Rheumatology is old school medicine. Clinical history and physical exam reign supreme. Tests provide clues, but rarely definitive diagnostic answers. That’s why I love it, and that’s why none of my friends picked it.
Affinity for the old school aside, ultrasound has emerged as a valuable tool for the rheumatologist, especially in cases where the diagnosis is unclear. It’s a billable point-of-care tool with the potential to rapidly and positively impact patient care. Several fellowship programs are incorporating ultrasound into training, and the number of practicing rheumatologists utilizing it in clinic continues to grow.
Eugene Kissin, MD, RhMSUS, clinical professor of medicine and program director of the rheumatology fellowship program, Chobanian & Avedisian School of Medicine, Boston University, co-founded the UltraSound School of North American Rheumatologists (USSONAR) and offered decades of insight.
And last, but not least, Minna Kohler, MD, RhMSUS, director of the rheumatology musculoskeletal ultrasound program, Massachusetts General Hospital, Harvard Medical School, Boston, is the current president of USSONAR and shared excitement about what’s coming down the pipeline.
Interview with the Experts
The Rheumatologist (TR): How did you get involved with ultrasound? What interested you in it in the first place?
Dr. Albayda
Dr. Albayda (JA): I basically started in fellowship. When I was a chief resident, I had matched at Johns Hopkins for fellowship and was worried about what I would do when I got there. I didn’t know much about rheumatology, but had been hearing about new developments in rheumatology ultrasound. Since it was my chief year, I had money for continuing medical education (CME), and I found an ultrasound course in Brussels. You clearly don’t learn ultrasound from a one-weekend course, but it sparked my interest.
When my first year of fellowship rolled around and there was an opportunity to complete training with the USSONAR, I took it. It was a really good way of learning ultrasound longitudinally. When I finished, I was well trained and joined the Hopkins faculty with another skill under my belt.
Dr. Kissin
Dr. Kissin (EK): I was drawn to ultrasound by the potential it offers to give instant feedback on physical exam findings. Is this joint boggy or are the soft tissues fatty? I thought that having gold standard feedback would help improve my exam skills. I also sought more certainty in rheumatology, a field where uncertainty is the norm. It seemed clear to me that more definite knowledge about the presence of joint effusions and synovial hyperemia should be helpful in making more reasoned treatment decisions.
TR: How does one learn ultrasound in rheumatology?
JA: There are a couple different training pathways: Both the ACR and USSONAR offer training. When you finish USSONAR, you have scanned a large number of joints to identify anatomy and interpret pathology.
The process of learning MSK ultrasound—carpal tunnel views. Scanning: Eva Petrow, MD
(rheumatology fellow, Boston Medical Center), being scanned: Berk Degirmenci, MD
(rheumatology fellow, Boston Medical Center), mentoring: Eugene Kissin, MD, RhMSUS
(rheumatology program director, Boston Medical Center).
By the time the program ends, you receive a certificate that confirms you’ve gone through vetted rigorous training. You really need to learn how to do it appropriately by a certain standard. [Editor’s note: See the “Learn More” sidebar below for more information on both the ACR and USSONAR programs.]
TR: Dr. Kissin, why did you create USSONAR? What did that journey look like? How has it grown over the years?
EK: When I started learning musculoskeletal ultrasound around 2000, I did not have a local mentor, so options included book study, radiology-based weekend courses or travel to Europe to study with rheumatologists there. There was also a short workshop at the ACR that was sufficient to “light the fire,” but needed more fuel.
We realized that radiologist application of musculoskeletal ultrasound was substantially different from what we needed in rheumatology [and faced] resistance to rheumatologists using and billing for ultrasound.
Thus, our group started USSONAR in an effort to make the learning process easier for other rheumatologists in the U.S., as well as to create a peer group to help withstand the external forces and allow the use of this valuable tool to flourish in our profession.
In our 16th year, we now have well over 60 mentor-teachers and over 700 members. We have published a number of collaborative research projects and have had some positive impact on the regulatory and reimbursement environment.
TR: Why should rheumatologists consider taking a course with USSONAR?
EK: USSONAR was founded to create a venue for rheumatologists to learn musculoskeletal ultrasound, and it still serves this function today. One can learn most rapidly with frequent feedback over an extended period, and USSONAR provides this for the rheumatologist trying to learn musculoskeletal ultrasound.
It allows the participant in the training course to get feedback from rheumatologists seasoned in musculoskeletal ultrasound on studies submitted for review via the internet. Thus, rheumatologists without a local mentor can get feedback to help them improve their scanning over an eight-month span. Even rheumatologists with a local mentor would likely benefit from the program by getting feedback from a more diverse instructor pool, and perhaps more importantly, through a curriculum that includes numerous deadlines in the form of assignments, quizzes and examinations.
I think almost all of us learn better under the motivating pressure of a deadline.
TR: What is the RhMSUS and how does one obtain it?
JA: The Musculoskeletal Ultrasound Certification in Rheumatology (RhMSUS) is a certification offered by the ACR that “demonstrates competency in musculoskeletal ultrasound and promotes quality of care.” It’s a theoretical multiple choice exam that you sit for after completing a prerequisite amount of prescribed ultrasound scans, as well as a certain amount of CME or USSONAR training.
TR: Why is the RhMSUS valuable?
JA: The RhMSUS came on board because rheumatologists started using ultrasound and billing for it. There needed to be standards in place to make sure the tool is used appropriately and by people who know how to use it. At this time, there’s no governing body that says a rheumatologist can’t do this without certification or training, but as a community we realized this could become a problem, especially because billing is involved. In academic centers, one cannot apply for ultrasound credentials without proper certification. Insurance companies may follow suit, requiring formal credentials for reimbursement, and RhMSUS helps fill this need.
TR: How have you seen ultrasound grow in rheumatology over the years? How do you think it will continue to change practice in the future?
EK: Over the past 24 years, we have gone from one fellowship program offering ultrasound training to almost all programs offering at least some training. I expect that over the coming decades most rheumatologists will be able to use ultrasound, at least in a limited way, to help diagnose joint inflammation and guide needle placement. We are expanding beyond the world of musculoskeletal ultrasound into the world of rheumatology ultrasound as we use it for assessment of salivary glands, skin, temporal arteries and all the other tissues affected by rheumatic diseases.
It is my sincere hope that ultrasound continues to evolve in a way that strengthens our fellows’ understanding of anatomy and enhances their physical exam skills, so they can become better clinicians than we are.
TR: Why is ultrasound important in rheumatology?
JA: I could go on and on about that. But in rheumatology, we often lack confirmatory data. For example, take seronegative rheumatoid arthritis. When you look with ultrasound and see more enthesophytes or tendon involvement, you realize that perhaps this is spondyloarthritis. Or perhaps you’re dealing with crystalline disease instead. Ultrasound allows us to narrow down the differential and gives us more certainty with the treatment pathway we are choosing.
What’s more, ultrasound made me a much better musculoskeletal doctor. As rheumatologists, we are good at inflammatory conditions but musculoskeletal complaints often aren’t our strengths. Now that I’m trained with ultrasound, I have a better appreciation for anatomy, musculoskeletal structures and how they inform disease processes. It’s not just shoulder pain. Now I think in layers: Is it tendon, joint or bone? You can get much more nuanced and detailed in your thinking. Shoulder pain could indicate glenohumeral synovitis, bursitis, biceps tendinitis, etc., and this distinction is important when for caring for patients.
Dr. Kohler
Dr. Kohler (MK): As technology has improved, point-of-care ultrasound (i.e., clinician-performed ultrasound at the patient’s office visit or bedside) has become more accessible within medical training among all medical specialties, including rheumatology. There has been growing evidence of the value of musculoskeletal ultrasound in rheumatology to differentiate inflammatory from mechanical conditions and identify subclinical inflammation and crystalline pathology to expedite diagnoses, monitor disease activity and provide needle guidance for diagnostic and therapeutic joint aspirations and injections. Ultrasound findings of various rheumatic conditions are also leading to better understanding of what joints, tendons or soft tissue structures may be involved, as well as detecting early erosive disease—ultrasound is more sensitive than X-ray.
TR: When should rheumatologists consider using ultrasound?
JA: There is really no scenario when you shouldn’t use it. That’s like asking, “Can I check labs?” But being judicious about its use is important, and I use it for scenarios in which I don’t have enough diagnostic certainty. For example, ultrasound is great when a patient isn’t responding to treatment and you need to rethink the diagnosis, or when clinical exam is discordant from labs or history.
TR: What conditions is ultrasound being used for outside inflammatory arthritis? What developments are coming down the pipeline in ultrasound that you’re most excited about?
JA: We’re now in the era where we’re calling it systemic rheumatic ultrasound, not musculoskeletal ultrasound. It’s being used to assess the parotid and salivary glands in Sjögren’s disease and temporal arteries in giant cell arteritis. My particular research has looked at using ultrasound to evaluate myositis, as well as diaphragm excursion and movement, and this is just the beginning.
MK: The future of ultrasound is already here. Portable, wireless handheld ultrasound devices are improving in image clarity and vascularity assessment at a rapid rate, and costs for these devices will become more affordable as technology continues to advance. A few medical schools throughout the [U.S.] have already given handheld ultrasound devices to every medical student to learn sonoanatomy, pathology and physiology. Contrast-enhanced ultrasound can enhance image quality and improve sensitivity to vascularity/inflammation among various tissues (e.g., joint vs. tendon).
Ultrasound elastography, commonly used to identify fibrosis in liver scans, can be applied to musculoskeletal applications to measure muscle, tendon and tissue properties of stiffness. Tele-ultrasound capabilities are allowing novice learners in remote locations to receive expert feedback. Lastly, software to include artificial intelligence (AI) technology will assist ultrasound users to more easily identify abnormalities vs. normal structures.
TR: Is it worth ordering a musculoskeletal ultrasound with radiology if I’m not trained in rheumatology ultrasound?
JA: Honestly, no. It’s really something that a rheumatologist should be doing. If you’re sending a patient to radiology for hand ultrasound, they aren’t going to know what to do. Rheumatology has our own protocols. Radiology is used to looking for cysts or masses, not synovitis, tophi or erosions.
TR: Guidance on ultrasound was last issued by the ACR in 2012. Are there any efforts to update these guidelines coming down the pipeline?
JA: Yes! There’s so much more data now that we can use to create guidance documents, and the ACR is in the process of updating and creating new guidance documents in conjunction with USSONAR. We’ve divided it up into several topics. The first to come out will be guidance for the use of ultrasound in inflammatory arthritis, followed by guidance for the use of ultrasound in procedures and soft tissue pathology. Guidance for crystalline arthritis and vasculitis will follow.
[Editor’s note: Get a first look at the guideline for ultrasound use in rheumatoid arthritis and psoriatic arthritis in a session at ACR Convergence 2024, and watch for highlights in a coming issue of this publication.]
Samantha C. Shapiro, MD, is a clinician educator
who is passionate about the care and education of
rheumatology patients. She writes for both medical
and lay audiences and practices telerheumatology.
