For most rheumatologists, the key elements of the physical exam—inspection, palpation, percussion and auscultation—have long been second nature, but a fifth modality has grown in importance with respect to making the correct diagnosis: ultrasound.
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Explore This IssueJuly 2020
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From evaluating for Doppler signal and additional findings indicative of synovitis to identifying bony erosions, chondrocalcinosis, tophi and other articular and periarticular pathology, ultrasonography has become more and more valuable as a clinical tool for practicing rheumatologists.
Amy Evangelisto, MD, past president of the Ultrasound School of North American Rheumatologists (USSONAR) and current clinician with Arthritis, Rheumatic & Back Disease Associates, New Jersey, was among the first U.S. rheumatologists to seek additional training in rheumatologic musculoskeletal ultrasound in Leeds, England, in the early 2000s.
“When I became interested in musculoskeletal ultrasound,” says Dr. Evangelisto, “there were no rheumatology-focused courses or training programs in the U.S., so we had to rely on radiology-based courses or find other pathways on our own. Now we are lucky to have so many excellent resources available for rheumatologists interested in learning ultrasound.”
Today, Dr. Evangelisto regularly uses ultrasound in her clinical practice, both to aid diagnosis and for guided injections. She is also active in USSONAR efforts to increase the knowledge of and competency in ultrasound across the field of medicine.
Training in ultrasound has, in recent years, spread much more diffusely across the medical education landscape. In a survey of 82 U.S. MD-granting medical schools, 62% of curricular administrators responded that ultrasound training is incorporated into their medical school’s curriculum, with 46% noting that the training is part of the student’s third year (i.e., at the start of their clinical training).1
Similarly, in a survey of 108 rheumatology fellowship training program directors, 94% responded their program teaches musculoskeletal ultrasound and 41% have a formal ultrasound curriculum. Close to 80% of programs teach image optimization, normal anatomy, disease-specific pathology and ultrasound-guided procedures, 51% cover ultrasound physics, and 43% discuss documentation and billing for ultrasound.2
With respect to internal medicine residency training, the Alliance for Academic Internal Medicine (AAIM) issued a position statement in 2019 recognizing and supporting the integration of point-of-care ultrasound (POCUS) across undergraduate, graduate and continuing medical education, but several barriers have been identified, including lack of POCUS-trained faculty and/or ultrasound equipment, and lack of crucial image archival systems and quality assurance.3
Karina Torralba, MD, division head and fellowship program director in the Division of Rheumatology at Loma Linda University School of Medicine, Calif., notes that some additional challenges to incorporating ultrasound teaching into curricula are the limited time allotted to this purpose and restrictions on a provider’s ability to bill for these services.
Dr. Torralba explains that, from an educational perspective, the question is: When will issues other than those that are purely musculoskeletal be included in ultrasonography teaching and evaluation? For example, salivary gland ultrasonography is now recognized as a potentially valuable and specific tool for the early recognition of Sjögren’s syndrome.4
Similarly, color duplex sonography of the temporal arteries has shown promise in helping diagnose giant cell arteritis, with edema throughout the wall of the vessel and resulting periluminal hypoechoic halo (referred to as the halo sign) showing higher sensitivity than arterial biopsy and bilateral halo sign reaching a specificity of nearly 100%.5
As more anatomic locations and clinical conditions can be explored with ultrasonography, the potential value of this tool increases and the ways in which it can and should be incorporated into rheumatologic training multiply.