Why aren't we all doing ultrasound?

Musculoskeletal ultrasound (MUS) is potentially the most exciting development in clinical rheumatology practice in recent years. It is readily accessible, patient friendly and relatively inexpensive. It can be used to detect small joint effusions and thus increase the accuracy of diagnostic aspiration and therapeutic injection [1]. It is more sensitive than clinical examination in detecting enthesitis [2] and seven times more sensitive than X-ray in detecting small erosions [3]. It is in the area of detection of early synovitis, however, where the greatest potential lies. MUS can detect subclinical inflammation and is comparable with MRI in this respect [4, 5], a phenomenon that may explain the apparent dissociation between clinical remission and joint damage in RA [6]. Power Doppler MUS can also be used to monitor response to biologic therapy [7] facilitating more rational decision making in the use of these very expensive treatments. These developments have stimulated a greatly increased interest in MUS, which can be gauged by the demand for courses organized by the British Society for Rheumatology (BSR) or the European League Against Rheumatism (EULAR) and the increase in publications related to this topic in recent years. Surely MUS is now indispensible in every rheumatology department. So why aren't we all doing it? Why is MUS not an integrated tool in every early arthritis clinic? Why is training in MUS not already part of the curriculum for trainee rheumatolo-gists in the UK as in other European countries? These questions have been asked before in previous editorials in Rheumatology citing the absence of defined training programmes and the investment in time required [8, 9]. We do not seem to have advanced much in the last few years. A survey presented at the MUS Special Interest Group at this year's BSR annual general meeting suggested that despite having had some training and access to an ultrasound (US) scanner, most rheumatologists would still ask a radiologist to undertake a US scan rather than do it themselves. It also indicated that US machines in UK rheumatology departments are grossly underused [10]. These results, admittedly based on a small sample, indicate either a lack of time or opportunity (probably both) to build on basic courses and acquire the skills needed to incorporate MUS into everyday practice. These difficulties exist despite publication of a specific competen-cies framework for rheumatologists [11], the EULAR Working Group for MUS in Rheumatology guideline [12] and OMERACT reports …