Imaging in Diagnosis and Management of Crystal-Induced Arthropathies in Clinical Practice

Publication Date: February 6, 2024
Last Updated: February 22, 2024

Overarching Statements

  • CiAs are typically characterised by intermittent, acute episodes of inflammation, but may also exhibit a persistent disease course with or without superimposed flares.
  • Imaging in CiAs provides useful information on crystal deposition, inflammation and structural damage.
  • The presence of imaging abnormalities, in particular, those related to crystal deposition, may not always be related to clinical manifestations.
  • Patient information (medical history, physical/laboratory examination, synovial fluid/tissue analysis, etc) should be taken into account when imaging is considered in CiAs.
  • Imaging in CiAs should be performed and interpreted by trained healthcare professionals.

Summary of Recommendations

When performing imaging in CiAs, both symptomatic areas and disease-specific target sites (ie, first metatarsophalangeal in gout, knee and wrist in CPPD, shoulder in BCPD) should be considered.

In the diagnostic assessment of gout, ultrasound and DECT are both recommended imaging modalities.

When characteristic features of MSU crystal deposition on ultrasound (ie, double-contour sign or tophi) or on DECT are identified, synovial fluid analysis is not needed to confirm a diagnosis of gout.

In the diagnostic assessment of CPPD, CR and ultrasound (or CT if axial involvement is suspected) are recommended imaging modalities.

In the diagnostic assessment of BCPD, imaging is necessary; CR or ultrasound is the recommended modality.

In gout, ultrasound and DECT can be used to monitor crystal deposition and in case of ultrasound, also inflammation. Both modalities provide additional information on top of clinical and biochemical assessment. In case ultrasound/DECT are not available, CR can be used to assess structural damage due to gout. The decision on when to repeat imaging depends on the clinical circumstances.

In CPPD and BCPD, serial imaging is not recommended, unless there is an unexpected change in clinical characteristics.

In gout, assessing the amount of MSU crystal deposition by ultrasound or DECT may be used to predict future flares.

If synovial fluid analysis is required in the assessment of CiAs, ultrasound guidance should be used in cases where aspiration based on anatomical landmarks is challenging.

Showing and explaining imaging findings of CiAs to people with such conditions may help them understand their condition and improve treatment adherence in gout.

Recommendation Grading


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.



Imaging in Diagnosis and Management of Crystal-Induced Arthropathies in Clinical Practice

Authoring Organization

Publication Month/Year

February 6, 2024

Last Updated Month/Year

March 13, 2024

Document Type


Country of Publication


Document Objectives

To formulate evidence-based recommendations and overarching principles on the use of imaging in the clinical management of crystal-induced arthropathies (CiAs).

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings


Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Management

Diseases/Conditions (MeSH)

D000070657 - Crystal Arthropathies


Crystal arthropathies

Source Citation

Mandl P, D'Agostino MA, Navarro-Compán V, Geßl I, Sakellariou G, Abhishek A, Becce F, Dalbeth N, Ea HK, Filippucci E, Hammer HB, Iagnocco A, de Thurah A, Naredo E, Ottaviani S, Pascart T, Pérez-Ruiz F, Pitsillidou IA, Proft F, Rech J, Schmidt WA, Sconfienza LM, Terslev L, Wildner B, Zufferey P, Filippou G. 2023 EULAR recommendations on imaging in diagnosis and management of crystal-induced arthropathies in clinical practice. Ann Rheum Dis. 2024 Feb 6:ard-2023-224771. doi: 10.1136/ard-2023-224771. Epub ahead of print. PMID: 38320811.

Supplemental Methodology Resources

Data Supplement