REVIEW
What Bedside Skills Could the Modern Rheumatologist
Possess? Part II. “Certain Technical Procedures”
Robert W. Ike, MD,* Sara S. McCoy, MD, PhD,† and Kenneth C. Kalunian, MD‡
5 years, reviewed the results, and incorporated them into text and
Abstract: Rheumatologists have never been reluctant to adopt procedures reference list when new findings expanded our own understanding.
that might enhance their diagnostic or therapeutic powers. Their propensity
to penetrate the joints of the patients they were treating set them apart from
the general internist. Since the 1980s, when a chance to look inside the ULTRASOUND
joints they were treating attracted a few rheumatologists, other things that Musculoskeletal ultrasound (MSKUS) has grown from an
could be done at the bedside emerged with now an array of bedside proce- obscure procedure practiced by a few radiologists using a machine
dures that could be part of a rheumatologist's skill set. Besides gains in di- the size of a refrigerator to something a rheumatologist can do at
agnosis and/or therapy, each constitutes a chance to restore the physical the bedside with a laptop on a rolling cart or even a pad in the
contact between physician and patient, riven by factors of the last decade, pocket. Application of US to situations in rheumatology followed
such as electronic medical records and COVID. With such contact so im- different paths in North America, where radiologists were first to
portant to satisfaction of the patient and physician alike, acquisition of pro- explore musculoskeletal US, and Europe, where rheumatologists
ficiency in certain technical procedures described herein offers one path to led the way. A leader among German rheumatologists, Berlin's
begin restoring rheumatology to the richly fulfilling practice it once was. Marina Backhaus, while visiting the University of Michigan in
Key Words: arthroscopy, biopsies, myositis, osteoarthritis, Sjögren 2001, convinced R.W.I.'s chief that buying a US machine would
syndrome, ultrasound be a good idea. The American College of Rheumatology (ACR)
recognized the potential of this procedure more than a decade
(J Clin Rheumatol 2024;30: 122–129)
ago,3 and its use by rheumatologists has grown considerably.
Machines continue to fall in price with small “pocket” units
U p until the 1980s, it is unlikely that any more than a few rheu-
matologists considered venturing beyond the simple but
helpful collection of bedside skills they had been applying, as de-
an attractive alternative (Fig. 1). One of us (R.W.I.) was told
when writing about MSKUS decade before last that calling
US the “rheumatologist's stethoscope” was inappropriate as US
scribed in part 1 of this series. Then, there was Bill Kelley1 on
has applications that go beyond diagnosis and the cardiologist
stage of the 1986 American Rheumatism Association meeting,
cannot bill for auscultation. Yet, the term persists,4 especially with
talking about taking on “certain technical procedures appropriate
the emergence of “pocket” models.
to our specialty.” Two of us (R.W.I. and K.C.K.) in the audience,
The diagnostic expertise of the rheumatologist using US may
already busy taking up the then-advanced (for rheumatology)
not approach that of an experienced radiologist who spends substan-
technical procedure of arthroscopy, saw his words as code lan-
tial time scrutinizing US videos for subtleties, but quickly obtained
guage for that procedure. Indeed, they were, but they implied
US views in the clinic can settle many questions, such as “fluid or
more. The years that followed found rheumatologists taking on
solid?” “calcinosis?” “effusion?” “synovial proliferation?” Ultra-
other technical and minimally invasive procedures. All required
sound can detect tissue deposition of crystalline material, with urate
a more substantial investment of time and equipment than the ba-
and calcium pyrophosphate dihydrate showing distinctly different
sic ones just described.2 But each also confers the sorts of benefits
location and appearance. Disruption of the structure of tendons
to physicians and patients that derive from hands-on contact.
and ligaments as they insert into bone can be discerned by US, mak-
ing the technique a valuable tool for detection of enthesopathy. Ul-
METHODS trasound appearance of a structure during movement can add value
For our review, we relied heavily on our collected recollections to physical assessment, particularly for the shoulder.
of a combined 83 years of posttraining clinical practice plus our own Experienced rheumatologists who had taught themselves
personal libraries. To ensure that we had not missed key advances or MSKUS were equally capable of diagnosing an array of clinical sit-
insights, we utilized the search engines Scopus, Web of Science, and uations as those with formal US training.5 Ultrasound is an
Pub Med, inputting terms “ultrasound,” “skin biopsy,” “salivary operator-dependent procedure, and facility with its use depends
gland biopsy,” “muscle biopsy,” “synovial biopsy,” “washout,” “ir- strongly on experience and innate skills of the operator. Another ad-
rigation,” “lavage,” and “arthroscopy.” We crossed these terms vantage of the “pocket” units is the likelihood that the operator will
with “rheumatology,” considered publications over the past scan many more structures, and there is no substitute for practice.
Ultrasound may be even more helpful as a guide to needle
placement for arthrocentesis.6 Wu et al.,7 in their systematic re-
From the *Department of Internal Medicine, Division of Rheumatology, University view, found that US-guided knee arthrocentesis offered signifi-
of Michigan Health System, Ann Arbor, MI; †Department of Medicine, Divi- cantly greater accuracy and clinical improvement over traditional
sion of Rheumatology, University of Wisconsin–Madison, Madison, WI;
and ‡Department of Medicine, Division of Rheumatology, Allergy, and Immu-
palpation-guided technique in adults with knee pain or joint effu-
nology, University of California at San Diego, San Diego, CA. sion. Ultrasound-guided synovial biopsy has become popular
The authors declare no conflict of interest. among those examining the synovium for research8 and may be-
Correspondence: Robert W. Ike, MD, 1611 Harbal Dr, Ann Arbor, MI 48105. come important to the practicing clinician as rheumatologic treat-
E‐mail: scopydoc52@yahoo.com.
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
ment moves to becoming “precision based.”9,10
ISSN: 1076-1608 Synovial features, without biopsy, utilizing power Doppler
DOI: 10.1097/RHU.0000000000002022 detecting red blood cell movement that can serve as a surrogate
122 www.jclinrheum.com JCR: Journal of Clinical Rheumatology • Volume 30, Number 3, April 2024
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
, JCR: Journal of Clinical Rheumatology • Volume 30, Number 3, April 2024 Certain Technical Procedures
FIGURE 1. “Pocket” US units. A, Lumify (Philips North America Corporation, Cambridge, MA, https://www.usa.philips.com/healthcare/sites/
lumify) probe projects image to the tablet. B, Clarius probe projects image wirelessly to cell phone or other Bluetooth-enabled devices (Clarius
Mobile Health Corp, Vancouver, British Columbia, Canada https://clarius.com/). C, Butterfly iQ projects images via wired connection (Butterfly
Network, Guilford, CT, https://www.butterflynetwork.com/). Images courtesy of manufacturers, reproduced with their permission.
marker for the presence and intensity of synovitis, have been ex- not always connote a systemic process, but finding immunoglobulin
tensively studied11 and proposed as an outcome measure for treat- A deposition on immunofluorescence confirms Henoch-Schönlein
ments of inflammatory arthropathies, although the utility of such purpura.27 Skin biopsy is important in discerning pseudovasculitis
techniques remains unsettled.12 Media comprised tiny gas-filled syndromes,28 such as levamisole-induced pseudovasculitis29 and
microbubbles, injected intravenously before US examination, calciphylaxis.30 Scleroderma syndromes can be great imitators,31
and enhanced the signal reflected by vascularized structures such and skin biopsy might be able to discern the occasional case of
as inflamed synovium. Such contrast-enhanced MSKUS exami- scleromyxedema.32 Other scleroderma mimics, such as eosinophilic
nation detects synovitis with greater sensitivity and accuracy13 fasciitis, require deeper biopsies for confirmation. An examination
but has not yet been adapted to the bedside. of the skin for molecular changes in scleroderma has become an
Indications for US in rheumatology continue to grow and intense research focus but not yet in the realm of regular clinical
now include salivary gland US for Sjögren syndrome diagnosis14 practice. Not every patch of biopsied skin needs to appear abnor-
with an emerging role for elastography,15 muscle US for myosi- mal to yield important diagnostic information. Finding deposition
tis,16 and temporal artery US for giant cell arteritis,17 among of immunoglobulin at the dermal-epidermal junction in a biopsy
others. Many courses are available to the rheumatologist interested of non–sun-exposed skin in a patient suspected of having lupus
in learning US, including daylong sessions preceding each ACR is highly supportive of the diagnosis (lupus band test).33 Reduced
meeting. A number of rheumatology training programs offer US epidermal nerve density on skin biopsy, an evaluation requiring
instruction to fellows.18 As ever more training programs offer specialized techniques to analyze, can confirm small-fiber neu-
some instruction in US to fellows, assessment of the efficacy of ropathy in a patient with puzzling neurologic symptoms.34,35
that training remains hampered by a lack of validated theoretical
and practical assessment tools.19 Likewise, methods to certify
competence in trained rheumatologists seeking to perform US in- Labial Salivary Gland Biopsy
dependently have not been agreed upon.20 As for many topics in Obtainment of labial salivary glands at the bedside is a simple
medicine, the internet provides many videos on MSKUS, al- procedure for any physician capable of sewing up a plain laceration
though they have been assessed to be of insufficient quality for (Fig. 2A),36 a skill not commonly taught in rheumatology or inter-
learning.21 There are many MSKUS textbooks, almost all written nal medicine training programs, but quickly acquired moonlighting
by radiologists. The slim red volume written by rheumatologists in a local emergency room or walk-in clinic. Complications of la-
Bruyn and Schmidt22 is the favorite of one of us (R.W.I.) who does bial salivary gland biopsy are minimal in experienced hands.37
MSKUS. An atlas devoted to US-guided injections is available.23 Some effort must be expended at the outset to get pathologists to
The independent organization of rheumatologists interested in US provide interpretations in a manner useful to the rheumatologist.
—USSONAR (Ultrasound School of North American Rheuma- Besides providing the pathology component to support a Sjögren
tologists ussonar.org)—conducts a program whereby trainees sub- syndrome diagnosis,38 conditions such as amyloidosis,39 sarcoido-
mit acquired US images for review and critique by experts, sis,40 hemochromatosis,41 lymphoma,42 graft-versus-host disease,43
allowing proctored training even where direct oversight by an ex- cystic fibrosis,44 and immunoglobulin G4–related disease45 can be
perienced ultrasonographer is not available.24 One of us (S.S.M.) supported by findings at labial salivary gland biopsy. Learning how
participated in that program and has been doing US independently to perform the procedure is a bedside matter, a challenge with few
since starting her faculty job. The ACR offers formal certification rheumatologists proficient in the technique and other specialists,
in US competence.25 Human performance of US may not ensure such as oral surgeons or otorhinolaryngologists, with minimal in-
job security, as automated methods for US assessment of joints terest in such a minor procedure and usually reluctant to spend
are being developed.26 time showing how to others. Group workshops using sheep
lip-based hands-on practice, such as the one conducted at the last
in-person ACR meeting, illustrate one example of how such skill
SUPERFICIAL BIOPSIES acquisition might be accomplished.46 The video demonstrating
the procedure that was shown during that workshop is available
Skin Biopsy on YouTube and VuMedi,47 as is a video of the entire workshop
Punch biopsy of the skin using local anesthesia and sutureless didactic presentation.48 Instruments (Fig. 2B) are inexpensive
adhesive-based closure is a simple and quick procedure to assess and can be obtained on Amazon. Enter “Adson's dual forceps
suspicious superficial lesions. Vasculitis seen on skin biopsy does (no teeth),” “needle holder driver,” and “curved iris scissors.”
© 2023 Wolters Kluwer Health, Inc. All rights reserved. www.jclinrheum.com 123
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.
