We read with great interest the article by McAlindon et al published recently in Arthritis Care & Research ([1]). The use of musculoskeletal ultrasound (US) has tremendously enhanced the field of rheumatology in the past 2 decades ([1]). Particularly, musculoskeletal US is paramount for the early diagnosis of various rheumatic diseases and for the close followup of patients (mainly as an objective means of outcome assessment) during their lengthy treatment periods ([2]). Furthermore, musculoskeletal US has even been included in the diagnostic criteria for rheumatoid arthritis, ankylosing spondylitis, and polymyalgia rheumatica ([3-5]).

Musculoskeletal US has some very well-known advantages; it is convenient and inexpensive, it does not contain radiation, and it readily provides comparative and dynamic imaging with great comfort for the patient and the physician alike. Additionally, with techniques such as sonopalpation or sonoauscultation, the role of musculoskeletal US as an extension of the physical examination (its use in musculoskeletal assessment is much like how the stethoscope is used in a physical examination) has also been noted ([6-8]). Also noteworthy is that musculoskeletal US can provide immediate guidance once the need for any type of intervention (aspiration/injection) has been determined ([9]).

In this regard, especially when considering its advantages in terms of radiation exposure (there is none) and dynamic imaging (the extra procedures required for magnetic resonance imaging in pediatric patients are unnecessary), one would expect musculoskeletal US to be much more commonly used in pediatric rheumatology; however, pertinent studies in the literature suggest the contrary ([10-12]). In general, the 2 important barriers against the use of musculoskeletal US by nonradiologists seem to be the lack of a device to administer musculoskeletal US and the lack of education on how to perform it ([13]). However, based on our experience organizing the musculoskeletal US workshops in the previous 2 PRES (Pediatric Rheumatology European Society) fellowship courses in 2009 and 2011, we believe that the former barrier outweighs the latter. Yet, parallel courses (for pediatric rheumatologists) are organized in several meetings because we are aware that, although the use of musculoskeletal US in pediatric rheumatology resembles that in adult rheumatology, there are particular differences/challenges pertaining to pediatric patients.

In short, we recommend that pediatric rheumatologists (and possibly of the whole field as well) should focus their attention on the need to expedite the use of musculoskeletal US in pediatric rheumatology. Aside from initial attempts to supply US machines to individual centers, the immediate agenda should also comprise setting up standardized international approaches to musculoskeletal US training and assessment for pediatric rheumatologist sonographers. If the immediate agenda is implemented this way, we foresee that musculoskeletal US will soon enhance the actual clinical practice of pediatric rheumatology, from the perspective of both patients and physicians alike.

  • 1
    McAlindon T, Kissin E, Nazarian L, Ranganath V, Prakash S, Taylor M, et al.American College of Rheumatology report on reasonable use of musculoskeletal ultrasonography in rheumatology clinical practice.Arthritis Care Res (Hoboken)2012;64:162540.
  • 2
    Wakefield RJ, D'Agostino MA, Naredo E, Buch MH, Iagnocco A, Terslev L, et al.After treat-to-target: can a targeted ultrasound initiative improve RA outcomes?Ann Rheum Dis2012;71:799803.
  • 3
    Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO III, et al.2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.Arthritis Rheum2010;62:256981.
  • 4
    Rudwaleit M, van der Heijde D, Landewe R, Akkoc N, Brandt J, Chou CT, et al.The Assessment of SpondyloArthritis international Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general.Ann Rheum Dis2011;70:2531.
  • 5
    Dasgupta B, Cimmino MA, Maradit Kremers H, Schmidt WA, Schirmer M, Salvarani C, et al.2012 classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology Collaborative Initiative.Arthritis Rheum2012;64:94354.
  • 6
    Ozcakar L, De Muynck M, Imamura M, Vanderstraeten G.Musculoskeletal ultrasound in PRM: from EURO-MUSCULUS towards WORLD-MUSCULUS.Eur J Phys Rehabil Med2012;48:64950.
  • 7
    Imamura M, Ozcakar L, Fregni F, Hsing WT, Battistella LR.Exploring a long-term global approach for musculoskeletal ultrasound training: WORLD-MUSCULUS [letter].J Rehabil2012;44:9912.
  • 8
    Ozcakar L, De Muynck M, Vanderstraeten G.EURO-MUSCULUS-I and -II behind and EURO-MUSCULUS-III ahead [letter].J Rehabil Med2011;43:736.
  • 9
    De Muynck M, Parlevliet T, De Cock K, Vanden Bossche L, Vanderstraeten G, Ozcakar L.Musculoskeletal ultrasound for interventional physiatry.Eur J Phys Rehabil Med2012;48:67588.
  • 10
    Tok F, Demirkaya E, Ozcakar L.Musculoskeletal ultrasound in pediatric rheumatology.Pediatr Rheumatol Online J2011;9:25.
  • 11
    Collado P, Jousse-Joulin S, Alcalde M, Naredo E, D'Agostino MA.Is ultrasound a validated imaging tool for the diagnosis and management of synovitis in juvenile idiopathic arthritis? A systematic literature review.Arthritis Care Res (Hoboken)2012;64:10119.
  • 12
    Ozcakar L, Celebi A, Kara M, Turker T, Polat A, Akse-Onal V, et al.FMF Arthritis Vasculitis and Orphan Disease Research in Paediatric Rheumatology (FAVOR).Ann Paediatr Rheumatol2012;1:547.
  • 13
    Ozcakar L, Tok F, Kesikburun S, Palamar D, Erden G, Ulasli A, et al.Musculoskeletal sonography in physical and rehabilitation medicine: results of the first worldwide survey study.Arch Phys Med Rehabil2010;91:32631.