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US Detects Subclinical MTP Synovitis — SCE Rheumatology MCQ

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EasyMusculoskeletal ImagingUS Detects Subclinical MTP SynovitisSCE Rheumatology

A 55-year-old woman with established rheumatoid arthritis has no tenderness or swelling at the fifth metatarsophalangeal joint. Ultrasound demonstrates synovial hypertrophy with intra-articular power Doppler signal at this joint. Which statement best explains the discordance between the clinical and ultrasound findings?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Ultrasound can detect subclinical synovitis missed by clinical examination

Explanation lettering: E = shown as A · C = shown as B · A = shown as C · B = shown as D · D = shown as E

E is correct. Synovial hypertrophy accompanied by intra-articular power Doppler signal indicates active synovial inflammation despite the absence of clinically detectable tenderness or swelling—subclinical synovitis. Ultrasound can therefore supplement clinical examination, including at MTP joints, which are commonly affected in RA but are omitted from DAS28. A is false because superficial MTP joints are readily accessible to ultrasound. B and C incorrectly assume that clinical examination is at least as sensitive as ultrasound. D is also false: ultrasound has a selective clinical role when examination is inconclusive or discordant, although NICE does not recommend it for routine disease-activity monitoring. An isolated ultrasound finding does not, by itself, mandate treatment escalation.

Reference: National Institute for Health and Care Excellence. Rheumatoid arthritis in adults: management (NG100), research recommendation NG100/3, Ultrasound in monitoring. 2018. https://www.nice.org.uk/about/what-we-do/research-and-development/research-recommendations/NG100/3