1. Top of page
  2. Abstract
  8. Acknowledgments


To report the baseline knowledge of clinical anatomy of rheumatology fellows and rheumatologists from Argentina, Chile, Ecuador, El Salvador, Mexico, the US, and Uruguay.


The invitation to attend a workshop in clinical anatomy was an open call by national rheumatology societies in 4 countries or by invitation from teaching program directors in 3 countries. Prior to the workshop, a practical test of anatomic structures commonly involved in rheumatic diseases was administered. The test consisted of the demonstration of these structures or their function in the participant's or instructor's body. At one site, a postworkshop practical test was administered immediately after the workshop.


There were 170 participants (84 rheumatology fellows, 61 rheumatologists, and 25 nonrheumatologists). The overall mean ± SD number of correct answers was 46.6% ± 19.9% and ranged from 32.5–67.0% by country. Rheumatology fellows scored significantly higher than nonrheumatologists. Questions related to anatomy of the hand scored the lowest of the regions surveyed.


Rheumatology fellows and rheumatologists showed a deficit in knowledge of musculoskeletal anatomy that is of central importance in rheumatologic assessment and diagnosis. This gap may hinder accurate and cost-effective rheumatologic diagnosis, particularly in the area of regional pain syndromes. Presently, widespread use of musculoskeletal ultrasound (MSUS) by rheumatologists may be premature, since a key component of expert-level MSUS is the integration of an accurate knowledge of anatomy with the views obtained with the ultrasound probe.


  1. Top of page
  2. Abstract
  8. Acknowledgments

The identification of abnormalities of anatomic structures is essential for accurate diagnosis and treatment of most rheumatic diseases. The recognition of arthritis, tenosynovitis, tendinopathy, enthesitis, bursitis, myositis, or nerve entrapment, which is so important in steering the clinician toward a sensible differential diagnosis, requires knowledge and skills in clinical anatomy. A prime example is the diagnosis and understanding of the regional pain syndromes, which comprise 13–30% of a rheumatologist's workload in the outpatient setting ([1-4]) and affect approximately 5% of individuals in the general population ([5]). Unfortunately, clinical anatomy in rheumatology training has too often been taught superficially and on an ad hoc basis, i.e., shoulder anatomy as it relates to shoulder pain, the lumbar spine as it relates to low back pain, and so on. This would be equivalent to studying only fragments of autoimmunity as they come up in learning about the immunologic abnormalities of lupus, rheumatoid arthritis, or granulomatosis with polyangiitis (Wegener's) rather than learning immunology as one of the foundations of rheumatology. Such an approach would lack a broader view of the pathogenesis of the rheumatic diseases and the higher level of understanding we all strive to achieve.

As shown in previous studies, the level of competency in clinical anatomy of the musculoskeletal system is shockingly deficient in medical students, residents, and staff physicians ([6]), and as a result, efforts have been initiated to remediate this at the undergraduate level ([7]). Furthermore, and closer to our subject matter, in a survey of young rheumatologists in Europe, 52.3% of respondents thought that their anatomic competency was inadequate ([8]). In addition, our impression gained in directing workshops on regional musculoskeletal pain syndromes in various countries has been that the anatomic knowledge of rheumatology fellows and practicing rheumatologists, even for common syndromes such as carpal tunnel syndrome, lateral epicondylalgia, trochanteric syndrome, and Baker's cysts, is rudimentary at best, suggesting that the expected knowledge increment ([9]) during rheumatology training falls short of the expected. This perceived deficit led us to expound on the recognition of anatomy as one of the missing foundations of rheumatology ([10]).

In 2007, aiming to enhance training and knowledge in musculoskeletal anatomy, one of the authors (JJC) directed a series of 6-hour workshops for all Mexican rheumatology fellows. A preworkshop test aimed at detecting their baseline knowledge had dismal results. Since then, the Mexican Group for the Study of Clinical Anatomy (GMAC) with one of the authors (RAK) as an off-site member was formed, consisting of rheumatologists who have individually taken on clinical anatomy as an area of specific interest in their practices and teaching. Hands-on workshops aimed at teaching clinical anatomy relevant to the rheumatologist and stimulating increased attention and interest in this area were held in 7 American countries, including Mexico ([11, 12]). A secondary goal of these workshops was to document the baseline anatomic knowledge of fellows and other participants, both rheumatologists and nonrheumatologists, by means of a preworkshop practical anatomy test. At one site, we also had the opportunity of performing an immediate postworkshop test. The results of these evaluations, summarized herein, showed a pervasive anatomic knowledge deficit that should be corrected if our clinical skills as rheumatologists are to be optimized.

Box 1. Significance & Innovations

  • Most surveyed fellows and rheumatologists from 7 American countries had a suboptimal knowledge of musculoskeletal clinical anatomy.
  • Competence in the regional pain syndromes and in the assessment of systemic rheumatic diseases may be limited by this deficit.
  • Efforts to improve the anatomic knowledge of rheumatology trainees appear warranted.


  1. Top of page
  2. Abstract
  8. Acknowledgments

Our clinical anatomy workshop is based on the presentation of clinical vignettes, a listing and description of anatomic structures relevant to the physical examination that would be appropriate for each vignette, and the identification of these structures by cross-examination of participants and teachers. The details of this workshop have been described previously ([12-17]). By previous agreement, if there was no time limitation or language barrier and the person power was adequate (participant to instructor ratio of ≤10), the workshops were preceded by a practical anatomy test. Eight such workshops were held from 2009 through 2012.


All of the GMAC instructors are rheumatologists, with >300 hours of clinical anatomy training. In addition, 2 had 1 year of training in musculoskeletal ultrasound (MSUS) and one is the head of MSUS at a large academic institution in Mexico. All of the instructors passed a self-certifying examination of 163 practical anatomy questions. One of the authors (RAK) was the examiner and ≥95% of questions had to be correctly answered to pass the test.

Questions asked

Each of the 2007 workshops was preceded by a practical anatomy test that was administered on a one-to-one basis. For this test, a list of 40 pertinent anatomic items was assembled by the instructor (JJC) and independently reviewed for accuracy, anatomic diversity, and relevance to rheumatologic practice by another author (RAK). From this pool, two 20-item sets were randomly selected and used in the pretest (Canoso JJ, et al: unpublished observations). In the practical test, for each anatomic item, examinees were required to either identify the structure in the instructor or demonstrate their function in their own bodies. For the present study, which took place from 2009–2012, 20 questions were selected from the same pool of 40 anatomic items by means of a 3-round Delphi exercise in which all authors (except JA-N and RAK) participated. The clinical significance and anatomic validation for each of the anatomic structures queried in the practical test are shown in Table 1 ([18-41]). In addition, the wording of the questions was independently reviewed for clarity and accuracy by a rheumatologist with extensive teaching experience. The relevance of these items had post hoc support from the results of a multinational Delphi study of the anatomic items that are relevant to the practice of rheumatology conducted by the authors. In this study, all upper extremity and cervical spine items used on the practical examination (14 of the 20 items) were considered important or very important (Hérnandez-Díaz C, et al: unpublished observations). A similar study on the thoracic and lumbar spine and lower extremity items that would apply to the other 6 questions is in progress. Both wrong and “don't know” answers were counted as wrong answers.

Table 1. The 20 practical anatomy questions*
 Structures surveyedIdentification or demonstrationClinical significanceAnatomic validation
  1. EPB = extensor pollicis brevis; APL = abductor pollicis longus; EPL = extensor pollicis longus; RA = rheumatoid arthritis; APB = abductor pollicis brevis; CTS = carpal tunnel syndrome; OA = osteoarthritis; CPPD = calcium pyrophosphate dihydrate; CT = computed tomography; MRI = magnetic resonance imaging; SpA = spondyloarthritis.

1Anatomic snuffbox, volar boundary (EPB, APL)Identification in instructor's handSite of de Quervain's tenosynovitis ([18])Inspection and palpation while keeping the thumb extended
2Anatomic snuffbox, dorsal boundary (EPL)Identification in instructor's handThis tendon frequently ruptures in RA ([19])Inspection and palpation while keeping the thumb extended
3Radial styloid (underlies EPB and APL)Identification in instructor's handBone landmark for injection in de Quervain's tenosynovitis ([20])Palpation of distal end of radius
4Dorsal (Lister) tubercle of radiusIdentification in instructor's handEPL tendon usually ruptures at this site in RA; landmark for wrist aspiration or infiltration ([21])Palpation of distal end of radius
5Dorsal interossei muscles (spread apart 2nd, 3rd, and 4th fingers)Demonstration by participantCause rheumatoid deformities when contractured; impaired and atrophied in ulnar neuropathy ([22, 23])Inspection and palpation of belly of 1st dorsal interosseus, shown by characteristic motion in 2nd, 3rd, and 4th fingers
6Palmar interossei (bring together 2nd, 4th, and 5th fingers)Demonstration by participantCause rheumatoid deformities when contractured; impaired and atrophied in ulnar neuropathy ([22, 23])Shown by characteristic motion in 2nd, 4th, and 5th fingers
7Thumb adduction (places thumb at the side of the index finger)Demonstration by participantAdds to the supporting hand; impaired and atrophied in ulnar neuropathy ([24])Shown by characteristic motion
8Thumb abduction (places thumb vertical to the palm)Demonstration by participantAllows grasp; impaired plus APB atrophied in longstanding CTS ([25])Belly of APB and tendon of APL are visible and palpable during thumb abduction
9Biceps brachii muscle and tendonIdentification in instructor's arm and elbowFlexes elbow and supinates forearm ([26])Inspection of muscle belly, palpation of tendon
10Brachialis muscle and tendon (underlie biceps brachii)Identification in instructor's arm and elbowFlexes elbow; it does not contribute to supination ([26])Tendon is palpable beneath biceps brachii tendon
11Supraspinatus muscle (abducts the arm)Demonstration by participantMost common site of injury in rotator cuff tendinopathy ([27, 28])Belly hardens above the scapular spine during resisted arm abduction
12Infraspinatus tendon (externally rotates the arm)Demonstration by participantSecond most common site of injury in rotator cuff tendinopathy ([28, 29])Belly hardens below the scapular spine during resisted arm external rotation
13Atlantooccipital joint motion (reluctant “yes” motion)Demonstration by participantAffected in RA, OA, and CPPD crystal deposition disease ([30, 31])Validation by shape of the articular surfaces and CT and MRI scans
14Atlantoaxial motion (reluctant “no” motion)Demonstration by participantAffected in RA (atlantoaxial subluxation), OA, and CPPD crystal deposition disease ([30, 31])Validation by shape of the articular surfaces and CT and MRI scans
15Tensor fasciae latae muscle (inserts anteriorly in the iliotibial band)Demonstration by participantContracture causes extraarticular hip limitation ([32])Belly is palpable during stance on one leg and during walking
16Gluteus medius (main hip abductor, also hip internal rotator)Demonstration by participantSite of injury in trochanteric syndrome (32–34)Belly is palpable during stance on one leg and during walking
17Infrapatellar (Hoffa's) fat pad (visible and palpable at the sides of the patellar tendon)Identification in instructor's kneeInferior corner is part of the patellar tendon enthesis organ; it has been confused with a knee effusion ([35-37])Inspection and palpation of the fat pad
18Pes anserinus insertion (3–5 cm distal to articular line on upper medial tibia)Identification in instructor's kneePes anserinus syndrome (anserine “bursitis”), site of therapeutic injection ([38, 39])Inspection and palpation of gracilis, palpation of semitendinosus
19Tibiotalar joint (dorsal and plantar flexion of the ankle)Demonstration by fellow on instructor's footOften involved in RA, SpA, and gout ([40])Motion of palpable articulating bones
20Subtalar joint (calcaneus out or valgus and calcaneus in or varus)Demonstration by fellow on instructor′s footOften involved in RA, SpA, and gout ([41])Motion of palpable articulating bones

A problem that we anticipated was that the anatomic nomenclature known by participants would vary according to their training site and year of training. Indeed, some had learned anatomy according to the old French terminology as in the publications by Testut and Latarjet ([42]) and Quiroz-Gutiérrez ([43]), whereas others had learned it according to the Nomina Anatomica, such as in the publications by Rouvière and Delmas ([44]) or Romanes ([45]) or the Terminologia Anatomica as in the books by Moore et al ([46]) and Standring ([47]), which for the surveyed items is identical to the Nomina Anatomica. Therefore, both sets of designations were used at each of the workshops ([48]).


The workshops, and therefore the practical anatomy tests, took place in 7 countries: Argentina, Chile, Ecuador, El Salvador, Mexico, the US, and Uruguay. In 4 countries, the invitation to give the workshop was by the local rheumatism societies, and in 3 countries, the invitation was by the directors of rheumatology training programs. One workshop was held in each country except for one country, in which 2 workshops were held. All participants were informed that the results of the preworkshop anatomic knowledge test would be blinded to the training program directors and the local rheumatism societies. Furthermore, the results of the study were to be blinded as to the country and participating training programs.

Mechanics of the preworkshop test

Participants were individually administered the preworkshop practical test at a location physically separated from the workshop room. Care was taken to make sure that the structures to be identified were made appropriately prominent. To prevent the chance of discussion of the content of the assessment between participants, those waiting for the pretest remained separated from those who had completed the test. Masking the test from those waiting to be examined was successful at all sites. The preworkshop 20-item anatomy test lasted 9–10 minutes. At the site in which the posttest was implemented, the time lag between the pre- and the postassessments was 3.5 days.

Statistical analysis

Descriptive statistics were initially used for exploring the data. One-way analysis of variance (with Scheffe's post hoc analysis, when needed), unpaired t-test, and paired t-test were used for comparing means, depending on the number of groups and the dependency of the data. Statistical analyses were done by using the SPSS statistical package, version 17.0. Statistical significance was set at 0.05.


  1. Top of page
  2. Abstract
  8. Acknowledgments

The pretest assessment was applied to 170 participants (Table 2) from 7 American countries. Eighty-four were rheumatology fellows (35 first year and 49 second or third year), 61 were rheumatologists in practice, and 25 were nonrheumatologists (7 primary care physicians, 6 physiatrists and sports physicians, 4 internists, 2 radiologists, 2 medical students, 1 endocrinologist, 1 obstetrician, 1 general surgeon, and 1 academic administrator).

Table 2. Preworkshop test participants by country and academic or professional activity

When all 170 participants were considered, the correct answer score averaged mean ± SD 46.6% ± 19.9% (median 45%, range 0–95%). We found that rheumatology fellows had significantly higher scores than nonrheumatologists. No difference was found between fellows and practicing rheumatologists. Significant differences were found according to fellowship year and between workshops organized by rheumatology societies and training program directors (Table 3). A range of scores was found between participants of the different countries that varied from mean ± SD 32.5% ± 12.1% in the lowest-scoring country to 67.0% ± 16.1% in the highest-scoring country. This resulted in significant differences between the scores of country D as compared to the scores of countries A, B, and F (P < 0.001) and country G (P = 0.006) (Table 4).

Table 3. Test scores according to professional group, years of fellowship, and type of invitation to attend the workshop
 Score, mean ± SDP
  1. a

    By one-way analysis of variance.

  2. b

    Compared to the fellows.

  3. c

    By unpaired t-test.

Professional groupa  
Nonrheumatologists39.1 ± 17.60.03b
Practicing rheumatologists44.3 ± 17.90.14b
Rheumatology fellows50.8 ± 17.6
Year of fellowshipc 0.03
First year48.9 ± 20.4 
Second or third year59.0 ± 21.7 
Invitation to workshopc 0.03
National rheumatology society43.4 ± 17.9 
Director of training program49.9 ± 21.6 
Table 4. Overall percentage of correct answers according to country
Country%, mean ± SD
D67.0 ± 16.1
E60.7 ± 14.2
C52.7 ± 19.7
G44.5 ± 12.4
A40.7 ± 20.0
B40.1 ± 18.5
F32.5 ± 12.1

A ranked list of items from those most frequently answered correctly to those least frequently answered correctly is shown in Table 5. Only 2 hand items appeared in the upper half, whereas 6 appeared in the lower half. This observation is in agreement with the results found when scores were considered according to the anatomic regions: hand items had the lower score (mean ± SD 40.6% ± 24.6%) as compared to the shoulder/neck (mean ± SD 44.0% ± 28.1%) and the lower extremity (mean ± SD 59.5% ± 26.9%). Although there was no correlation between test scores and length of professional experience in the entire group (r = 0.00, P = 0.49), when we restricted this analysis to the 61 practicing rheumatologists, a significant correlation was found (r = 0.24, P = 0.02). Finally, in country B, where a postworkshop test was taken, the mean ± SD increased from 37.6% ± 15.6% in the preworkshop test to 78.2% ± 15.5% in the postworkshop test (95% confidence interval 34.7–46.5, P < 0.0001 for the difference).

Table 5. Percentage of correct answers for each of the 20 anatomic items evaluated
Gluteus medius muscle71.2
Biceps brachialis muscle65.3
Tensor fasciae latae muscle63.5
Subtalar joint59.2
Thumb abduction58.8
Radial styloid58.2
Pes anserinus56.5
Tibiotalar joint50.7
Atlantooccipital joint50.0
Infrapatellar (Hoffa's) fat pad49.4
Supraspinatus muscle44.7
Thumb adduction43.5
Dorsal interossei muscles42.9
Palmar interossei muscles41.2
Atlantoaxial joint39.4
Brachialis muscle35.9
Anatomic snuffbox, dorsal boundary31.8
Infraspinatus muscle28.8
Dorsal (Lister) tubercle of radius28.8
Anatomic snuffbox, palmar boundary22.4


  1. Top of page
  2. Abstract
  8. Acknowledgments

Our study demonstrated that in diverse American countries, rheumatologists appear to be suboptimally trained in musculoskeletal anatomy. The deficit may be widespread, since it was consistently shown in the 7 countries where we conducted our workshops. Participation resulted from 2 mechanisms. In 4 countries, the workshop was organized by the local rheumatism societies and attendance was voluntary, whereas in 3 countries, the events were organized by the directors of training programs and attendance was virtually complete. Because some of the society workshops provided Continuing Medical Education credits, some nonrheumatologists attended. Anatomic knowledge was significantly higher in the rheumatology fellows, whose scores were statistically higher than in nonrheumatologists, with the practicing rheumatologists scoring in between. More experience resulted in higher scores both in the fellows and practicing rheumatologists. This finding suggests that anatomy is indeed used and is learned as experience accrues. The trend to lower scores in practicing rheumatologists compared to fellows is surprising and could reflect the more recent formal learning of clinical anatomy in current fellows or a drop in detailed knowledge of anatomy in practicing rheumatologists with the passage of time in the absence of periodic review and updating, or could indicate selection bias if the rheumatology fellowship program directors who chose to participate had greater interest and skill in teaching their fellows than those who did not participate. A disturbing finding was that the hand items were lesser known than the shoulder/neck and lower extremity items. This is a significant omission given the importance and relevance of the hand in many rheumatic diseases; indeed, preliminary results of the previously cited multinational Delphi study that we are conducting looking to identify all anatomic structures important to rheumatology practice reveal that the hand is the anatomic region with which rheumatologists should be the most familiar (Canoso JJ, et al: unpublished observations).

From the above findings, we would like to advance the disturbing notion that, at present, and within the limitations of our study, we have found that rheumatologists, whom we believe achieve a high level of scientific knowledge in the autoimmune, metabolic, infectious, autoinflammatory, and pain amplification conditions, fall short in the expertise they should also possess in clinical anatomy that is essential for the proper and efficient diagnosis of musculoskeletal disorders and especially the regional pain syndromes.

We are unaware of similar studies in which an attempt was made to test the knowledge of clinical anatomy of rheumatologists in a given country or region. Realization of this deficiency in rheumatology training must lead to mechanisms for remediation, including development of curricula for more adequate teaching of clinical anatomy.

A goal of our group is that every rheumatology training program in Mexico should have a staff member with special training in clinical anatomy and physical examination. We have so far been only partially successful. Clinical anatomy, and by extension proficiency in the examination of the musculoskeletal system, is a skill that can be quickly learned (in 7–10 sessions) regardless of the primary interest of that person. Our group is a prime example of such diversity of interests ([12]).

There are several strengths to our study. One is the wide and diverse representation of fellows and rheumatologists from 7 American countries. Another is that the practical test of baseline knowledge in anatomy was immediately followed by a hands-on, intensive workshop designed to strengthen the learners' knowledge base and stimulate interest in clinical anatomy of the musculoskeletal system. A final strength is the delight participants had when they saw the instructors in shorts and sandals and in being able to trace a tendon in the instructor's forearm or move his or her foot.

There are also limitations to our study. One is the lack of formal validation of our questionnaire. Another is the small number of items surveyed. This resulted from a compromise, since trial questionnaires prior to the 2007 workshops showed that more questions would be unduly burdensome to participants and necessarily shorten the time devoted to the actual workshop. In addition, there is a disproportion between hand-related items and items pertaining to other anatomic regions. We have already mentioned a post hoc justification of this asymmetry, with participants' lower scores on anatomic questions related to the hand indicating the need for this emphasis. A further limitation is that in some countries, we were able to test most fellows or practicing rheumatologists, whereas in 2 countries, only a small sample was tested.

The enthusiasm shown by participants in a small unpublished survey obtained 1–3 months after the sessions (Saavedra MA, et al: unpublished observations) and the favorable feedback we have received at the Annual Scientific Meeting of the American College of Rheumatology, where we presented a shorter version of the workshop from 2005–2013, suggests that the methodology as used is sound and well received by learners from a didactic viewpoint. There is a pervasive, if unstated, view that superior clinical skills are no longer necessary because technologies such as ultrasonography and magnetic resonance imaging (MRI) surpass physical examination in the detection of certain musculoskeletal abnormalities. Our contention is that clinical skills must be developed to the highest degree possible and once on this platform, the rheumatologist would then be empowered to use technology as needed in a more cost-effective and clinically sound manner, i.e., for analysis of what remains unclear and not because the technology is there to be used. This construct has several advantages. One is that the decrease in the cost of medical care is an extremely relevant issue both to developing countries and many developed countries as well, where the cost of medical care is increasing at an unsustainable rate. Additionally, false-positive observations resulting from the unnecessary use of sensitive technologies (consider the premature MRI in someone with cervical, shoulder, or lumbar pain) may not only add cost but also send the rheumatologist's reasoning and therapeutic efforts astray. Knowledge of clinical anatomy and the rheumatologist's ability to apply it in his or her care of the patient may increase the physician's self-esteem and satisfaction that is to be gained in making a diagnosis using these basic bedside skills alone. Similarly, a methodical and insightful physical examination enhances partnership with the patient as a part of “the art of medicine” that can enhance comfort and confidence in the doctor–patient relationship and be a significant component of humanistic care. Finally, an insightful history followed by a skilled physical examination sum up what we, as clinicians, can do ourselves and therefore vouch for.

In summary, we have shown a deficit in anatomic knowledge in 7 American countries, and we hypothesize that this may reflect a broader trend in rheumatology training in much of the world. We have designed a teaching exercise that we believe represents the type of didactic effort and attention that is needed to start to correct this deficiency ([11-17, 48]). We hope that these efforts will eventually result in a more balanced educational outcome in which our graduating fellows will have expertise not only in systemic conditions, but also in clinical anatomy and the diagnosis of the regional pain syndromes.


  1. Top of page
  2. Abstract
  8. Acknowledgments

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Canoso had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Navarro-Zarza, Hernández-Díaz, Alvarez-Nemegyei, Kalish, Canoso, Villaseñor-Ovies.

Acquisition of data. Navarro-Zarza, Hernández-Díaz, Saavedra, Kalish, Canoso, Villaseñor-Ovies.

Analysis and interpretation of data. Navarro-Zarza, Saavedra, Alvarez-Nemegyei, Kalish, Canoso, Villaseñor-Ovies.


  1. Top of page
  2. Abstract
  8. Acknowledgments

The authors would like to thank the participating rheumatology societies and academic centers from Argentina, Chile, Ecuador, El Salvador, Mexico, the US, and Uruguay, and the participants in the knowledge tests.


  1. Top of page
  2. Abstract
  8. Acknowledgments
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