Rheumatology 2020;00:1–6

Rheumatology doi:10.1093/rheumatology/keaa656

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Original article
Recommendations for rheumatology ultrasound
training and practice in the UK
Ismaël Atchia1, Andrew K. Brown2, Sarang Chitale3, Anna Ciechomska4,
Cristina Estrach5, Zunaid Karim6Richard J. Wakefield7; for the British Society
for Rheumatology Ultrasound Special Interest Group (BSRUSSIG)

Abstract
Objective. The aim of this paper is to present a UK-based consensus of principles and recommendations to
guide rheumatology US training and practice.
Method. A Delphi process was conducted involving 19 US experts representing each of the 14 regions of the UK.
A working group of experienced British Society for Rheumatology Ultrasound Special Interest Group (BSRUSSIG)
members made seven proposals that were presented to the whole group for further discussion. This resulted in
minor modifications and seven preliminary recommendations. Members were then asked to anonymously agree or
disagree with each recommendation using an electronic ballot. A threshold of 75% was used to determine consen-
sus agreement. Results were collated by an independent chairperson and presented to the BSRUSSIG in a face to
face meeting where agreement for each recommendation was ratified and an action plan agreed for dissemination
of the results and future development work.
Results. Using a validated process, experts in rheumatology US have worked through an iterative process and
have unanimously agreed seven recommendations for rheumatology training and practice. These cover a hierarchy
of practice indications, education and training, including the need for practitioners to demonstrate lifelong learning,
as well as a commitment to support mentors and trainers through the BSRUSSIG.
Conclusion. These are the first specific education and practice recommendations for rheumatology US in the UK
and have been developed and endorsed by the BSRUSSIG. We intend that these proposals will help to support
and validate rheumatology US practice and inform the development of future rheumatology training curricula and
education programmes.

CL IN IC A L
SC I E NC E
Key words: ultrasound, training, education research, rheumatoid arthritis, giant cell arteritis, hot joint

Rheumatology key messages

. There are no current national guidelines on training and independent practice in rheumatology US in the UK.
. A consensus of principles and recommendations to guide practice have been developed.
. These recommendations will help to ensure ongoing best quality and safe practice in rheumatology US.

Introduction improved technology have enabled clinicians to have

access to machines, allowing them to directly perform
Over the past 20 years, US has become an increasingly scans themselves at the bedside or in clinic to immedi-
accepted and validated imaging tool for the investigation ately inform clinical decision making [1]. In rheumatol-
of musculoskeletal conditions. Falling costs and ogy, the applications of US continue to grow particularly

Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds,

1
Rheumatology Department, Northumbria Healthcare NHS UK
Foundation Trust, Northumbria, 2Hull York Medical School, Submitted 6 May 2020; accepted 30 July 2020
University of York, York, 3Rheumatology, Wrightington Wigan and
Leigh NHS Foundation Trust, Wigan, 4Rheumatology, Wishaw Correspondence to: Ismaël Atchia, Rheumatology Department,
General Hospital, Wishaw, 5Rheumatology, Liverpool University Northumbria Healthcare NHS Foundation Trust, Rake Lane, North
Hospitals Foundation Trust, Liverpool, 6Rheumatology, Mid Shields, Tyne and Wear NE29 8NH, UK. E-mail: ismael.atchia@ncl.ac.
Yorkshire NHS Trust, Yorkshire and 7Department of Rheumatology, uk or ish@doctors.org.uk

C The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com
V
Ismaël Atchia et al.
in inflammatory arthritis, vasculitis and the assessment
of soft tissue musculoskeletal pathologies [2–5].
Whilst the EULAR and other national societies have
developed recommendations for training [6], there
remains wide variation in what knowledge and skills are
considered important and how training should be deliv-
ered, assessed and monitored [7]. Many of the current
proposals only consider the requirements of those who
want to attain the level of expertly skilled sonographers
and not those who are in general training and may only
want to have basic level training, perhaps only in certain
disease-specific areas. In the UK, only a basic know-
ledge of US is specified in the training curriculum for
specialization in rheumatology, and despite high levels
of interest and enthusiasm from trainees in the UK [8],
performing US is not a formal part of the training cur-
riculum. This has been identified as a key barrier for
rheumatologists learning and performing US [9].
In the UK, the British Society for Rheumatology (BSR)
has delivered US courses since 2003, but these do not
include any summative competency assessment. In
addition, there are no published criteria or requirements
for independent practice, and there are no specific certi-
fication of competency or accreditation standards. This
is challenging, particularly as some hospital Trusts insist
on a certification of competency to enable a rheuma-
tologist to practice US (personal communication/e-mail,
July 2016). The European Federation of Societies for
Ultrasound in Medicine and Biology (EFSUMB) has pro-
posed minimal training requirements for the practice of
medical US in Europe [10], which have been supported
by the Royal College of Radiologists and the British
Medical Ultrasound Society [11]. From 2015, EULAR has
incorporated competency assessment and certification
as part of their training programme. There are also
university-linked courses (some accredited by the
Consortium for the Accreditation of Sonographic
Education), which were initially developed for musculo-
skeletal radiographers but are beginning to include sec-
tions on inflammatory arthritis, such as the
Rheumatology Sonography Course from the Glasgow
Caledonian University and the ‘Hands, Wrists and Feet
in Rheumatology’ course by Canterbury Christ Church
University.
All training programmes leading to certification specify
a minimum number of scans to be performed with
supervision and peer review. These specifications are
different between programmes and are not necessarily
based on evidence. It is well recognized that performing
a set number of scans does not necessarily guarantee
competency. We also observe significant geographical
variance in the UK, including availability and access to
supervisors and local training programmes [12].
Therefore, only a minority of trainees have the necessary
local infrastructure and supervisor support. This has led
a small number of motivated individuals to organize their
own bespoke training through a personal fellowship [13],
which has enabled accreditation for independent prac-
tice by a Certificate of Completion of Training. Access
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to US machines is a factor hampering learning. In add-
ition, service pressures from general medicine, modifica-
tions to the structure of rheumatology and general
medical training and a lack of clarity from national
bodies regarding US practice has led some rheumatolo-
gists to feel that US training is a lower priority, despite
the evidence to support its utility.
Given these ongoing challenges, the BSRUSSIG felt it
was the opportune time to propose recommendations
for UK rheumatology US practice. It is hoped that this
will facilitate infrastructure development, support equit-
able training opportunities and enhance educational
resources to support the training and practice of com-
petent rheumatology US practitioners.
Method
A Delphi consensus-defining process was conducted in
order to establish a set of principles for training and
practice. An expert working group of the BSRUSSIG
was nominated (the authors), with all seven members
having appropriate qualifications and experience
(EFSUMB level 2/3 qualification and/or >10 years’ ex-
perience in US practice/research, and are all EULAR
certified). This group are all current teachers and trainers
on BSR and EULAR courses and had access to detailed
feedback from trainees in the UK and from BSR US
courses over the last 10 years.
This group also reviewed current US practice (with a
focus on application of US at point of care in rheumatol-
ogy practice), education and training literature. A scop-
ing review of the literature rather than a systematic
review was performed. Following this initial phase, they
agreed broad priority areas for US rheumatology training
and practice in the UK. This was consolidated into
seven key proposal statements.
These proposals were shared and discussed with the
wider BSRUSSIG with minor modifications (the first
statement which was initially ‘all rheumatologists should
be able to perform US guided joint aspiration’ was
modified). This constituency comprised 19 rheumatology
ultrasonographers representing each of the 14 regions
of the UK. The clinical background of the US experts
was as follows: 17 consultant rheumatologists, 1 Allied
Health Professional (AHP) and 1 Specialist Registrar.
The 14 regions corresponded to the BSR regional map
at the time of the study and comprised East England,
East Midlands, London, North East, Northern Ireland,
North West, Mersey, Scotland, South East, South
Central, South West, Yorkshire, Wales and West
Midlands.
An anonymous electronic ballot was then conducted.
We used Google Forms to create an on-line question-
naire and send the link to this group of experts. The
results of the survey were collected in the Google Forms
spreadsheet. Each correspondent was asked to agree
or disagree with each statement. Additional comments
were also requested. A threshold of 75% was used to
determine consensus agreement. The e-mail addresses

were requested to avoid one participant completing the
survey more than once. The results were collated, sum-
marized and presented by an independent chairperson
(P.P.) who is experienced in US but did not complete
the Delphi process to avoid any conflict of interest.
The results were presented at a face to face meeting
of the BSRUSSIG, which was also attended by the
Royal College of Physicians rheumatologist representa-
tive (V.Srinivasan), and representatives from the BSR
Education Committee (K. Chaudhuri and A.B.). This pro-
vided an opportunity for further discussion and debate
and to agree the next steps in the education develop-
ment process.
Results
The seven proposals that emerged from the expert
working group are presented in Table 1, column 1.
These were sent to 19 members of the BSRUSSIG.
There were 16 responses (84% response rate).
TABLE 1 Proposals/recommendations for US training and
practice with corresponding stakeholder agreement
Proposals/recommendations Agreement
1. All future rheumatologists should know 100%
indications for US examination in
rheumatology and be able to operate
the US machine for basic procedures
such as aspiration of the acute hot
joint.
2. Independent musculoskeletal US 100%
scanning of the hands, wrists, ankles
and feet in patients with inflammatory
arthritis is desirable for
Rheumatologists/AHPs (BSR Level 1).
3. Independent musculoskeletal US 81%
scanning of other anatomical regions
for other indications is appropriate for
Rheumatologists/AHPs (BSR Level 2).
4. A blended modular educational pro- 87%
gramme will be developed and deliv-
ered by the BSR US SIG to facilitate
BSR Level 1 and 2 rheumatology US
training.
5. Mentors and trainers in rheumatology 94%
US will receive on-going training and
support through the BSRUSSIG (BSR
Level 3).
6. Rheumatologists/AHPs performing US 100%
scanning need to be able to demon-
strate their on-going training, practice
and competence.
7. Mentors and trainers should be able to 100%
demonstrate their ongoing training,
practice and competence in US scan-
ning and teaching.
AHP: Allied Health Professional, BSR: British Society for
Rheumatology; SIG: special interest group; BSRUSSIG:
British Society for Rheumatology Ultrasound Special
Interest Group.
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All seven proposals met the consensus agreement
threshold, and three received unanimous 100% agree-
ment. The agreement percentage and comments from
stakeholders are presented in Table 1. All seven pro-
posals therefore became the recommendations of the
BSRUSSIG. Two areas provoked significant debate in
the discussion group:
1. US-guided aspiration of a hot joint.
It was initially suggested that all rheumatologists
should be able to perform a US-guided aspiration in
the acute care setting of a patient presenting with a
hot swollen joint. However, on reflection it was consid-
ered that US-guided procedures require significant
practice and experience as well as competence in
scanning and identification of normal musculoskeletal
anatomy and pathology. Therefore, it was agreed that
the more basic application of confirming the target
area for aspiration with US rather than guiding the
needle in real-time, was more realistic and feasible,
and this would still offer the advantages of optimizing
the success and safety of needle aspiration.
2. Prioritization of topics and structure of an educational
programme in rheumatology US.
It was agreed that the current BSR US courses would
be modified and a new educational programme would
be developed. This would employ blended learning
principles building on the current face-to-face BSR
courses for the development of practical skills, com-
plemented by self-directed online eLearning resour-
ces for knowledge-based learning which could be
accessed before, during and after the practical course
to promote ongoing and lifelong learning.
There was agreement that five topic areas would be
developed in a modular format:
1. US in the hot swollen joint.
2. US in inflammatory arthritis (hands and feet).
3. Regional US scanning I (upper limb).
4. Regional US scanning II (lower limb).
5. Large vessel vasculitis.
Topics would be divided into basic and advanced lev-
els with relevant skills and competencies. Each module
would include US physics, machine craft and core
knowledge elements supported by eLearning resources
comprising narrated presentations, interactive quizzes
and case studies, key references and additional reading.
The practical US skills training course would focus on
small group teaching and practice with the emphasis on
hands-on scanning and formative assessment, facili-
tated by expert tutors.
Discussion
The BSRUSSIG has reached consensus agreement on
seven key principles and propose that these recommen-
dations will form the framework for the training and
practice of rheumatology US in the UK. Other important
stakeholders including representatives from the Royal
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Ismaël Atchia et al.
College of Physicians and BSR Education Committee
have also been engaged in this process to ensure pro-
posals are realistic and consistent with developing spe-
cialist training curricula.
Whilst there are existing European guidelines for US
training and accreditation (e.g. EFSUMB and EULAR),
these are aimed at developing expert musculoskeletal
US practitioners with a broad repertoire of practice and
require many years of training to achieve the compe-
tency and certification. This is not feasible for many
busy clinical rheumatology practitioners in the UK
National Health Service, who may also be undertaking
their clinical training. Indeed, elements of the EFSUMB
curriculum have been omitted in a recent review that
clarifies the US skills required by rheumatologists [14].
We believe that a more focused and pragmatic ap-
proach is required. Therefore, it is logical to target the
key areas most relevant to rheumatologists and deliver
this content in smaller more feasible and accessible
training modules. Trainees can then choose which area
is most relevant to their practice and therefore which
training module to undertake, and they do not necessar-
ily have to complete the entire musculoskeletal US cur-
riculum. Evidence supports the application of this
focused modular training to enable rapid achievement of
competency in a specific aspect of US [15] with the de-
velopment of transferable knowledge and generic skills
that can then be applied to other specialist areas. The
structure of training is key to maximize accessibility and
opportunities for bespoke learner-driven education.
Training should adopt a blended learning approach,
emphasizing the practical training opportunities of face-
to-face contact in small groups with peers and an expert
tutor, whilst delivering other elements as eLearning that
are always available and accessible for self-directed
learning on a web-based platform. Local mentorship for
‘on-the-job’ training and regular formative feedback is
also an important element, and summative assessment
will be required to ensure competency.
We have agreed a minimum standard of knowledge
that is required by all rheumatology ultrasonographers,
including indications, anatomy and physics relating to
the operation of the US machine, and image optimiza-
tion. This should be the core element for all training and
from this foundation we can build indication and
anatomy-specific competencies.
Prioritizing these topic/content areas was more chal-
lenging and required more detailed debate and discus-
sion. As part of this, it was important to consider the
evolving evidence base for US assessment and the cur-
rent National Health Service working environment and
service priorities. It was agreed that the core rheumatol-
ogy emergencies are the acute hot joint and temporal
arteritis, and there continues to be a priority around
early inflammatory arthritis. In each of these indications
there are advantages for the physician specialist per-
forming a US scan to complement their clinical assess-
ment [16–18]. Also, an anatomical and region-based
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approach, divided into upper and lower limb joints, was
considered an important and logical distinction and
focus for additional training.
Applying recommendation 1, ‘indications for ultra-
sound examination in rheumatology and be able to op-
erate the ultrasound machine for basic procedures such
as aspiration of the acute hot joint’ to ‘all future rheuma-
tologists’ was the outcome of significant discussion.
Several factors were considered in drawing this conclu-
sion. These included the evidence base supporting the
utility of US; the advantages of the assessing clinician
performing the scan to complement their clinical assess-
ment including timeliness, efficiency and clinical reson-
ance; patient safety, e.g. attempting aspiration of a
swollen red ankle when the diagnosis is in fact cellulitis
and not septic or inflammatory arthritis; the changing
training environment with increasing emphasis on gen-
eral medicine (e.g. ‘Shape of Training’) [19]; the expect-
ation that the on-call clinician with rheumatology training
will perform the hot joint aspiration; standard practices
of using US to guide vascular access and pleural aspir-
ation with which most trainees are now familiar; and
availability of US machines in Emergency Departments
and on hospital wards. It was noted that many estab-
lished rheumatology clinicians did not have an obligatory
commitment to provide on-call or acute services or gen-
eral medicine, so it was felt most reasonable to apply
this to colleagues who currently have this commitment
and future rheumatologists who have trained as part of
this new system.
Following on from this, a hierarchy of priority, skill
level and training requirements was ascribed to each
key topic/content area. Independent musculoskeletal US
scanning of the hands, wrists, ankles and feet in
patients with inflammatory arthritis was considered ‘de-
sirable’ and equivalent to ‘BSR Level 1’. Independent
musculoskeletal US scanning of other anatomical
regions for other indications (upper limb, lower limb and
large vessel vasculitis) was considered ‘appropriate’ and
equivalent to ‘BSR Level 2’.
With regard to the specific setting of the acute hot
swollen joint, in an environment where US is successful-
ly utilized in many medical settings by non-radiologists
including those in training, it is a consistent and natural
step for training rheumatologists to attain the basic skills
required to position the US probe over the joint/structure
of interest to confirm that there is appropriate pathology
present and to measure the depth/location of the effu-
sion to improve the accuracy of an aspiration procedure.
This will improve fluid yield and therefore the accuracy
of diagnosis and management as well as reduce the risk
of complications and so optimize patient safety and the
quality of care. It was agreed that the more basic appli-
cation of confirming the target area for aspiration with
US rather than guiding the needle in real-time, was
more realistic and feasible, and this would still confer
the same advantages. Those with more experience over

time will subsequently be able to perform US-guided as-
piration with real-time visualization of the needle.
One of the particular ongoing challenges in the UK is
the availability of local trainers and mentors to support
the development of skills and regular on-the-job learning
between nationally convened education events.
Previously, the BSRUSSIG has funded attendance of
one or two members per year to attend the EULAR
Train the Trainers course. This has helped to build a crit-
ical mass of expertise, but only in selected
Rheumatology centres. This has aided the development
of a number of strong regional programmes, but this ex-
pertise and good practice needs to be consolidated and
disseminated more widely across all regions. Therefore,
it was agreed that the BSRUSSIG will prioritize training
and support for mentors in order to facilitate the devel-
opment of a regional network of trainers/mentors and
consistent training and practice. This will form Level 3 of
the BSR programme. As part of this there is also enthu-
siasm to develop a bespoke UK programme building on
the present ad hoc ‘Teach the Teachers’ events, to
focus on higher level skills in US and education as well
as sharing expertise and best practice.
There was unanimous agreement that it was neces-
sary for Rheumatology ultrasonographers and trainers/
mentors to be able to demonstrate their on-going train-
ing, practice and thereby maintenance of skills and
competence. This is in line with General Medical
Council’s expectations of Good Clinical Practice and the
Royal College of Radiologists’ recommendations for
safe and effective US practice [11, 20, 21]. This should
be reviewed locally as part of the established annual ap-
praisal process. The final activity was to agree priority
actions for the BSRUSSIG. These are summarized in
Table 2.
TABLE 2 Agreed priorities for the BSRUSSIG
a. Already implemented
I. Development of blended learning modules in the following
areas:
1. Acute hot swollen joint
2. Inflammatory arthritis (hands and feet)
3. Upper limb
4. Lower limb
5. Large vessel vasculitis
II. Development of eLearning content covering key know-
ledge areas for basic and advanced levels and ensure
these are available to compliment practical training and
facilitate lifelong learning
III. Restructuring the existing BSR US courses to prioritize
practical scanning skills
b. In development
I. Support the development of trainers/mentors and facili-
tate a regional network of consistent training and practice.
II. Support regular Teach the Teachers events for trainers/
mentors
III. Consider assessment strategy and process
BSR: British Society for Rheumatology; BSRUSSIG: British
Society for Rheumatology Ultrasound Special Interest
Group.
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Conclusion
The BSRUSSIG supports the published evidence that in
certain clinical settings, patients will benefit from an US
assessment by their assessing rheumatology health pro-
fessional at the point of care. To facilitate this, we pre-
sent a series of recommendations developed by expert
consensus for rheumatology healthcare professionals
learning and performing ultrasonography in UK clinical
practice. This will provide a standard framework for
modern US training and practice; inform and support
the development of rheumatology training curricula and
education programmes; and ensure ongoing best quality
and safe practice in rheumatology US.
This work was completed for the British Society for
Rheumatology Ultrasound Special Interest Group. A full
list of group members can be found in the Supplementary
Data S1, available at Rheumatology online.
The discussion group meeting was hosted at the BSR
offices and refreshments and travel expenses were funded
by an educational grant from Eli Lilly. Eli Lilly had no input
in the content/agenda/process or this manuscript.
Data availability statement
Data are available upon reasonable request by any
qualified researchers who engage in rigorous, independ-
ent scientific research, and will be provided following re-
view and approval of a research proposal and Statistical
Analysis Plan (SAP) and execution of a Data Sharing
Agreement (DSA). All data relevant to the study are
included in the article.
Acknowledgements
We are grateful to the following colleagues for their input
in the Delphi process: Tazeen Ahmed, Kaushik
Chaudhuri, Bhaskar Dasgupta, Sandeep Dahiya, Susie
Earl, Andrew Filer, Toby Garood, Alison Hall, Ravik
Mascarenhas, Phil Platt, Ilfita Sahbudin, Venkatachelam
Srinivasan, Allister Taggart, Robert Thompson and
Ernest Wong.
Funding: No specific funding was received from any
funding bodies in the public, commercial or not-for-
profit sectors to carry out the work described in this
manuscript.
Disclosure statement: The authors have declared no
conflicts of interest.
Supplementary data
Supplementary data are available at Rheumatology
online.
References
1 Kane D, Balint PV, Sturrock R, Grassi W.
Musculoskeletal ultrasound—a state of the art review in
5
Ismaël Atchia et al.
rheumatology. Part 1: current controversies and issues in
the development of musculoskeletal ultrasound in
rheumatology. Rheumatology (Oxford) 2004;43:823–8.
2 Karim Z, Wakefield RJ, Conaghan PG et al. The impact
of ultrasonography on diagnosis and management of
patients with musculoskeletal conditions. Arthritis Rheum
2001;44:2932–3.
3 Kane D, Grassi W, Sturrock R, Balint PV.
Musculoskeletal ultrasound—a state of the art review in
rheumatology. Part 2: clinical indications for
musculoskeletal ultrasound in rheumatology.
Rheumatology (Oxford) 2004;43:829–38.
4 Schmidt WA. Ultrasound in the diagnosis and
management of giant cell arteritis. Rheumatology
(Oxford) 2018;57:ii22–ii31.
5 Dasgupta B, Cimmino MA, Maradit-Kremers H et al.
Provisional classification criteria for polymyalgia
rheumatica: a European League Against Rheumatism/
American College of Rheumatology collaborative
initiative. Ann Rheum Dis 2012;71:484–92.
6 Backhaus M, Burmester G, Gerber T et al. Guidelines for
musculoskeletal ultrasound in rheumatology. Ann Rheum
Dis 2001;60:641–9.
7 Naredo E, D’Agostino MA, Conaghan P et al. Current
state of musculoskeletal ultrasound training and
implementation in Europe: results of a survey of experts
and scientific societies. Rheumatology (Oxford) 2010;49:
2438–43.
8 Garrood T, Platt P. Access to training in musculoskeletal
ultrasound: a survey of UK rheumatology trainees.
Rheumatology (Oxford) 2010;49:391.
9 Estrach C, Thompson RN. Why aren’t we all
doing ultrasound? Rheumatology (Oxford) 2009;48:
1019–20.
10 Terslev L, Hammer HB, Torp-Pedersen S et al. EFSUMB
minimum training requirements for rheumatologists
performing musculoskeletal ultrasound. Ultraschall Med
2013;34:475–7.
11 The Royal College of Radiologists. Ultrasound training
recommendations for medical and surgical specialties.
2nd edn. London: The Royal College of Radiologists,
2012.
6 https://academic.oup.com/rheumatology
Downloaded from https://academic.oup.com/rheumatology/advance-article/doi/10.1093/rheumatology/keaa656/5964141 by San Francisco State University Library user on 11 November 2020
12 Taggart A, Filippucci E, Wright G et al. Musculoskeletal
training in the UK: the Belfast experience. Rheumatology
(Oxford) 2006;45:102–5.
13 Akram Q. Training issues in ultrasound and the benefits
of an International Fellowship. Rheumatology (Oxford)
2018;57:947–8.
14 Möller I, Janta I, Backhaus M et al. The 2017
EULAR standardised procedures for ultrasound
imaging in rheumatology. Ann Rheum Dis 2017;76:
1974–9.
15 Atchia I, Birrell F, Kane D. A modular, flexible training
strategy to achieve competence in diagnostic and
interventional musculoskeletal ultrasound in patients with
hip osteoarthritis. Rheumatology (Oxford) 2007;46:
1583–6.
16 Micu MC, Alcalde M, Sáenz JI et al. Impact of
musculoskeletal ultrasound in an outpatient
rheumatology clinic. Arthritis Care Res (Hoboken) 2013;
65:615–21.
17 Situ-LaCasse E, Grieger RW, Crabbe S et al. Utility of
point-of-care musculoskeletal ultrasound in the evalu-
ation of emergency department musculoskeletal path-
ology. World J Emerg Med 2018;9:262–6.
18 Schmidt WA. The ultrasound halo sign of temporal
arteries: is it always giant cell arteritis? Rheumatology
(Oxford) 2019;58:1898–9.
19 Report from the UK shape of training steering group.
https://www.gmc-uk.org/-/media/documents/report-
from-the-uk-shape-of-training-steering-group_pdf-
79105880.pdf. Published 29 March 2017 (30 March
2020, date last accessed).
20 Good Medical Practice. General Medical Council.
https://www.gmc-uk.org/ethical-guidance/ethical-
guidance-for-doctors/good-medical-practice/domain-1—
knowledge-skills-and-performance (30 March 2020, date
last accessed).
21 Guidelines for professional Ultrasound Practice. Society
and College of Radiographers and British Medical
Ultrasound Society. Revision 4. 2019. https://www.bmus.
org/static/uploads/resources/Guidelines_for_
Professional_Ultrasound_Practice_v3_OHoz76r.pdf (30
March 2020, date last accessed).