In a patient with joint pain and a positive anti-CCP but no swelling, the instinct is to look for synovitis — and finding none, to reassure and review in six months. The tendons are where the information is.
Tenosynovitis is often the first inflammatory change in this group, and it is easy to miss because it is not what the probe is pointed at. Scan the extensor compartments and the flexor tendon sheaths at the wrist and fingers deliberately, in both transverse and longitudinal planes, and look for bone erosion at the metacarpal heads and the fifth metatarsal — the classic early sites.
And write the negative down properly. 'No synovitis' in a CCP-positive patient is a different statement from 'no synovitis, no tenosynovitis, no erosions on a 36-joint protocol', and the second is what makes the next scan interpretable.
- Examine and scan the flexor and extensor tendon sheaths, not only the joints
- Look specifically for erosion at the metacarpal heads and the fifth metatarsal
- Record exactly which structures were assessed, not just the conclusion
- Set the review interval by risk rather than defaulting to six months for everyone
- Tell a CCP-positive patient what symptoms should bring them back sooner
Why it matters
The earliest sign in this group is in a structure most scanning protocols pass over.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for rheumatology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free