Ultrasound in American Rheumatology Practice: Report of the American College of Rheumatology Musculoskeletal Ultrasound Task Force

Introduction The current status of American rheumatologists with respect to the use of musculoskeletal ultrasound (US) considerably trails that of European peers. In Europe, the development of US applications by rheumatologists began nearly 2 decades ago (1). US is now routinely used by many European rheumatologists (2); however, only a few American rheumatologists use the technique regularly in their practices. This nascent interest is showing signs of maturing. In a recent survey of American College of Rheumatology (ACR) members and rheumatology fellows, 360 of 562 respondents replied that they utilize US, with 122 performing it themselves. (3). A number of factors drive rheumatologists’ interest in US. Since the first reported application of US to musculoskeletal diagnosis in 1972, differentiating Baker’s cysts from deep venous thrombosis (4), investigation of a wide range of pathologies affecting soft tissue and bone have demonstrated distinct US characteristics (5,6). Highquality machines produce sharply-defined images with a high degree of spatial resolution that have replaced the vague gray shadows of early US scans. Also, power Doppler capabilities showing blood movement in the microvasculature can serve as a surrogate marker for detecting local inflammation (7). US is patient friendly, noninvasive, radiation free, and relatively inexpensive when compared with other imaging modalities. It is directly applicable at the time of a patient’s visit, is capable of showing the relationships of structures during movement, can examine multiple joints in a single visit, and is readily repeatable. At the point of care, the clinician can gain an understanding of the patient’s unique structural pathology, describe the problem, and outline possible solutions. Besides enhancing the clinician’s physical examination skills, US holds tremendous promise in disease management, enabling both assessment and monitoring of inflammatory arthropathies. These are increasingly important capabilities, given the modern clinical goals of increasing emphasis on early identification of synovitis, implementing ever more effective (if expensive) treatments, and monitoring the effects of those treatments. While magnetic resonance imaging (MRI) has been proposed as a sensitive technique for monitoring disease (8), US may prove to be an attractive alternative in many cases. US is a technique that has near-equivalent accuracy to MRI in identifying many of the relevant pathologies in rheumatology, yet carries practical advantages such as far lower cost and portability. Obstacles remain that impede implementation of US in American rheumatology practices. Learning opportunities beyond introductory courses remain sparse, with the only path to acquiring added skills being self-directed efforts with a steep curve leading to implementation in the clinic, since preliminary hands-on practice is time consuming. To date, standards are lacking for what constitutes competence in this operator-dependent technique. In addition, not all radiologists agree that US should be within the purview of rheumatologists (9). Practically speaking, clinMembers of the American College of Rheumatology Musculoskeletal Ultrasound Task Force are as follows: Robert Ike, MD: University of Michigan Health System, Ann Arbor; Erin Arnold, MD, William Arnold, MD: Illinois Bone and Joint Institute, Morton Grove; Jurgen Craig-Muller, MD: CentraCare Clinic, St. Cloud, Minnesota; Gurjit Kaeley, MBBS: University of Florida, Gainesville; Timothy McAlindon, MD, MPH: Tufts Medical Center, Boston, Massachusetts; Levon Nazarian, MD: Jefferson Medical College, Philadelphia, Pennsylvania; Antonio Reginato, PhD, MD: Brown University and Massachusetts General Hospital, Boston. The American College of Rheumatology is an independent, professional, medical and scientific society which does not guarantee, warrant, or endorse any commercial product or service. Dr. Ike has received consultant fees, speaking fees, and/or honoraria (less than $10,000) from Genzyme. Dr. CraigMuller is employed by CentraCare Rheumatology. Dr. Kaeley’s work was supported by an unrestricted equipment loan from Biosound Esaote and Sonosite. Dr. Reginato’s work was supported by a grant from the Robert Wood Johnson Foundation and he has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from UCB, Takeda, URL Pharma, and Centocor. Address correspondence to Robert Ike, MD, Department of Internal Medicine, Division of Rheumatology, University of Michigan Health System, 1500 East Medical Center Drive, 3918 Taubman Center, Ann Arbor, MI 48109-0358. E-mail: rike@umich.edu. Submitted for publication December 31, 2009; accepted in revised form April 19, 2010. Arthritis Care & Research Vol. 62, No. 9, September 2010, pp 1206–1219 DOI 10.1002/acr.20241 © 2010, American College of Rheumatology