In the late 1980s and early 1990s, a small group of very enthusiastic European rheumatologists from Italy, Germany, Finland, The Netherlands, Switzerland, Austria, and Spain started to practice musculoskeletal ultrasound (MSKUS) and to publish pioneering articles on the use of MSKUS in rheumatologic clinical practice and research. These investigators and their colleagues demonstrated the capability of MSKUS to detect joint synovitis and to facilitate the study of tendons and articular cartilage in rheumatic patients. Later in the same decade, other rheumatologists from these and other European countries, including Great Britain, France, Hungary, Ireland, Denmark, and Norway, began acquiring expertise in MSKUS. These rheumatologists discovered the potential of MSKUS as a powerful bedside tool in the diagnosis and management of rheumatic diseases.
Most of the European pioneers in rheumatology MSKUS had received formal or informal training from eminent radiologists, such as Marnix van Holsbeek and Jose Antonio Bouffard in the United States and Wayne W. Gibbon in the United Kingdom. Many had attended MSKUS courses organized by radiology societies or by the EUROSON School, which was established in 1992 by the European Federation of Ultrasound in Medicine and Biology (EFSUMB).
Training
The European League Against Rheumatism (EULAR), the umbrella organization of the scientific and rheumatology societies of all the European countries, patients’ organizations, and allied health care organizations, has promoted MSKUS education for rheumatologists. In the 1990s, Walter Grassi formed the first core of rheumatologist experts in MSKUS into an unofficial but solid group called the EULAR Working Group for Musculoskeletal Ultrasound. During this period, European national training programs for MSKUS among rheumatologists began to develop in some European countries, such as France, Germany, Italy, Slovakia, Spain, Switzerland, and the United Kingdom. These rheumatology ultrasound schools were usually led by rheumatologists who were also involved in the EULAR Working Group for Musculoskeletal Ultrasound. During the 9th EULAR symposium (Madrid, 1996), for the first time, a session was dedicated to ultrasonography in rheumatic diseases.
In the first decade of the 21st century, the increasing utility of MSKUS in rheumatology and the decreasing cost of the machines have led to a great demand for appropriate education in this technique among European rheumatologists. However, there is a paucity of radiologists with expertise in rheumatology MSKUS who are willing to teach rheumatologists in most European countries. EULAR has supported 16 courses on MSKUS since 1998. Introductory, intermediate, and advanced MSKUS courses have been held in various European countries under the auspices of the EULAR Standing Committee on Education and Training. Most of the faculty for these courses have been drawn from the EULAR Working Group for Musculoskeletal Ultrasound, and they have generated sustained and extensive interest. Because these courses include hands-on scanning, the number of participants is always limited, and there are usually more applications than can be accepted.
In 2001, the first guidelines for performing MSKUS in rheumatology were published by the EULAR Working Group for Musculoskeletal Ultrasound. They provided extensive information on the technical basis for MSKUS, equipment specifications, basic scanning methods, image acquisition, and the principal pathologic findings in each anatomic area ( Fig. 25B-1 ).
The teachers of the EULAR ultrasound courses organized two teacher-training courses, in Berlin, Germany, and Sitges, Spain, in 2004. These courses had two objectives: to test the ability and reliability of the experts in detecting the main rheumatology ultrasound findings and to compare and discuss MSKUS scanning techniques, image interpretation, and diagnostic criteria among the experts. These sorts of exercises are highly recommended to ensure that trainers have enough capability to teach and a standardized teaching method.
Most of the members of the EULAR Working Group for Musculoskeletal Ultrasound formed a special interest group at the 7th Outcome Measures in Rheumatology (OMERACT) conference in 2004 (Asimolar Conference Grounds, Pacific Grove, CA) to address the metric qualities of MSKUS findings as outcome measures in rheumatic diseases. This group later produced the first consensus on the definitions for common MSKUS inflammatory pathologies and conducted a number of studies on MSKUS validity and reproducibility in inflammatory arthritis.
An international interdisciplinary consensus on the specific training curriculum for rheumatologists performing MSKUS was produced.16-18 This consensus included the indications, anatomic areas, and required knowledge and skills.
In 2007, the rheumatologists (from 11 European countries) who comprised the faculty of the 14th EULAR ultrasound course (Sitges, Barcelona, Spain) developed educational guidelines for the content and conduct of EULAR ultrasound courses ; these are recommended for national and local MSKUS training programs. They might also be useful for standardizing rheumatology MSKUS training in Europe. The group consensus on EULAR guidelines and curriculum proposed an education model with three levels: basic, intermediate, and advanced. Basic courses focused on examination technique and included some basic rheumatology ultrasound findings. Intermediate courses focused on a wide spectrum of rheumatologic pathology, the basic use of MSKUS Doppler, and MSKUS-guided injections. Advanced courses focused on advanced use of Doppler, MSKUS research in rheumatology, new technologic developments, uncommon pathologic findings in rheumatology, pathologic findings in other specialties (nerve, ligament, and muscle lesions; sport-related lesions), and MSKUS methodology ( Table 25B-1 ). The recommended course duration was 20 hours. There should be a maximum of six participants per teacher, and 50% to 60% of the total time should be spent in practical sessions. These agreed guidelines have been successfully applied to the last three EULAR ultrasound courses (2007, 2008, and 2009).
| Basic Course Curriculum |
| Application, indications, and limitations of MSKUS in rheumatology |
| Ultrasound physics and technology |
| Sonographic pattern of the various musculoskeletal tissues |
| MSKUS artifacts and pitfalls |
| Standard sonographic scans of the shoulder, elbow, wrist and hand, hip, knee, ankle, and foot |
| Holding the probe and optimizing the gray-scale settings of the sonographic system |
| Image documentation |
| Reporting ultrasound findings and diagnosis |
| Basic Course Pathologies |
| Joint synovitis |
| Joint effusion |
| Synovial hypertrophy |
| Bursitis |
| Tenosynovitis |
| Intermediate Course Curriculum |
| Color and power Doppler physics and technology |
| Application, indications, and limitations of color and power Doppler in rheumatology |
| Use of the color and power Doppler settings |
| Color and power Doppler artifacts |
| Use of color and power Doppler to detect synovial and entheseal inflammation |
| Assessment and quantification of structural joint damage (bone, tendons, ligaments) |
| Sonographic-guided periarticular and articular injections |
| Intermediate Course Pathologies |
| Joint synovitis, synovial hypertrophy, tenosynovitis |
| Tendon calcification |
| Enthesopathy |
| Tendinosis |
| Paratenonitis |
| Tendon subluxation/luxation |
| Intrasubstance tendon lesions |
| Tendon impingement |
| Complete tendon tear |
| Partial tendon tear |
| Bone erosions |
| Osteophytes |
| Ganglia and cysts |
| Articular cartilage lesions |
| Periarticular and intra-articular microcrystal deposit |
| Ligament, muscle, cartilage, fibrocartilage, and synovial calcification |
| Advanced Course Curriculum |
| Optimization of color and power Doppler settings |
| Sonographic-guided musculoskeletal interventional procedures |
| Assessment and quantification of synovial, tenosynovial, and entheseal inflammatory activity |
| Role of ultrasound in vasculitis |
| Evaluation of vessels and detection of vasculitis by sonography |
| Pediatric sonography: musculoskeletal sonoanatomy and pathologic findings in rheumatic diseases |
| Uncommon sonographic pathologic findings in rheumatology |
| MSKUS technologic development |
| Three- and four-dimensional MSKUS |
| Update on MSKUS in rheumatology |
| MSKUS research and methodology |
| Advanced Course Pathologies |
| Peripheral nerve entrapment and lesions |
| Ligament lesions |
| Fibrocartilage lesions |
| Myopathy |
| Myositis |
| Muscle injury |
| Soft tissue masses |
| Loose bodies |
| Foreign bodies |
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