Differences and differentiation in musculoskeletal ultrasound signs between gouty arthritis and rheumatoid arthritis

doi:10.3877/cma.j.issn.1674-134X.2026.03.008

Abstract

Abstract:

Objective

To construct a differential diagnosis model for musculoskeletal ultrasound (MSUS)signs in patients with gouty arthritis (GA) and rheumatoid arthritis (RA).

Methods

A total of 180 patients from the Department of Rheumatology and Immunology of Xuzhou First People’s Hospital between January 2020 and May 2025 were selected. Inclusion criteria: age between 18 and 75 years old; present with typical symptoms of arthritis such as joint pain and swelling; Patients can cooperate to complete musculoskeletal ultrasound examination. Exclusion criteria: complicated with other types of arthritis, such as infectious arthritis, reactive arthritis, etc.; severe functional disorders of important organs like heart, liver, and kidney; pregnant or lactating women. Based on diagnostic results, they were divided into the GA group (n=92) and the RA group (n=88). High-frequency musculoskeletal ultrasound was used to detect synovial thickness, blood flow signals, bone erosion, the double-contour sign, and tophi. Differences in ultrasound findings between the two groups were compared by independent t test. Multivariate logistic regression and receiver operating characteristic (ROC) curve analysis were employed to evaluate the differential diagnostic performance of the ultrasound signs.

Results

There were statistically significant differences between the two groups in terms of age (t=2.916), gender (χ²=17.370), body mass index (BMI) ( t=5.427), knee joint (χ²=4.447), toe joint involvement rate (χ²=13.310), wrist joint (χ²=11.117), shoulder joint involvement rate (χ²=5.692), double-track sign (χ²=59.732), punctate hyperechoic area (χ²=34.567), positive rate of gout stones (χ²=46.075), bone erosion depth (t=6.640), synovial hyperplasia (t=8.586), joint cavity effusion (t=9.164), blood flow signal over level two (χ²=17.759), and cartilage destruction (χ²=10.940) ( all P<0.05). Multivariate logistic regression analysis revealed that bone erosion [odds ratio (OR)=7.655, β=2.035], joint cavity effusion (OR=6.323, β=1.844), blood flow signal (OR=4.791, β=1.567), gender (OR=7.202, β=1.974), and BMI (OR=0.684, β=-0.38) (all P<0.05) were independent influencing factors for GA and RA. Additionally, ROC results demonstrated that the combined model of double-track sign, punctate hyperechoic, and tophus in GA differentiation had an area under the curve (AUC) of 0.921, with sensitivity of 82.4% and specificity of 94.3%. For RA differentiation, the combined model of bone erosion and joint cavity effusion had an AUC of 0.882, with sensitivity of 78.4% and specificity of 87.0%. The combined diagnostic models exhibited good diagnostic efficacy.

Conclusion

Musculoskeletal ultrasound signs are valuable in the differentiation between GA and RA, and the combination of characteristic signs such as double-track sign and gout stone can improve the diagnostic efficacy of GA, while bone erosion and joint cavity effusion are significant in the differentiation of RA.

Key words: Gouty arthritis, Rheumatoid arthritis, Ultrasonography, Diagnosis, differential

Mingjing Xu, Bao Liu, Guoqiang Sun, Jing Zhou, Mengyu Nian. Differences and differentiation in musculoskeletal ultrasound signs between gouty arthritis and rheumatoid arthritis[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2026, 20(03): 314-321.

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URL: https://zhgjwkzz.cma-cmc.com.cn/EN/10.3877/cma.j.issn.1674-134X.2026.03.008

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Figures/Tables 9

Table 1 Analysis of general data of the two groups of patients

一般资料 General information		GA组 GA group	RA组 RA group	统计值 Statistical values	P值
例数 Number of cases		92	88
年龄［岁，（ $x ¯$ ±s）］ Age（year）		58.1±9.7	62.5±10.2	t=2.916	0.004
性别［n（%）］ Gender	男 Male	71（77.2）	35（39.8）	χ²=17.370	＜0.001
性别［n（%）］ Gender	女 Female	21（22.8）	53（60.2）	χ²=17.370	＜0.001
病程［年，（ $x ¯$ ±s）］ Course of disease（year）		3.5±2.1	3.8±2.6	t=0.901	＞0.05
BMI［kg/m²，（ $x ¯$ ±s）］		24.9±3.1	22.7±3.2	t=5.427	＜0.001
关节压痛数［个，（ $x ¯$ ±s）］ Number of joint tenderness（unit）		5.2±2.5	5.5±2.8	t = 0.182	＞0.05
关节肿胀数［个，（ $x ¯$ ±s）］ Number of swollen joints（unit）		3.8±1.9	4.0±2.1	t = 0.203	＞0.05
CRP［mg/L，（ $x ¯$ ±s）］		34.1±16.2	32.8±15.7	t = 0.58	＞0.05
ESR［mm/h，（ $x ¯$ ±s）］		42.5±19.1	40.8±18.5	t = 0.63	＞0.05
血小板计数［10⁹/L，（ $x ¯$ ±s）］ Platelet count（10⁹/L）		285.4±75.0	278.0±72.3	t = 0.65	＞0.05
白细胞计数［10⁹/L，（ $x ¯$ ±s）］ White blood cell count		7.6±2.3	7.9±2.2	t = 1.01	＞0.05

Table 1 Analysis of general data of the two groups of patients

一般资料 General information		GA组 GA group	RA组 RA group	统计值 Statistical values	P值
例数 Number of cases		92	88
年龄［岁，（ $x ¯$ ±s）］ Age（year）		58.1±9.7	62.5±10.2	t=2.916	0.004
性别［n（%）］ Gender	男 Male	71（77.2）	35（39.8）	χ²=17.370	＜0.001
性别［n（%）］ Gender	女 Female	21（22.8）	53（60.2）	χ²=17.370	＜0.001
病程［年，（ $x ¯$ ±s）］ Course of disease（year）		3.5±2.1	3.8±2.6	t=0.901	＞0.05
BMI［kg/m²，（ $x ¯$ ±s）］		24.9±3.1	22.7±3.2	t=5.427	＜0.001
关节压痛数［个，（ $x ¯$ ±s）］ Number of joint tenderness（unit）		5.2±2.5	5.5±2.8	t = 0.182	＞0.05
关节肿胀数［个，（ $x ¯$ ±s）］ Number of swollen joints（unit）		3.8±1.9	4.0±2.1	t = 0.203	＞0.05
CRP［mg/L，（ $x ¯$ ±s）］		34.1±16.2	32.8±15.7	t = 0.58	＞0.05
ESR［mm/h，（ $x ¯$ ±s）］		42.5±19.1	40.8±18.5	t = 0.63	＞0.05
血小板计数［10⁹/L，（ $x ¯$ ±s）］ Platelet count（10⁹/L）		285.4±75.0	278.0±72.3	t = 0.65	＞0.05
白细胞计数［10⁹/L，（ $x ¯$ ±s）］ White blood cell count		7.6±2.3	7.9±2.2	t = 1.01	＞0.05

Table 2 Analysis of joint involvement in the two groups

组别 Groups	例数 Number of cases	膝 Knee	踝 Ankle	腕 Wrist	肩 Shoulder	足趾关节 Toe joints
GA组 GA group	92	68（73.9）	34（37.0）	40（43.5）	12（13.0）	54（58.7）
RA组 RA group	88	52（59.1）	45（51.1）	60（68.2）	24（27.3）	21（23.9）
χ²值		4.447	3.672	11.117	5.692	12.310
P值		＜0.05	＞0.05	＜0.001	0.017	＜0.001

Table 3 Differences in musculoskeletal ultrasound signs

超声征象 Ultrasound findings		GA组（n=92） GA group	RA组（n=88） RA group	统计值 Statistical values	P值
骨侵蚀［mm，（ $x ¯$ ±s）］ Bone erosion		1.5±0.5	2.1±0.7	t=6.640	＜0.001
双轨征［n（%）］ Dual-track levy		65（84.8）	12（13.6）	χ²=59.732	＜0.001
点状高回声［n（%）］ Dense hyperechoic areas		55（59.8）	15（17.1）	χ²=34.567	＜0.001
痛风石［n（%）］ Gout stone		38（41.3）	0	χ²=46.075	＜0.001
滑膜增生［mm，（ $x ¯$ ±s）］ Synovial hyperplasia		2.5±0.8	3.8±1.2	t=8.586	＜0.001
血流信号［n（%）］ Blood flow signal	≤2级 ≤Level 2	70（76.1）	40（45.5）	χ²=17.759	＜0.001
血流信号［n（%）］ Blood flow signal	＞2级＞Level 2	22（23.9）	48（54.5）	χ²=17.759	＜0.001
关节腔积液［mm，（ $x ¯$ ±s）］ Joint cavity effusion		3.1±0.5	4.5±1.3	t=9.614	＜0.001
腱鞘积液［n（%）］ Tendon sheath effusion		28（30.4）	32（36.4）	χ²=0.712	＞0.05
软骨破坏［n（%）］ Cartilage destruction		38（41.3）	58（65.9）	χ²=10.940	＜0.001

Table 3 Differences in musculoskeletal ultrasound signs

超声征象 Ultrasound findings		GA组（n=92） GA group	RA组（n=88） RA group	统计值 Statistical values	P值
骨侵蚀［mm，（ $x ¯$ ±s）］ Bone erosion		1.5±0.5	2.1±0.7	t=6.640	＜0.001
双轨征［n（%）］ Dual-track levy		65（84.8）	12（13.6）	χ²=59.732	＜0.001
点状高回声［n（%）］ Dense hyperechoic areas		55（59.8）	15（17.1）	χ²=34.567	＜0.001
痛风石［n（%）］ Gout stone		38（41.3）	0	χ²=46.075	＜0.001
滑膜增生［mm，（ $x ¯$ ±s）］ Synovial hyperplasia		2.5±0.8	3.8±1.2	t=8.586	＜0.001
血流信号［n（%）］ Blood flow signal	≤2级 ≤Level 2	70（76.1）	40（45.5）	χ²=17.759	＜0.001
血流信号［n（%）］ Blood flow signal	＞2级＞Level 2	22（23.9）	48（54.5）	χ²=17.759	＜0.001
关节腔积液［mm，（ $x ¯$ ±s）］ Joint cavity effusion		3.1±0.5	4.5±1.3	t=9.614	＜0.001
腱鞘积液［n（%）］ Tendon sheath effusion		28（30.4）	32（36.4）	χ²=0.712	＞0.05
软骨破坏［n（%）］ Cartilage destruction		38（41.3）	58（65.9）	χ²=10.940	＜0.001

Figure 1 Musculoskeletal ultrasound imaging. A shows effusion in the first toe joint of the right foot, with punctate strong echoes and thickened synovium; B shows thickening of the medial joint capsule, with cloudy-like gout stones and slightly abundant blood flow signals; C shows double-track sign on the surface of the cartilage of both knees; D shows double-track sign on the surface of the cartilage of both knees; E shows gout stones in the right popliteal tendon; F shows thickening of the synovium of the knee joint

Table 4 Multivariate logistic regression analysis of the two groups

因素 Factors	β	SE	Wald值	OR	95%CI	P值
年龄 Age	0.022	0.014	2.469	1.022	（0.895，2.741）	＞0.05
骨侵蚀 Bone erosion	2.035	0.559	13.235	7.655	（2.557，22.919）	＜0.001
关节腔积液 Joint cavity effusion	1.844	0.346	28.393	6.323	（3.209，12.461）	＜0.001
血流信号 Blood flow signal	1.567	0.713	4.829	4.791	（1.184，1.961）	0.028
性别 Gender	1.974	0.725	7.407	7.202	（1.738，29.850）	0.006
BMI	-0.380	0.115	10.877	0.684	（0.546，0.857）	0.001

Table 5 The diagnostic efficacy of musculoskeletal ultrasound signs for GA

指标 Indicators	血药浓度-时间AUC AUC of the concentration-time	SE	P值	95% CI	灵敏度（%） Sensitivity	特异度（%） Specificity	Youden指数 Youden’s index
双轨征 Dual-track levy	0.782	0.039	＜0.001	（0.706，0.858）	68.5	76.2	0.447
点状高回声 Dense hyperechoic areas	0.761	0.043	＜0.001	（0.677，0.845）	59.8	82.5	0.551
痛风石 Gout stone	0.863	0.032	＜0.001	（0.800，0.926）	70.1	92.5	0.626
三者联合 Combination of the three	0.921	0.024	＜0.001	（0.874，0.968）	82.4	94.3	0.767

Figure 2 ROC (receiver operating characteristic curve) diagram for diagnosing GA (gouty arthritis) based on musculoskeletal ultrasound signs

Table 6 The diagnostic efficacy of musculoskeletal ultrasound signs for rheumatoid arthritis

指标 Indicators	血药浓度-时间AUC AUC of the concentration-time	SE	P值	95% CI	灵敏度（%） Sensitivity	特异度（%） Specificity	Youden指数 Youden’s index
骨侵蚀 Bone erosion	0.730	0.037	＜0.001	（0.657，0.803）	83.0	48.9	0.319
关节腔积液 Joint cavity effusion	0.830	0.033	＜0.001	（0.766，0.895）	77.3	84.8	0.621
二者联合 Combination of the two	0.882	0.025	＜0.001	（0.833，0.930）	78.4	87.0	0.654

Figure 3 ROC (receiver operating characteristic curve) diagram for diagnosing RA (rheumatoid arthritis) based on musculoskeletal ultrasound signs

References 20

［1］	Ni Z, Xiao Q, Xia Z, et al. Electroacupuncture for acute gouty arthritis: a systematic review and meta-analysis of randomized controlled trials［J］. Front Immunol, 2024, 14: 1295154. DOI: 10.3389/fimmu.2023.1295154.
［2］	Zhao M, Jian J, Yang D, et al. Knowledge, attitudes, and practices of gouty arthritis in the general population aged＞30［J］. BMC Med Educ, 2024, 24（1）: 775. DOI: 10.1186/s12909－024－05690－x.
［3］	Nevalainen MT, Uusimaa A-P, Saarakkala S. The ultrasound assessment of osteoarthritis: the current status［J］. Skeletal Radiol, 2023, 52（11）: 2271－2282.
［4］	张汀, 王丁一, 魏晓伟, 等. 痛风不同临床分期的肌骨超声特征及应用价值［J］. 中国超声医学杂志, 2025, 41（4）: 462－465.
［5］	李占兰. 肌骨超声在膝关节滑膜炎诊断中的价值及准确率［J］. 现代医用影像学, 2023, 32（2）: 332－334.
［6］	Wu J, Yan J, Chang J, et al. Diagnostic values of different musculoskeletal ultrasound signs, serum uric acid, and their combined detection for gouty arthritis［J］. Arch Rheumatol, 2024, 39（2）: 265－273.
［7］	中华医学会内分泌学分会. 中国高尿酸血症与痛风诊疗指南（2019）［J］. 中华内分泌代谢杂志, 2020, 36（1）: 1－13.
［8］	van der Linden MPM, Knevel R, Huizinga TWJ, et al. Classification of rheumatoid arthritis: comparison of the 1987 American College of Rheumatology criteria and the 2010 American College of Rheumatology/European League Against Rheumatism criteria［J］. Arthritis Rheum, 2011, 63（1）: 37－42.
［9］	宋小雯. 延续性护理干预对痛风性关节炎患者术后康复的影响［J/OL］. 中华关节外科杂志（电子版）, 2021, 15（3）: 387－390.
［10］	曾广吾, 董时纯, 陈健, 等. 全膝关节置换术在类风湿关节炎的应用效果分析［J/OL］. 中华关节外科杂志（电子版）, 2021, 15（3）: 359－363.
［11］	Manske RC, Wolfe C, Page P, et al. The utilization of diagnostic musculoskeletal ultrasound in the evaluation of gluteus medius tendon pathology: a perspective for rehabilitation providers［J］. Int J Sports Phys Ther, 2024, 19（5）: 642－645.
［12］	李春林, 彭超. 痛风性关节炎伴痛风石形成患者的临床特点分析［J］. 西藏医药, 2022, 43（3）: 64－66.
［13］	张伟, 胡晰杨, 张云娜, 等. 双能量CT联合肌骨超声鉴别诊断焦磷酸钙沉积病与痛风性关节炎的价值［J］. 实用医学杂志, 2024, 40（17）: 2477－2482.
［14］	Han P, Liu X, He J, et al. Overview of mechanisms and novel therapies on rheumatoid arthritis from a cellular perspective［J］. Front Immunol, 2024, 15: 1461756. DOI: 10.3389/fimmu.2024.1461756.
［15］	Nandakumar KS, Fang Q, Wingbro Ågren I, et al. Aberrant activation of immune and non-immune cells contributes to joint inflammation and bone degradation in rheumatoid arthritis［J］. Int J Mol Sci, 2023, 24（21）: 15883. DOI: 10.3390/ijms242115883.
［16］	Weaver JS, Omar I, Epstein K, et al. High-resolution ultrasound in the evaluation of musculoskeletal infections［J］. J Ultrason, 2023, 23（95）: 270－282.
［17］	程雅萍, 李晓燕, 闫妮. 痛风性关节炎免疫学发病机制和靶向治疗新进展［J］. 中国医药, 2024, 19（10）: 1591－1595.
［18］	Mohammad Razali A, Mohamed Shafit MA, Md Saleh R, et al. Ocular ischemic syndrome with bilateral carotid artery stenosis in a patient with chronic tophaceous gout［J］. Cureus, 2023, 15（11）: e49270. DOI: 10.7759/cureus.49270.
［19］	温远云, 季春香, 王晓锋, 等. 超微血流成像联合能量多普勒超声在痛风性关节炎诊断中的应用价值观察［J］. 影像研究与医学应用, 2024, 8（17）: 75－77, 80.
［20］	Gao X, Gao H, Zhang L, et al. Comparison of diagnostic efficacy of dual-energy CT and ultrasound in gouty arthritis［J］. Int J Rheum Dis. 2023, 26（9）: 1697－1703.

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