7 Osteoarthritis Imaging Recommendations

September 11, 2017

EULAR’s evidence-based guidelines cover the use of imaging in the clinical management of peripheral joint OA.

Evidence-based recommendations on the use of imaging in the management of symptomatic, peripheral joint osteoarthritis have been developed by a European League Against Rheumatism (EULAR) task force for clinicians who treat patients with the condition in their clinical practice.

The EULAR task force included rheumatologists, radiologists, methodologists, primary care physicians, and patients from 9 countries who defined 10 questions on the role of imaging in OA to support a systematic literature review; 17,011 references were identified from which 390 studies were included.

The knee, hip, hand, and foot were joints of interest. Imaging modalities included conventional radiography, MRI, ultrasonography, CT, and nuclear medicine.

Recommendations were developed to cover various areas in the routine management of osteoarthritis, including the lack of need for diagnostic imaging in patients with typical symptoms, the role of imaging in differential diagnosis, and the lack of benefit in monitoring when no therapeutic modification is related.


The task force offered the following overview:

The recommendations pertain only to symptomatic osteoarthritis.

Imaging abnormalities of osteoarthritis are seen frequently, especially with increasing age.

Joint symptoms are common and increase with age. Symptoms are not always causally related to imaging abnormalities.

A full history and examination are always needed before the need for investigations, including imaging, is considered.

Modern imaging modalities provide the capability to detect a wide range of soft tissue, bony, and cartilage pathology in osteoarthritis, but the increased information provided has not yet had any influence on clinical decision-making with respect to management.

Following are the 7 osteoarthritis imaging recommendations with findings:

1. Imaging is not required to make the diagnosis in patients with a typical presentation of osteoarthritis.

Studies in which imaging was applied in addition to clinical findings to evaluate its additional impact on the certainty of diagnosis were lacking.

Because strong evidence supporting the use of different imaging modalities at different anatomical sites was absent, the systematic use of imaging in the diagnostic process was not recommended in cases with typical clinical presentations.

Based on the joint site and clinical presentation, imaging might be considered when diagnoses other than osteoarthritis are suspected.

2. In atypical presentations, imaging is recommended to help confirm the diagnosis of osteoarthritis or make alternative or additional diagnoses.

Among studies that evaluated the application of imaging for differential diagnosis, no study evaluated the impact of the addition of imaging above clinical findings. But the experts recognized the possible application of imaging in atypical clinical scenarios.

3. Routine imaging in osteoarthritis follow-up is not recommended, but imaging is recommended if there is unexpected rapid progression of symptoms or change in clinical characteristics to determine if this relates to osteoarthritis severity or an additional diagnosis.

Most of the included studies focused on sensitivity to change; others investigated the trajectories of changes of elementary lesions detected by imaging when following osteoarthritis natural history or described the parallel changes between different abnormalities detected by different imaging modalities.

Only a minority of studies examined the correlation between the change in imaging features and symptoms or relevant clinical outcomes.

No studies compared clinical follow-up with imaging follow-up or strategies adding imaging to clinical management.

Three studies addressed the impact of imaging in the management of osteoarthritis. No studies evaluated the impact of imaging for the management of hand or foot osteoarthritis, and no studies specifically addressed the issue of nonsurgical management.

4. If imaging is needed, conventional radiography should be used before other modalities. To make additional diagnoses, soft tissues are best imaged by ultrasonography or MRI and bone by CT or MRI.

The use of conventional radiography was mainly to detect bone and indirectly cartilage loss; MRI was used for bone, cartilage; and soft tissues; and a single study assessed ultrasonography for the evaluation of cartilage.

Conventional radiography was the imaging modality most frequently used for diagnostic, prognostic, and follow-up purposes. No studies of the cost-effectiveness of each imaging modality or its sequence were found. The experts decided to emphasize the role of the most easily available and less costly imaging modality.

5. Consideration of radiographic views is important for optimizing detection of osteoarthritis features. In particular for the knee, weight-bearing and patellofemoral views are recommended.

Included were 27 studies that compared different views for knee osteoarthritis. Five studies assessed the hip. No studies assessing the hand and the foot were found.

6. According to current evidence, imaging features do not predict nonsurgical treatment response and imaging cannot be recommended for this purpose.

Because the results on the prediction of response were mostly inconsistent across studies, the use of imaging for this purpose was not recommended.

7. The accuracy of intra-articular injection depends on the joint and on the skills of the practitioner and imaging may improve accuracy. Imaging is particularly recommended for joints that are difficult to access because of factors that include site (eg, hip), degree of deformity, and obesity.

Accuracy was found to be better in imaging guided compared with blind procedures, but the results on the clinical outcomes of the injection were less consistent across studies. Therefore, systematic use of imaging to drive injections was not recommended.

The imaging modality is not specified in the recommendation, but there is published evidence for the use of ultrasonography, and imaging allows for real-time evaluation of injection placement.


Although recommendations have been made on how to use imaging in osteoarthritis clinical trials, these are the first recommendations on the use of imaging in osteoarthritis in clinical practice, the authors noted. Because only a small part of the information was relevant for clinical practice, however, they identified many areas that need further investigation.

The recommendations and related research agenda provide the basis for sensible use of imaging in routine clinical assessment of patients with osteoarthritis, they concluded.

The recommendations appeared in the September issue of Annals of the Rheumatic Diseases.


Sakellariou G, Conaghan PG, Zhang W, et al. “EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis.” Ann Rheum Dis. 2017;76:1484-1494. doi: 10.1136/annrheumdis-2016-210815. Epub 2017 Apr 7.