Promoting the utilization of rheumatologic musculoskeletal anatomy: a 50-year travel log

This report traces the authors' long journey toward a deeper understanding of the anatomical basis of rheumatologic physical examination. Fifty years ago, one of the authors was struck by the prevalence of subcutaneous and deep bursitis and regional musculoskeletal pain syndromes at his new workplace, prompting studies of bursal swelling, lubrication, and the dynamics of distended superficial and deep bursae. Subsequently, a deficiency in anatomical knowledge was noted across multiple workshops at the American College of Rheumatology and elsewhere. Later, in a different setting, musculoskeletal anatomy workshops were held, based on cross-examination between rheumatology learners and instructors. Palpation was used in the upper extremity, and the spine and lower extremity were demonstrated through motion and self-palpation. Pre-workshop tests consistently revealed poor recall of musculoskeletal anatomy among trainees and practitioners, including orthopedic trainees. All questions were rated highly important in an international Delphi survey of anatomical items relevant to rheumatology. Subsequently, a self-examination method was developed to allow learners to practice, in privacy, the anatomical knowledge traditionally acquired. More recently, an international, unfunded, and enthusiastic study group comprising anatomists, rheumatologists, and ultrasonographers made independent observations of defined neck and upper extremity structures, including the elusive lower belly of omohyoid, the dorsal forearm muscle-tendon intersection, the concurrent contraction of anconeus and pronator teres, and dynamic aspects of the extensor apparatus of the fingers, the natatory ligament, the web spaces, and the intertendinous connections. In these studies, physical examination and ultrasound complemented each other. Thus, physical examination, rather than being replaced, should be strengthened. Key Points • We describe a sustained effort spanning more than 50 years to reinstate MSK anatomy as a basic competence for MSK conditions and general rheumatologic examination. • The initial studies focused on subcutaneous and deep bursae and on seminars regarding musculoskeletal pain syndromes and, much later, the anatomical basis of rheumatologic examination. • This was followed by a one-on-one assessment of rheumatology fellows' and practitioners' anatomical knowledge and by participatory MSK anatomy seminars held across the Americas with support from ILAR. • Subsequently, a method of self-examination was developed as an accessible way to reinforce anatomical learning. • Currently, independent physical examination and ultrasonography, along with dissection performed by anatomists, have resulted in a series of innovative and fruitful proof-of-concept studies.