Musculoskeletal Ultrasound in Rheumatoid Arthritis: Training Is Essential

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In the several articles on RAW about using musculoskeletal ultrasound in Rheumatoid Arthritis I’ve stipulated “with training” for good reason. Let’s look closer at the need for training in ultrasound use for rheumatology patients. Please see the recent post Rheumatoid Arthritis Ultrasound News describing the significant role musculoskeletal ultrasound can play for people with Rheumatoid Disease (PRD) in revealing disease activity that doctors can’t see with the naked eye.

The versatile, valuable technology of ultrasound

Sonosite Bakers cyst YouTube videoPower Doppler ultrasound has many uses. The same basic technology allows us to look at weather systems, ocean depths, and preborn babies. But the weatherman can’t tell you when your baby is due. Training for each use is specific.

One sign of how important training is for musculoskeletal ultrasound (MSUS) is the response when I called local orthopedic practices and imaging centers. None of them are willing to use their equipment to perform musculoskeletal ultrasound because they are not yet trained to use their machines on joints and tendons. They are obviously trained to know not to use their tools to do things they don’t know how to do. That’s actually good to know.

Another sign of the importance of training for MSUS is the fact that the American College of Rheumatology offered MSUS training sessions at the annual scientific meeting.

And, pediatric rheumatologists want training that is specific to pediatric use of MSUS.[1]

The importance of adequate training has been mentioned several times in ultrasound studies. Researchers report the value that MSUS can have when a clinician is appropriately trained to use it.[2,3,4]

But, look at what one ultrasound technologist said about the use of ultrasound in JRA: “I am very confused! What exactly is the technologist seeing on the screen…? Isn’t synovial fluid quite static unless you are pushing quite vigorously, and are able to slosh it around, the fluid won’t move enough to make ‘power doppler’ provide you with any significant diagnostic information…”[5](See image for full quote).

screenshot comment Rheumatology News MSUS

“To become an expert, plenty of clinical experience and a long period of training is needed.”[7]

WITH expert training, we repeatedly see that patients who appear to have no clinical disease activity actually have synovitis or other inflammation inside of hard and soft tissues, including bone.[5,6]

WITHOUT expert training, a clinician could mistakenly identify something (perhaps eliciting unnecessary tests) or much more likely, could fail to recognize disease activity and give false reassurance of low disease activity.

“a technique that is particularly operator-, machine- and setting-dependent”[2]

Training for MSUS must also be ongoing because techniques and best practices are still evolving.[8,3] “Although the predictive value of PDUS is higher than that of GSUS to predict early RA, flare of RA and radiographic progression, PDUS has limitations as well. It is a technique that is particularly operator-, machine- and setting-dependent. It is important to avoid pressure on the transducer, and motion artifacts, and to use the correct US settings, for example, wall filter and pulse repetition frequency should be low when assessing joints.”[2]

More reasons for ongoing training:

  • The value of power Doppler ultrasound (PDUS) versus gray scale ultrasound (GSUS)[9]
  • The usefulness of the palmar view versus the top of the hand
  • The value of looking at non-hand joints to demonstrate disease activity
  • Using MSUS to detect early changes in RD (other than synovial inflammation)
  • The role of MSUS in early diagnosis or in determining remission
  • Experts say advances in technology will necessitate further training[10]
  • Developing MSUS-based inflammatory arthritis disease activity scoring systems
  • Development of a MSUS certification program for rheumatologic practice[3]

Diagnostic ultrasound versus ultrasound for guided injection

These are two distinct uses for ultrasound equipment in rheumatology. If your doctor’s practice has purchased an ultrasound machine (a small percentage of offices in the U.S.), it is likely used for guiding a needle when aspirating or injecting a joint. Studies have shown that these procedures are more accurately performed with ultrasound guidance, providing better and longer-lasting relief to patients.[3]

Even if your doctor has not been trained to use MSUS to diagnose the many musculoskeletal aspects of RD, it’s good news if she / he has recently purchased a machine because the cost of a machine is one big hurdle that’s already crossed. You might want to find out whether it is PDUS or GSUS, and then ask about whether they’d like to practice on you. That’s actually done often since MSUS can require hundreds of uses before one becomes proficient in its use.

My 1st clue an ultrasound machine doesn’t mean you know how to use it

Long ago and far away, I read all about a wonderful new way to see what’s going on inside of joints and tendons, even when visible swelling is subtle: musculoskeletal ultrasound. After calling numerous rheumatologists, orthopedists, and imaging centers in my area, and reading about how few are trained in MSUS, I met someone who knew a rheumatologist who had an ultrasound machine. Soon, I traveled across three states to see this doctor.

Dr. DIP unequivocally told me (and two others who’d traveled with me):

  • Ultrasound only works on the MCP joints (knuckles at the base of fingers), not on feet or any other joint.
  • RA never attacks the DIP joints.
  • The CRP is always an accurate indicator of disease activity.
  • Everyone’s anti-CCP test is always over 250.

All things we now know are wrong.

It was obvious that he didn’t know how to use the machine. But the point is that in the hands of someone who is poorly trained, even a good tool can be only a blunt weapon. We’ve seen a tool be turned into a weapon against PRD before. The Rheumatoid factor test was an earlier example. And then the ESR / sed rate. And then the CRP test. And most recently, rheumatologists have misused the new Vectra DA test that way (see one example in discussion here). Those who are not adequately trained will misuse MSUS, like Dr. DIP, giving false information to patients, or even using it to “prove” they have no disease activity.

I will continue to advocate that PRD have accessed to expertly trained MSUS.

There are many more musculoskeletal videos on the MSK page at Sonosite’s YouTube page here. I’ve just watched this one so many times since I’ve had painful Baker’s cysts for three years. Hopefully the videos and the next post in this series will convince any doctor who’s still a naysayer on MSUS, thinking it’s not worth the trouble.

POSTBLOG: It wasn’t pertinent to the post, but of course I was stunned and disappointed by Dr. DIP’s dismissal, and accompanying scolding for seeking out this test. But it made me think of the many other patients with such stories. When I verified how wrong he was, and realized how few PRD in the U.S. have access to MSUS, I wanted to go to nursing school, travel to Leeds (in England with Paul Emery) for MSUS training, and the purchase an US machine, and start helping PRD get answers. Unfortunately my own RD is unrelenting, so I could not. It sounds crazy, but so does starting a national non-profit from your sofa. Soon afterwards, I decided to found RPF and work to help PRD get better care through education, advocacy, and research.

Edit: 9-5-16 Updated video link

Recommended reading


Polat A, Demirkaya E, Özçakar L. Musculoskeletal ultrasound for enhancing pediatric rheumatology: comment on the article by McAlindon et al. Arthrit Care Res [Internet]. 2013 Jul [cited 2013 Aug 29];65(7):1205–1206. Available from:

Ten Cate DF, Luime JJ, Swen N, Gerards AH, De Jager MH, Basoski NM, Hazes JMW, Haagsma CJ, Jacobs JWG. Role of ultrasonography in diagnosing early rheumatoid arthritis and remission of rheumatoid arthritis – a systematic review of the literature. Arthritis Res Ther 2013 [cited 2013 Aug 6];15:R4. Available from:

McAlindon T, Kissin E, Nazarian L, Ranganath V, Prakash S, Taylor M, Bannuru RR, Srinivasan S, Gogia M, McMahon MA, Grossman J, Kafaja S, FitzGerald J. American College of Rheumatology report on reasonable use of musculoskeletal ultrasonography in rheumatology clinical practice. Arthritis Care Res. 2012 Nov [cited 2013 Aug 3];64(11): 1625–1640. Available from:

American College of Rheumatology Musculoskeletal Ultrasound Task Force (2010), Ultrasound in American Rheumatology Practice: Report of the American College of rheumatology musculoskeletal ultrasound task force. Arthritis Care Res [Internet], 2010 Sep [cited 2013 Aug 29];62:1206–1219. Available from:

Blum K. Doppler ultrasound detected synovitis in clinically inactive JIA. Rheumatology News [Internet]. 2013 Jun 6 [cited 2013 Aug 29]. Available from:

Brown AK, Quinn MA, Karim Z, Conaghan PG, Peterfy CG, Hensor E, Wakefield RJ, O’Connor PJ, Emery P. Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug–induced clinical remission: Evidence from an imaging study may explain structural progression. Arthritis Rheum. 2006 Dec [cited 2013 Aug 3];54(12):3761–3773. Available from:

Kang T, Horton L Emery P, Wakefield RJ. Value of ultrasound in rheumatologic diseases. J Korean Med Sci. 2013 Mar 27 Apr[cited 2013 Aug 29];28(4):497-507. English. Available from:

Colebatch AN, Edwards CJ, Østergaard M, van der Heijde D, Balint PV, D’Agostino MA, Forslind K, Grassi W, Haavardsholm EA, Haugeberg G, et al. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis. 2013 Mar 21 [cited 2013 Aug 3]; Recommendation. Available from:

Witt M, Mueller F, Nigg A, Reindl C, Leipe J, Proft F,  Stein N, Hammitzsch A, Mayer S, Dechant C, et al.  Relevance of Grade 1 Gray-Scale Ultrasound findings in wrists and small joints to the assessment of subclinical synovitis in rheumatoid arthritis. Arthritis Rheum [Internet]. 2013 Jul [cited 2013 Aug 6]; 65(7):1694–1701. Available from:

Gould P. MRI and ultrasound reveal early signs of rheumatoid arthritis. Diagnostic Imaging [website].  2009 Mar 10 [cited 2013 Aug 29]. Available from:

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This entry was posted on Friday, August 30th, 2013 at 4:44 am and is filed under RA Research, Resources, and Rheumatology. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.


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