To the Editors:
The editorial in a recent issue of Arthritis Care & Research by Roemer and colleagues (1) identified several issues related to improved development of musculoskeletal ultrasound (MSUS) for rheumatologists. Why should rheumatologists perform MSUS? Rheumatologists in the US have been slow to learn about the benefits of MSUS from their European colleagues. Rheumatologists, in contrast to radiologists, typically perform careful clinical examinations and would benefit from the additional imaging information provided by the immediate and flexible application of MSUS. MSUS is quite useful in identifying fluid collections within and adjacent to joints. Peritendinous fluid collections are also quite easily imaged with MSUS.
Pathology suitable for local corticosteroid injections, guided by anatomic landmarks or by MSUS, permits rheumatologists to promptly provide appropriate treatment. It is quite plausible that MSUS-guided injections will result in more favorable clinical outcomes than those injections guided only by anatomic landmarks, although there are only limited data presently available to support this conclusion (2–4).
The technology of MSUS has improved considerably in recent years, and there are reasonably priced portable or transportable units optimized for MSUS. Gray scale images define anatomy and pathology reasonably well, and color or power Doppler capability detects vascularity that is frequently associated with inflammation.
Roemer et al pleaded their case that only a radiologist trained in multiple imaging technologies such as plain radiology, magnetic resonance imaging, computed tomography, and nuclear medicine is qualified to perform ultrasound. It is notable that these authors emphasize that there are 4 months of ultrasound training required during residency in radiology, however; this training may or may not include MSUS.
Radiologists engage in their own form of self-referral by frequently suggesting additional imaging procedures in their written reports to clinicians; although these additional procedures may be more definitive, performing them does generate additional revenue for the radiologist.
Roemer et al do highlight important issues of training physicians properly to perform MSUS and the need for better standardization of MSUS examinations. They also point out that development of MSUS will “…best be served by cooperation and constant communication between the specialties…” Unfortunately, too many radiologists appear to feel threatened by the desire for rheumatologists to perform their own MSUS and are unwilling to teach them to perform and interpret MSUS studies. However, some radiologists (including at least 2 of the authors in the Roemer et al editorial) do participate in MSUS courses open to rheumatologists.
As rheumatologists become skilled in the application of MSUS for improved diagnosis and MSUS-guided therapies, they will continue to expand its use. They do need the benefits of musculoskeletal imaging to provide the best care for their patients. Radiologists should redefine their role to work as consultants and teachers for rheumatologists in all aspects of musculoskeletal imaging, including MSUS. Such cooperation will only improve the care of patients with rheumatic diseases.