Value of power Doppler sonography. AJR Am J Roentgenol 153: 385–389

    Article  Google Scholar 

  3. Terslev L et al. (2005) Doppler ultrasound findings in healthy wrists and finger joints before and after use of two different contrast agents. Ann Rheum Dis 64: 824–827

    Article  CAS  Google Scholar 

  4. Schmidt WA et al. (2000) Colour Doppler ultrasonography to detect pannus in knee-joint synovitis. Clin Exp Rheumatol 18: 439–444

    CAS  PubMed  Google Scholar 

  5. Wakefield RJ et al. (2005) Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 32: 2485–2487

    PubMed  Google Scholar 

  6. Szkudlarek M et al. (2001) Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging. Arthritis Rheum 44: 2018–2023

    Article  CAS  Google Scholar 

  7. Weidekamm C et al. (2003) Diagnostic value of high-resolution B-mode and doppler sonography for imaging of hand and finger joints in rheumatoid arthritis. Arthritis Rheum 48: 325–333

    Article  CAS  Google Scholar 

  8. Naredo E et al. (2005) Ultrasonographic assessment of inflammatory activity in rheumatoid arthritis: comparison of extended versus reduced joint evaluation. Clin Exp Rheumatol 23: 881–884

    CAS  PubMed  Google Scholar 

  9. D'Agostino MA et al. (2003) Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross-sectional study. Arthritis Rheum 48: 523–533

    Article  Google Scholar 

  10. Kiris A et al. (2006) Assessment of enthesitis in ankylosing spondylitis by power Doppler ultrasonography. Skeletal Radiol 35: 522–528

    Article  Google Scholar 

  11. Salaffi F et al. (2004) Contrast-enhanced power Doppler sonography of knee synovitis in rheumatoid arthritis: assessment of therapeutic response. Clin Rheumatol 23: 285–290

    Article  CAS  Google Scholar 

  12. Hau M et al. (2002) High resolution ultrasound detects a decrease in pannus vascularisation of small finger joints in patients with rheumatoid arthritis receiving treatment with soluble tumour necrosis factor alpha receptor (etanercept). Ann Rheum Dis 61: 55–58

    Article  CAS  Google Scholar 

  13. Terslev L et al. (2003) Effects of treatment with etanercept (Enbrel, TNRF:Fc) on rheumatoid arthritis evaluated by Doppler ultrasonography. Ann Rheum Dis 62: 178–181

    Article  CAS  Google Scholar 

  14. Fiocco U et al. (2005) Rheumatoid and psoriatic knee synovitis: clinical, grey scale, and power Doppler ultrasound assessment of the response to etanercept. Ann Rheum Dis 64: 899–905

    Article  CAS  Google Scholar 

  15. Taylor PC et al. (2006) Ultrasonographic and radiographic results from a two-year controlled trial of immediate or one-year-delayed addition of infliximab to ongoing methotrexate therapy in patients with erosive early rheumatoid arthritis. Arthritis Rheum 54: 47–53

    Article  CAS  Google Scholar 

  16. Strunk J et al. (2003) Doppler sonographic findings in the long bicipital tendon sheath in patients with rheumatoid arthritis as compared with patients with degenerative diseases of the shoulder. Arthritis Rheum 48: 1828–1832

    Article  Google Scholar 

  17. Schmidt WA et al. (2004) Standard reference values for musculoskeletal ultrasonography. Ann Rheum Dis 63: 988–994

    CAS  Google Scholar 

  18. Joshua F et al. (2005) Power Doppler 'blanching' after the application of transducer pressure. Australas Radiol 49: 218–221

    Article  CAS  Google Scholar 

  19. Cook JL et al. (2005) Is vascularity more evident after exercise? Implications for tendon imaging. AJR Am J Roentgenol 185: 1138–1140

    Article  Google Scholar 

  20. Scheel AK et al. (2005) Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR “Train the trainers” course. Ann Rheum Dis 64: 1043–1049

    Article  CAS  Google Scholar 

  21. Naredo E et al. (2006) Inter-observer reliability in musculoskeletal ultrasonography: results from a “Teach-the-Teachers” rheumatologist course. Ann Rheum Dis 65: 14–19

    Article  CAS  Google Scholar 

  22. Oliveira GH et al. (2005) Echocardiographic findings in patients with Wegener granulomatosis. Mayo Clin Proc 80: 1435–1440

    Article  Google Scholar 

  23. Newburger JW et al. (2004) Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics 114: 1708–1733

    Article  Google Scholar 

  24. Schmidt WA et al. (1997) Color duplex ultrasonography in the diagnosis of temporal arteritis. N Engl J Med 337: 1336–1342

    Article  CAS  Google Scholar 

  25. Vianna RN et al. (2005) The role of ultrasound biomicroscopy in predicting the result of temporal artery biopsy in temporal arteritis patients: a preliminary study. Eur J Ophthalmol 15: 655–659

    Article  Google Scholar 

  26. Bruyn GA and Schmidt WA (2006) Introductory Guide to Musculoskeletal Ultrasound for the Rheumatologist. The Netherlands: Bohn Stafleu van Logum

    Google Scholar 

  27. Karassa FB et al. (2005) Diagnostic performance of ultrasonography for giant-cell arteritis: a meta-analysis. Ann Intern Med 142: 359–369

    Article  Google Scholar 

  28. Schmidt WA and Gromnica-Ihle E (2003) Duplex ultrasonography in temporal arteritis. Ann Intern Med 138: 609

    Article  Google Scholar 

  29. Schmidt WA and Gromnica-Ihle E (2005) What is the best approach to diagnose large-vessel vasculitis? Best Pract Res Clin Rheumatol 19: 223–242

    Article  Google Scholar 

  30. Müller E et al. (2004) Temporal arteritis with pauci-immune glomerulonephritis: a systemic disease. Clin Nephrol 62: 384–386

    Article  Google Scholar 

  31. Bley TA et al. (2005) High-resolution MRI in giant cell arteritis: imaging of the wall of the superficial temporal artery. AJR Am J Roentgenol 184: 283–287

    Article  Google Scholar 

  32. Schmidt WA and Gromnica-Ihle E (2002) Incidence of temporal arteritis in patients with polymyalgia rheumatica—a prospective study using colour Doppler ultrasonography of the temporal arteries. Rheumatology (Oxford) 41: 46–52

    Article  CAS  Google Scholar 

  33. Cantini F et al. (2001) Shoulder ultrasonography in the diagnosis of polymyalgia rheumatica: A case-control study. J Rheumatol 28: 1049–1055

    CAS  PubMed  Google Scholar 

  34. Cantini F et al. (2005) Inflammatory changes of hip synovial structures in polymyalgia rheumatica. Clin Exp Rheumatol 23: 462–468

    CAS  PubMed  Google Scholar 

  35. Schmidt WA et al. (2002) Involvement of peripheral arteries in giant cell arteritis: a color Doppler sonography study. Clin Exp Rheumatol 20: 309–318

    CAS  PubMed  Google Scholar 

  36. Schmidt WA and Blockmans D (2005) Use of ultrasonography and positron emission tomography in the diagnosis and assessment of large-vessel vasculitis. Curr Opin Rheumatol 17: 9–15

    Article  Google Scholar 

  37. Brodmann M et al. (2004) The role of 2-18F-fluoro-2-deoxy-D-glucose positron emission tomography in the diagnosis of giant cell arteritis of the temporal arteries. Rheumatology (Oxford) 43: 241–242

    Article  CAS  Google Scholar 

  38. Pfadenhauer K et al. (2005) Vertebrobasilar ischemia and structural abnormalities of the vertebral arteries in active temporal arteritis and polymyalgia rheumatica—an ultrasonographic case-control study. J Rheumatol 32: 2356–2360

    PubMed  Google Scholar 

  39. Kerr G et al. (1994) Takayasu arteritis. Ann Intern Med 120: 919–929

    Article  CAS  Google Scholar 

  40. Schmidt WA et al. (2002) Diagnosis of early Takayasu arteritis by colour Doppler ultrasonography. Rheumatology (Oxford) 41: 496–502

    Article  CAS  Google Scholar 

  41. Ringleb PA et al. (2005) Cerebrovascular manifestations of Takayasu arteritis in Europe. Rheumatology (Oxford) 44: 1012–1015

    Article  CAS  Google Scholar 

  42. Schmidt WA et al. (2006) Colour duplex sonography of finger arteries in vasculitis and in systemic sclerosis. Ann Rheum Dis 65: 265–267

    Article  CAS  Google Scholar 

  43. Cook JL et al. (2005) High reproducibility of patellar tendon vascularity assessed by colour Doppler ultrasonography: a reliable measurement tool for quantifying tendon pathology. Br J Sports Med 39: 700–703

    Article  CAS  Google Scholar 

  44. Carotti M et al. (2002) Power Doppler sonography in the assessment of synovial tissue of the knee joint in rheumatoid arthritis: a preliminary experience. Ann Rheum Dis 61: 877–882

    Article  CAS  Google Scholar 

  45. Klauser A et al. (2005) Contrast enhanced gray-scale sonography in assessment of joint vascularity in rheumatoid arthritis: results from the IACUS study group. Eur Radiol 15: 2404–2410

    Article  Google Scholar 

Download references

Author information

Author notes

  1. Medical Center for Rheumatology Berlin–Buch, Immanuel Diakonie Group, Karower Str. 11, 13125 Berlin, Germany w.schmidt@immanuel.de

Authors and Affiliations

  1. WA Schmidt is a Consultant Rheumatologist and the Deputy Director of the Medical Center for Rheumatology in Berlin–Buch and is Clinical Professor at Humboldt University in Berlin, Germany.,

    Wolfgang A Schmidt

Authors
  1. Wolfgang A Schmidt
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schmidt, W. Technology Insight: the role of color and power Doppler ultrasonography in rheumatology. Nat Rev Rheumatol 3, 35–42 (2007). https://doi.org/10.1038/ncprheum0377

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncprheum0377

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing