Bombardieri, S.

Delle Sedie, A.

Di Geso, L.

Filippucci, E.

Grassi, W.

Guido, Valesini

Iagnocco, Annamaria

Meenagh, G.

Montecucco, C.

Riente, L.

Sakellariou, G.

English

Institutional Research Information System University of Turin

3191Department of Rheumatology, Antrim Hospital, Antrim, United Kingdom;2Cattedra di Reumatologia, IRCCS Policlinico San Matteo, Università di Pavia, Pavia, Italy;3Cattedra di Reumatologia, Sapienza Università di Roma, Roma, Italy;4Unità Operativa di Reumatologia, Università di Pisa, Pisa, Italy;5Clinica Reumatologica, Università Politecnica delle Marche, Ancona, Italy.Gary Meenagh, MDGarifallia Sakellariou, MDAnnamaria Iagnocco, MDAndrea Delle Sedie, MDLucrezia Riente, MDLuca Di Geso, MDEmilio Filippucci, MDWalter Grassi, MD,   Professor of RheumatologyStefano Bombardieri, MD,   Professor of RheumatologyGuido Valesini, MD,   Professor of RheumatologyCarlomaurizio Montecucco, MD,   Professor of RheumatologyPlease address correspondence to: Prof. Walter Grassi, Clinica Reumatologica, Università Politecnica delle Marche,Ospedale “C. Urbani”, Via dei Colli 52, 60035 Jesi (Ancona), Italy.E-mail: walter.grassi@univpm.itReceived and accepted on June 17, 2012.Clin Exp Rheumatol 2012; 30: 319-321.© Copyright CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2012.Key words: hip, ultrasound, fibromyalgia, synovitis, LequesneCompeting interests: none declared.ABSTRACTFibromyalgia syndrome (FMS) is a common form of non-inflammatory rheumatism within the general popu-lation with symptoms often mimicking those of arthritis or muscle disorders. Arthralgic symptoms in the region of the hip are commonly mentioned by patients with FMS and one of the diag-nostic trigger points for the condition is found around the greater trochanter. To date, no formal imaging studies using ultrasound (US) have been performed in FMS.This study describes the correlation between clinical and US findings in pa-tients presenting with primary FMS to rheumatology clinics. In the majority of the patients, no sig-nificant pathological US abnormalities were detected.IntroductionFibromyalgia syndrome (FMS) is a common disorder within the general population with estimates of prevalence between 1–4% (1-2). The condition can be primary or secondary to other chron-ic conditions, including rheumatoid ar-thritis, osteoarthritis, connective tissue disorders and chronic infection (3-5). The underlying etiology of FMS is cur-rently unknown and indeed views relat-ing to the disorder can be quite contro-versial within the medical community.The hip is amongst several anatomical regions from which patients with FMS frequently derive pain. To date, no large population studies have been per-formed estimating its exact prevalence (6). Classification criteria for FMS fo-cus on the presence of tender points, also known as trigger points, and one such trigger point is found on the outer aspect of the greater trochanter (5, 7). In recent years, proposals to change the diagnostic criteria have been suggested, with less emphasis on the identification of such trigger points and more towards symptom-based diagnosis (8). In patients with FMS it is imperative to exclude alternative pathologies and this often involves imaging modalities to look for structural anomalies of the hip joint. US is being increasingly used as an effective tool to identify soft tissue and joint pathology in the hip region.Our group have already described the advantages relating to the superiority of US to blind clinical examination of the hip region (9-11).To our knowledge, this is the first for-mal imaging study using ultrasound (US) to have been performed in FMS.This study describes the correlation be-tween clinical and US findings in pa-tients presenting with primary FMS to rheumatology clinics. MethodsThe study was conducted according to the Declaration of Helsinki and local regulations, and informed consent was obtained from all patients.PatientsPatients who fulfilled the 1990 Ameri-can College of Rheumatology criteria for FMS (7), and attending the out-pa-tient clinics of the Rheumatology De-partments involved in this multicentre study were consecutively recruited. Study designAll patients underwent a complete clin-ical assessment by an expert rheuma-tologist who recorded the presence/ab-sence of pain/tenderness (by palpation and/or active or passive mobilisation of the hip). Moreover, the Lequesne questionnaire was used to estimate the ImagingUltrasound imaging for the rheumatologist XXXIX. Sonographic assessment of the hip in fibromyalgia  G. Meenagh1 , G. Sakellariou2, A. Iagnocco3, A. Delle Sedie4, L. Riente4, E. Filippucci5, L. Di Geso5, W. Grassi5, S. Bombardieri4, G. Valesini3, C. Montecucco2320IMAGING XXXIX. Sonographic assessment of the hip in fibromyalgia / G. Meenagh et al.severity of hip impairment (12). Prior to the beginning of the study, sonogra-phers reached a consensus on both the scanning technique to adopt and the pathological findings to detect. One sonographer for each centre performed the US examinations, blinded to pa-tients’ clinical data.The patients were placed in a supine position, with the hip joints in neu-tral position. US was performed with a Logiq 9 machine (General Electrics Medical Systems, Milwaukee, WI) with a 6–8 MHz multi-frequency lin-ear array transducer. A standardised longitudinal anatomic section plane along the neck of the femur was used to visualise the anterior capsule, in or-der to detect US findings indicative of hip joint inflammation according to the EULAR guidelines for musculoskel-etal ultrasound in rheumatology (13). A multiplanar scanning technique was adopted to confirm the presence of all pathological findings.Sonographic measurements of enthe-seal thickness were performed where it appeared maximal as in previous stud-ies by the group (10, 11). The following anatomic sites were examined: hip joint, trochanteric bursa, ilio-psoas bursa, glu-teus tendons, and ilio-psoas tendon.Power Doppler assessments were car-ried out according to the indications provided by Torp-Pedersen et al. (14). US image interpretationSonographic findings indicative of hip pathology were documented and re-ported. For the detection of synovial fluid, synovial hypertrophy, bone ero-sion and enthesopathy the US defini-tions described by the OMERACT spe-cial interest group (15) were adopted. The limit for normal hip dimension was defined according to Koski et al., with values ≥7 mm and a difference of 1 or more mm is suggestive of joint space widening (16). The presence of osteophytes was de-fined by the detection of characteristic irregularities of the bone profile as de-scribed in previous studies concentrat-ing on osteoarthritis (17-21).ResultsA total of 64 patients were assessed. Basic patient demographic and clinical data of the study population are report-ed in the Table I US examination of the hip joint re-vealed evidence of minimal joint effu-sion in 14% of cases, mostly correlating with the presence of hip pain. A bursae effusion was present in 9/64 (14%) pa-tients. Other hallmark features of in-flammatory hip joint disease including synovial hypertrophy, bone erosion and intra-articular Doppler signal were not seen.The most common tendon to demon-strate US pathology was the gluteus tendon.Table II shows the relationship between clinical and US findings indicative of hip region pathology.The results of the Lequesne question-naire showed that a severe to extremely severe impairment was present in at least 19/64 (29.7%) patients, while a normal value was found in only 11/64 (17.2%) of patients. US findings were poorly represented in the group with no impair-ment (data derived from the Lequesne questionnaire), with only two patients Table I. Patient demographic and clinical data. Number of patients           64 Gender (female/male)         40/24 Age in years (range)     54.6 (23-81) Disease duration in months; mean (range)                 92.9 (6-360) Tender points (mean)                  12.3 (0-18) Lequesne score; mean (range)                      6.2 (0-17) Number of patients with current painful hip in at least one side (%)                  33 (52%)  Number of patients with history of painful hip in at least one side (%)                  38 (59%) Number of patients with no history of painful hip and no current painful hip (%)             19 (30%) Number of patients on NSAIDs (%)                        10 (16%) Number of patients on steroid therapy (%)                        6 (9%)Table II. Relationship between sonographic and clinical findings. The presence of at least one clinical finding indicative of pain at hip level was used to compile the table.              Clinical findings - Painful hip     Presence Absence Total Sonographic  Joint effusion Presence 9 2 11 findings  Absence 39 78 117  Total 48 80 128  Synovial hypertrophy Presence 0 0 0  Absence 48 80 128  Total 48 80 128  Intra-articular power Presence 0 0 0  Doppler signal Absence 48 80 128  Total 48 80 128  Osteophytes Presence 15 25 40  Absence 33 55 88  Total 48 80 128  Trochanteric bursitis Presence 5 4 9  Absence 43 76 119  Total 48 80 128  Ilio-psoas bursitis Presence 0 2 2  Absence 48 78 126  Total 48 80 128  Gluteus tendinopathy Presence 10 25 35  Absence 38 55 93  Total 48 80 128  Ilio-psoas tendinopathy Presence 4 11 15  Absence 44 69 113  Total 48 80 128321IMAGINGXXXIX. Sonographic assessment of the hip in fibromyalgia / G. Meenagh et al.showing monolateral ilio-psoas tendino-pathy and another couple monolateral osteophytes. Only four patients in the group of severe to extremely severe im-pairment had negative US findings. DiscussionPain in the hip region is a frequent complaint from patients suffering from FMS.The hip region does contain one of the classical trigger points seen common-ly in the condition. However, appar-ently, there is no relationship between the Lequesne results and the number of positive tender points (only one of the Lequesne negative patients was also negative for tender points), with no significant differences for this item between the subgroup of impairment as shown by the Lequesne results, con-firming the scarce utility of using ten-der points to investigate the severity of the disease (22). Our group has previ-ously shown that US is an effective tool to image the hip region and which can be a more sensitive indicator of the underlying focus for pain (8-10). In pa-tients with FMS, pain in the hip region can often be diffuse thereby making di-agnosis of musculoskeletal pathology complex.To date, no imaging studies using US have been performed in patient cohorts with FMS.This observational multicentre study has shown that there is a low yield of definite musculoskeletal abnormalities within the hip region in a small cohort of FMS patients. Whilst a small number had US detected hip effusion, this was minimal and not felt to correlate with any inflammatory symptoms.There was clinical over-estimation of inflammatory involvement of the soft tissues which was not borne out by the subsequent US examination. Due to the relatively small number of patients enrolled in the present study, it is dif-ficult to draw definite conclusions on the prevalence of US findings in FMS and to be certain how much these find-ings may be contributing to some of the pain within the hip region in this pa-tient group. For instance, the quite high number of osteophytes detected by US can be explained by the mean age of the study population, higher than 50 years. Moreover, the impact of US findings in patients with FMS should be compara-tively investigated in healthy and dis-ease controls.In conclusion, since clinical examina-tion may generate frequently false-pos-itive results in patients with FMS, the higher specificity of the US findings can be used to confirm hip joint and peri-articular soft-tissue involvement.References  1. WHITE KP, SPEECHLEY M, HARTH M, OST-BYE T: The London fibromyalgia epidemi-ology study: the prevalence of fibromyalgia syndrome in London, Ontario. J Rheumatol 1999; 26: 1570-6.  2. BAZZICHI L, SERNISSI F, CONSENSI A, GI-ACOMELLI C, SARZI-PUTTINI P: Fibromyal-gia: a critical digest of the recent literature. Clin Exp Rheumatol 2011; 29 (Suppl. 69):S1-11.  3. YUNUS M: The prevalence of fibromyalgia in other chronic pain conditions. Pain Res Treat 2012; 10: 1-8.  4. CROFT P, SCHOLLUM J, SILMAN A: Popula-tion study of tender point counts and pain as evidence of fibromyalgia. BMJ 1994; 309: 696-9.  5. GOLDENBERG DL: Fibromyalgia: why such controversy? Ann Rheum Dis 1995; 54: 3-5.  6. WOLFE F, ROSS K, ANDERSON J, RUSSELL IJ, HEBERT L: The prevalence and character-istics of fibromyalgia in the general popula-tion. Arthritis Rheum 1995; 38: 19-28.  7. WOLFE F, SMYTHE HA, YUNUS M, BENNETT RM, BOMBARDIER C, GOLDENBERG DL: The American College of Rheumatology 1990 criteria for the classification of fibro-myalgia: Report of the multicentre criteria committee. Arthritis Rheum 1990; 33: 160-72.  8. WOLFE F, CLAUW DJ, FITZCHARLES MA et al.: The American College of Rheumatology preliminary diagnostic criteria for fibromyal-gia and measurement of symptom severity. Arthritis Care Res 2010; 62: 600-10.  9. IAGNOCCO A, FILIPPUCCI E, MEENAGH G et al.: Ultrasound imaging for the rheumatolo-gist III. Ultrasonography of the hip. 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Ultrasound imaging for the rheumatologist XXXIX. Sonographic assessment of the hip in fibromyalgia

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Ultrasound imaging for the rheumatologist XXXIX. Sonographic assessment of the hip in fibromyalgia

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