Clinical Rheumatology (2020) 39:651–657

https://doi.org/10.1007/s10067-019-04725-9

REVIEW ARTICLE

The rheumatology physical examination: making clinical

anatomy relevant
Pablo Villaseñor-Ovies 1,2,3 & José Eduardo Navarro-Zarza 4 & Juan J. Canoso 5,6

Received: 30 May 2019 / Revised: 24 July 2019 / Accepted: 30 July 2019 / Published online: 24 August 2019
# International League of Associations for Rheumatology (ILAR) 2019

Abstract
To review the importance of physical examination in the diagnostic process of musculoskeletal conditions vis-a-vis the development of
sensitive and powerful technologies such as MRI and high-resolution ultrasound. Because the physical examination of the musculo-
skeletal system is an exercise of applied clinical anatomy, the authors tested, in one-to-one practical examinations, the basal knowledge
of musculoskeletal anatomy of rheumatology trainees, rheumatologists, and other professionals of musculoskeletal medicine. The
results of the authors’ surveys were disappointing, with a correct response rate of 50 to 60% depending on the locales. To correct this
deficit, the authors gave many active-learning, case-centered seminars throughout the Americas and some overseas that may have
fostered an interest in the study of clinical anatomy. There was an increased interaction between anatomy departments and clinicians,
and that daily use of clinical anatomy would make anatomy relevant, improve clinical skills, and probably reduce the overall costs of
the health care system.

Key Points
• Knowledge of musculoskeletal anatomy is the basic diagnostic tool in the regional pain syndromes
• Knowledge of musculoskeletal anatomy helps understand the musculoskeletal involvement in the regional and systemic rheumatic disorders
• An active-learning methodology was used since 2006 to review the anatomy that is relevant for rheumatology trainees and practitioners of musculoskeletal medicine
• A skilled, anatomy-based physical examination and a well-thought diagnostic hypothesis could reduce the use of expensive technologies that, being too
sensitive, may lead the unaware clinician astray

Synopsis Knowledge of musculoskeletal structure and function is essential

in the practice of rheumatology. The authors describe an active learning, case-
centered teaching methodology they have used in musculoskeletal clinical
anatomy seminars since 2006. These seminars, with an optimal participant
to instructor ratio of 10 to one, are based on case discussions and the cross-
examination of participants and instructors. Pre-seminar surveys have consis-
tently revealed a minimal recollection of the musculoskeletal anatomy as
taught in medical school. There is no proof of the long-term efficacy of the
method. However, the consistency of encouraging participants’ comments
and the many invitations to replicate the seminars at regional and national
rheumatologic meetings indicate a favorable perception of the method.
Indeed, the short-term efficacy of the method was shown in three studies.
Part of the Topical Collection entitled ‘Empowering Medical Education
to Transform: Learnings from an international perspective’

* Pablo Villaseñor-Ovies 2
Hospital Angeles Tijuana, Tijuana, Baja California, Mexico
pablovo@gmail.com
3
Universidad Autónoma de Baja California, Tijuana, Baja California,
Mexico
José Eduardo Navarro-Zarza
eduardo@navarrozarza.com.mx 4
Hospital General Dr. Raymundo Abarca Alarcón,
Juan J. Canoso Chilpancingo, Guerrero, Mexico
jcanoso@gmail.com 5
ABC Medical Center, Mexico City, Mexico
1 6
Hospital General de Tijuana, Tijuana, Baja California, Mexico Tufts University School of Medicine, Boston, MA, USA
652
Keywords Active learning . Cross-examination of participants and instructors . Musculoskeletal anatomy . Physical examination .
Regional pain syndromes
Clinical anatomy in rheumatology
The subject of clinical anatomy in the practice of rheumatology
in 2019 seems to be an outdated idea. Is there still a place for
musculoskeletal disease localization and characterization in the
era of magnetic resonance imaging and high-resolution ultra-
sound? Notwithstanding the technological revolution that has
transformed the field of diagnostic medicine in the last 50 years,
physical examination (PE) while evolving itself remains the
foundation of effective diagnosis. Unfortunately, PE remains a
neglected aspect of scientific medicine [1]. The new technolo-
gies, while representing a great advance in diagnosis and dis-
ease understanding, have by no means lessened the need for an
accurate clinical diagnostic evaluation. The responsible use of
these and other highly sensitive imaging technologies create a
more profound dependence on PE, as advanced imaging may
uncover anatomical anomalies not germane to the actual clini-
cal problem (and often of no clinical relevance) [2–4]. These
may be pursued obstinately unless a thorough understanding of
the clinical picture places them in a proper perspective.
Rheumatology is a clinical discipline that lacks a specific
organ or system constraint. Most of the rheumatic diseases are
systemic and can potentially involve different organs, simulta-
neously or in sequence. This level of complexity demands the
creation of a framework that allows an intelligent, reasonable,
and parsimonious approach based upon accurate history taking
and a comprehensive PE. Consequently, clinical rheumatolo-
gists need to be thorough and diligent in the exploration of the
different organs of the human body, especially including the
skin; the eyes; the ears, nose and throat; the lymph nodes; the
cardiovascular and pulmonary systems; the abdomen; the blood
vessels; and the central and peripheral nervous systems [5].
Unique to rheumatology is an underscored focus on the mus-
culoskeletal (MSK) system. Whether dealing with a systemic
disease with secondary MSK involvement, or a primary disease
of the MSK system, it is the evaluation of MSK signs and
symptoms that often leads to a definitive diagnosis. The mus-
culoskeletal diagnostic process begins by determining which
structures are involved. Is it the joint, proper, or a periarticular
structure? Is it an intra-synovial or an extra-synovial structure
enclosed within a joint (e.g., meniscal or a labral tear)? Is there
involvement of tendons, entheses, bursae, or synovial sheaths?
This essential, usually very early question in the diagnostic
workup of patients is almost always answerable through an
anatomy-oriented physical examination.
Clinical anatomy is the engagement between theoretical
knowledge of the structure and function of the human body
and the many activities involved in patient care, including PE.
Clin Rheumatol (2020) 39:651–657
It is an understanding of the human body not as a plain mass of
tissue to be seen, felt, and moved, but also to be known and
understood [6]. An anatomical approach to PE enhances the
rheumatologic clinical examination skills in many ways: (1)
The ability to precisely identify the anatomic component affect-
ing a patient delivers a more insightful understanding of symp-
toms and physical findings, simplifies nosology, narrows dif-
ferential diagnosis, and reduces the use of expensive, often
unavailable diagnostic tests. (2) A background of clinical anat-
omy is essential in the use of musculoskeletal ultrasound [7, 8].
(3) The merging of information gathered from patient interro-
gation, examination, and that which comes from complemen-
tary imaging evaluation is facilitated when this integration oc-
curs in the context of sophisticated anatomical understanding.
(4) PE-oriented infiltration of specific targets in the MSK sys-
tem is not safe without a basic anatomical knowledge.
MSK anatomy competency gaps
Many groups have shown that the competency in clinical anato-
my of the MSK system is deficient at various levels of medical
education, up to and including rheumatology trainees and prac-
ticing rheumatologists. In Europe, only 52.7% of a group of 170
young rheumatologists were satisfied with their abilities in anat-
omy, and the mean self-assessment on this subject was 4.8/10 [9].
Recently, a small group of rheumatologists in the UK revealed
very low levels of confidence in MSK surface anatomy (52%),
performing intra-articular injections (57%), and performing an
examination of the limbs (59%) before completion of an MSK
anatomy course [10]. Between 2009 and 2012, the authors’
group conducted a preworkshop practical evaluation of clinical
anatomy on 170 attendees to clinical anatomy seminars that were
held in Argentina, Chile, Ecuador, El Salvador, México, USA,
and Uruguay. The attendees, mostly rheumatologists (33%) and
rheumatology trainees (45%), were asked to identify or demon-
strate the action of 20 different anatomical items on their bodies
or the bodies of the instructors undertaking the test, such as
identify the dorsal (Lister’s) tubercle of the radius, demonstrate
the action of the dorsal interossei muscles, identify the insertion
of pes anserinus, and demonstrate the action of the subtalar joint.
The overall mean percentile score was 46.6 ± 19.9, with only 8%
of participants scoring above the minimum approbatory mark of
70% [11]. This study demonstrates that among a large and di-
verse group of rheumatologists from different American coun-
tries, there is an unsettling lack of basic knowledge in clinical
anatomy. In other words, based on published studies originating
in Europe and America, there appears to be a generalized
Clin Rheumatol (2020) 39:651–657
deficiency of anatomical knowledge among rheumatologists and
rheumatology trainees.
The Mexican Group for the Study of MSK
clinical anatomy
The authors’ group was the recipient of the 2010 ILAR 1-year
Grant to Advance Rheumatology in Developing Countries, and
from 2010 to 2015, aiming to enhance training and knowledge
on MSK, 34 clinical anatomy seminars were conducted in ten
Latin American countries and the USA, accounting for over 900
participants. Additionally, two short versions of the seminar have
been given at the American College of Rheumatology meetings
since 2005 to the present, and individual members of our group
delivered several additional seminars in the USA, Spain, and
South America. During these seminars, a simple methodology
was followed [12, 13]: After a clinical vignette is presented de-
scribing ordinary cases such as a man with rheumatoid tenosyn-
ovitis or a woman with carpal tunnel syndrome, the pertinent
anatomical items are reviewed in slides that depict the anatomical
structures involved, their function, and their clinical relevance.
Finally, a hands-on, practical review of these structures include
their surface landmarks, the examination techniques, and when
appropriate, a simulation of infiltration techniques. Practical re-
views are done in small groups, aiming to maintain a 1:10 in-
structor to participant ratio. Participants are encouraged to bring
loose, casual clothing, and sandals, as instructors do so that ev-
eryone, teachers, and attendees became a living model for each
other. This learning format, while seemingly informal, allows an
appreciation of the variability of human anatomy. It is our obser-
vation that there is a profound dissociation between the tradition-
al teaching of anatomy, and the ‘barefoot anatomy’ that the au-
thors have implemented, that in turn serves to highlight the lived
experience of structure as it relates to function. Thus, from the
viewpoint of learning methodologies, our system is a student-
centered, active learning approach that (a) is case-based, (b) in-
cludes a direct collaboration between instructors and learners
(extended peer-examination), (c) often leads to conceptual
changes such as where is the transverse carpal ligament located,
and (d) is based on the discovery, often reaching the point of
surprise, of anatomical structures both in the body of instructors
and learners [14]. An example of the latter is that one wraps a
string around the wrist, the transverse carpal ligament is distal to
the string, and the extensor retinaculum proximal to the string.
By intertwining the theoretical knowledge of human anato-
my and the practical skills of PE in a sequence where didactic
information is followed by practical demonstration, the authors
believe that this educational format adapts very well to Kolb’s
adult learning model [15]. The result is that learners not only do
a PE, but they understand the physical exam that they are doing.
By presenting prototypical clinical vignettes, past experiences
are evoked. Reflective observation begins with the first slide
653
that follows the case presentation, which is always entitled
“Relevant anatomy” and progresses through the initial steps
of practical review of structures where the instructor performs
a practical demonstration. Abstract conceptualization is encour-
aged by facilitating the association of anatomical concepts with
physical findings; this is reinforced by the discussion of classi-
cal findings in PE, limits of the PE as a discrimination tool, and
alternative diagnoses. A few remarks on additional testing and
treatment may be discussed, but the emphasis is placed on
anatomy and PE. Concrete experiences with these newly ac-
quired concepts will happen with future patient encounters.
Nonetheless, the workshop format allows the participants to test
the applicability of knowledge in what the authors call “practi-
cal review of structures” where the goal is to test the anatomical
concepts and how to apply them to improve PE skills.
While all anatomical structures related to MSK diseases are
reviewed in these seminars, the emphasis is placed on the soft
tissues including skin creases, fasciae, pulleys, muscles, tendons,
ligaments, bursae, and nerves. Throughout the years, this educa-
tional proposal has received uniformly positive feedback, and it
has been shown to enhance the self-assessed competence in ex-
amination skills and clinical anatomy knowledge [16].
Moreover, in 2015, the authors tested the capability of the clinical
anatomy workshop to improve the learning of practical clinical
anatomy for end-of-1st year orthopedic and rheumatology fel-
lows from different programs in Mexico City [17]. It was found
that both groups improved their ability to correctly identify the
key anatomical structures and functions tested. Out of a total of
20 questions, the median of correct answers increased from 7 to
15 among the orthopedic fellows and from 5 to 12 among the
rheumatology fellows. Although statistically significant, this im-
provement was thought to be suboptimal, and its long-term ef-
fects are yet to be established. It was concluded that a more
substantial course of anatomy, based upon longitudinal reinforce-
ment throughout training, would be the ideal way of teaching
meaningful clinical anatomy. Not surprisingly, it was found that
the fellows of the only participating rheumatology program that
runs a formal clinical anatomy course showed significantly
higher scores in the pre- and post-workshop evaluations.
Since its creation, the authors’ group has championed the
incorporation of clinical anatomy teaching during rheumatolo-
gy training [11, 18]. Planning to assist in this undertaking, the
authors’ group plus five experienced, academic rheumatologists
from Canada, England, Spain, and the USA winnowed a com-
prehensive list of specific anatomical concepts, facts, and ideas
using a single-round, online, Delphi exercise. A total of 560
items related to the upper extremity and 470 items that covered
the pelvis, lower extremity, and gait were graded by its impor-
tance in the practice of clinical rheumatology utilizing a Likert-
type scale. A total of 115 (20%) of the upper extremity and 101
(21%) of the lower extremity items reached the pre-specified
criteria of acquiesced importance [19, 20]. The authors believe
that through this exercise, they have prioritized the anatomical
654
knowledge that is most relevant to the practice and care of
patients with rheumatic diseases and thus helped define the field
of anatomy that is basic for rheumatologic training and curric-
ulum development.
Real-life examples: usefulness of an
anatomy-oriented PE
Of the many useful clinical maneuvers that are based upon an
anatomical understanding of the MSK system and that are
available not just to rheumatologists, orthopedic surgeons, and
neurologists, the authors picked two examples of the clinical
usefulness of the “tenodesis effect,” a time-honored maneuver
to distinguish tendon rupture from paralysis. Tenodesis refers to
the effect that extrinsic hand muscles exert through their intact
Fig. 1 a An asymptomatic lumb
was noted in the dorsoateral
forearm just distal to the elbow. b
Tenodesis effect on all the digits,
including the thumb. Digit
extension during passive wrist
flexion and digit flexion during
passive wrist extension
Clin Rheumatol (2020) 39:651–657
tendons on the relative digit position during wrist flexion and
extension. The patient is asked to flex and extend the wrist
while keeping the fingers relaxed. When extensor tendons are
intact, wrist flexion will produce digital extension, and with
wrist extension, the digits will flex. This simple maneuver de-
termines the integrity of the flexor and extensor tendons and
helps distinguish tendon rupture from motor neuropathy [21].
Patient 1 is a 72-year old woman consulted because of a
dropped right thumb that occurred suddenly following a transient
pain and swelling at her right dorsal wrist. An asymptomatic
lump was noted in the dorsolateral forearm just distal to the
elbow (Fig. 1a). Various opinions had been given, and it had
been agreed that the extensor pollicis longus tendon had broken
at the wrist, with the lump resulting from the retracted muscle.
However, because of the extensor pollicis longus muscle inserts
in the mid-forearm, another explanation was needed.
Clin Rheumatol (2020) 39:651–657
Fig. 2 a Man with a dropped
thumb and a possible diagnosis of
extensor pollicis longus tendon
rupture. b. Allodynia was noted
over the thumb and radial wrist.
Two days later, herpes zoster was
noted over lateral arm and
forearm
Furthermore, upon directed questioning, there had been some
painful dorsal swelling on the left wrist. The salient finding on
examination (tenodesis effect) was that upon passive palmar flex-
ion of the right wrist, all fingers extended including the thumb,
and on passive dorsiflexion, all fingers flexed (Fig. 1b) [21, 22].
Thus, a tendon rupture was ruled out. Additionally, when the
patient was asked to point with the right index finger, she was
unable to align the finger with its metacarpal, but rather followed
the proximal phalanx of the lateral fingers, suggesting a concur-
rent palsy of the extensor indicis. Thus, the patient had a palsy of
two muscles that are innervated by the deep branch of the radial
nerve. The author’s attention was therefore brought to the prox-
imal forearm mass, which was firm, non-tender, and about 5 cm
in diameter. An MRI showed a convoluted cyst that appeared to
originate in the proximal radioulnar joint. The rheumatoid factor
test was positive, and there was a high titer of anti-citrullinated
peptide antibodies. Subcutaneous methotrexate and low-dose
prednisone were started, and the patient was advised to have
the cyst removed to free the nerve. Because surgery was delayed,
the cyst was injected with 2 ml of lidocaine 2% plus 2 ml of a
depo-steroid. Within 1 min, the wrist and all fingers dropped,
further supporting compression of the deep branch of the radial
nerve. Thirty minutes later, the added palsy resolved.
Patient 2, which is a 56-year old man, was referred with a
dropped thumb and a possible diagnosis of extensor pollicis
longus tendon rupture (Fig. 1b). Tenodesis effect was present.
Allodynia was noted over the thumb and radial wrist. Two days
later, herpes zoster was noted over lateral arm and forearm (Fig.
1b). He was treated, and there was a full recovery of function.
The individuality of PE techniques
During their clinical anatomy workshops, the authors de-
scribed anatomy-oriented methods and techniques of exami-
nation of the MSK system. However, they soon learned that
no single method or technique in PE is comprehensive. For
instance, in every workshop, upon showing a technique for a
specific examination, many participants would offer a differ-
ent method with variations that were often subtle but some-
times shockingly remarkable. The authors did not reject those
655
teachings but rather challenged themselves by analyzing their
theoretical and often practical virtues. Some of these methods
were discarded, but some were anatomically congruent and
clinically accurate. One such case entailed the infiltration of
Morton’s neuroma. The traditional method called for a dorsal
approach, piercing through the intermetatarsal ligament,
which lies plantar in the intermetatarsal space (Fig. 2a) [23].
Anatomically, this makes little sense, since the needle travels a
long distance and must penetrate a thick, sensitive structure.
Dr. Lilia Andrade, a noted Mexican Rheumatologist, attend-
ing one of the workshops, suggested an approach that required
the needle to be placed between the adjacent toes of the space
involved while having them spread using the non-dominant
hand and aiming the needle to the neuroma, if palpable (Figs.
2b, 3a, and 3b). This entry site, while eliciting gruesome faces
among workshop attendees, is in fact harmonious with ana-
tomical knowledge and almost painless. With the use of ultra-
sound, we have observed that using a 31G, 0.8 cm needle,
Morton’s neuroma is reached using this approach. This and
other examples remind us that the clinical examination re-
mains a personal activity that is irremediably influenced by
anecdotal factors, individual experiences, and uniquely deter-
mined characteristics of the patient such as age, sex, and joint
stiffness or laxity. It must be acknowledged that while this
enriches the technical diversity of PE, it is also responsible,
at least in part, for the poor reproducibility and accuracy that
has traditionally stigmatized clinical data as scientifically un-
reliable [24, 25]. Consider how laboratory tests are performed.
Every step is a prescribed component of a checklist-based
process, from sampling to handling the sample and to
performing the test itself and reporting a result. There are
many reasons that explain why clinical medicine has not come
close to reaching such high degrees of standardization, but this
does not mean that clinicians should not aspire to standardize
their PEs. In medicine, students are often taught that informa-
tion that derives from a process that is heavily operator- and
technique-dependent equals dubious information, but tech-
nique dependency should not be synonymous with unreliabil-
ity. The ever-shorter time spent per patient that is currently
forced upon physicians by the health care system tends to
abbreviate the PE to only the painful parts. One of the authors
656 Clin Rheumatol (2020) 39:651–657

Fig. 3 a The traditional method called for a dorsal approach, piercing that required the needle to be placed between the adjacent toes of the
through the intermetatarsal ligament, which lies plantar in the space involved while having them spread using the non-dominant hand
intermetatarsal space. Reproduced from Bossley CJ and Cairney PC, J and aiming the needle to the neuroma, if palpable
Bone Joint Surg B 1980, with permission of the publisher. b An approach
Clin Rheumatol (2020) 39:651–657
(JJC), attempting to achieve at least internal consistency, ex-
amines all patients summarily in the same fashion, leaving the
painful part(s) to last. The yield of an expanded PE may be
significant. The impact of this system on clinical outcomes
remains unknown. However, MSK and other comorbidities
are often found that help diagnosis. As an example, among
1223 women who did not have a breast examination in the
past year or could have a paraneoplastic syndrome seen in a
private rheumatology office, seven cases of breast cancer were
found by breast palpation [26] and three additional cases were
found in the past 9 years. Initiatives like the Stanford 25 and
the Society of Bedside Medicine foster and promote PE tech-
nique education and evaluation are firm steps toward
standardization.
Conclusion
There is a major gap between the anatomy being taught
in anatomy departments and the anatomy that is useful
to the clinician. Efforts are being made to increase the
clinical relevance of the anatomy courses, and the sem-
inars herein described could go a long way toward that
desirable goal.
Compliance with ethical standards
Disclosures None.
References
1. Zaman J, Verghese A, Elder A (2016) The value of physical exam-
ination: a new conceptual framework. South Med J 109:754–757
2. Neviaser RJ (2000) Glenohumeral motion in patients with rotator
cuff tears: a comparison of asymptomatic and symptomatic shoul-
ders. J Shoulder Elb Surg 9:6–11
3. Iagnocco A, Filippucci E, Sakellariou G, Ceccarelli F, Di Geso L,
Carli L, Riente L, Delle Sedie A, Valesini G (2013) Ultrasound
imaging for the rheumatologist XLIV. Ultrasound of the shoulder
in healthy individuals. Clin Exp Rheumatol 31:165–171
4. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S
(1990) Abnormal magnetic-resonance scans of the cervical spine in
asymptomatic subjects. A prospective investigation. J Bone Joint
Surg Am 72:1178–1184
5. Panush RS (2011) Why rheumatology and the care of patients with
rheumatic diseases are important, interesting, and exciting.
Rheumatologist 5:65–72
6. Kalish RA, Canoso JJ (2007) Clinical anatomy: an unmet agenda in
rheumatology training (Editorial). J Rheumatol 34:1208–1211
7. Iagnocco A, Naredo E, Bijlsma JW (2013) Becoming a musculoskel-
etal ultrasonographer. Best Pract Res Clin Rheumatol 27:271–281
8. Cannella AC, Kissin EY, Torralba KD, Higgs JB, Kaeley GS (2014)
Evolution of musculoskeletal ultrasound in the United States: im-
plementation and practice in rheumatology. Arthritis Care Res
(Hoboken) 66:7–13
9. Bandinelli F, Bijlsma JW, Ramiro MS, Pia E, Goekoop-Ruiterman
YP, Sivera F, Molto Revilla A, Marinescu C, Rimar D, Norkuviene
657
E, Mayer M, Duarte Marques CC, da Silva JA, Cutolo M (2011)
Rheumatology education in Europe: results of a survey of young
rheumatologists. Clin Exp Rheumatol 29:843–845
10. Blake T, Marais D, Hassell AB, Stevenson K, Paskins Z (2017)
Getting back to the dissecting room: an evaluation of an innovative
course in musculoskeletal anatomy for UK-based rheumatology
training. Musculoskeletal Care 15:405–412
11. Navarro-Zarza JE, Hernández-Díaz C, Saavedra MA, Alvarez-
Nemegyei J, Kalish RA, Canoso JJ, Villaseñor-Ovies P (2014)
Preworkshop knowledge of musculoskeletal anatomy of rheuma-
tology fellows and rheumatologists of seven North, Central, and
South American countries. Arthritis Care Res (Hoboken) 66:270–
276
12. Torralba KD, Villaseñor-Ovies P, Evelyn CM, Koolaee RM, Kalish
RA (2015) Teaching of clinical anatomy in rheumatology: a review
of methodologies. Clin Rheumatol 34:1157–1163
13. Kalish RA, Canoso JJ (2012) Development of the seminar.
Reumatol Clin 8(Suppl 2):10–12
14. Michael J (2006) Where’s the evidence that active learning works?
Adv Physiol Educ 30:159–167
15. Taylor DCM, Hamdy H (2013) Adult learning theories: implica-
tions for learning and teaching in medical education: AMEE guide
no. 83. Med Teacher 35(11):e1561–e1572
16. Saavedra MÁ, Navarro-Zarza JE, Alvarez-Nemegyei J, Canoso JJ,
Kalish RA, Villaseñor-Ovies P, Hernández-Díaz C (2015) Self-
assessed efficacy of a clinical musculoskeletal anatomy workshop:
a preliminary survey. Reumatol Clin 11:224–226
17. Saavedra MA, Villaseñor-Ovies P, Harfush LA, Navarro-Zarza JE,
Canoso JJ, Cruz-Domínguez P, Vargas A, Hernández-Díaz C,
Chiapas-Gasca K, Camacho-Galindo J, Alvarez-Nemegyei J,
Kalish RA (2016) Educational impact of a clinical anatomy work-
shop on 1st-year orthopedic and rheumatology fellows in Mexico
City. Clin Rheumatol 35:1299–1306
18. Canoso JJ (2011) Clinical anatomy: a basic discipline for the rheu-
matologist [Spanish]. Reumatol Clin 7:215–216
19. Villaseñor-Ovies P, Navarro-Zarza JE, Saavedra MÁ, Hernández-
Díaz C, Canoso JJ, Biundo JJ, Kalish RA, de Toro Santos FJ,
McGonagle D, Carette S, Alvarez-Nemegyei J (2016) A survey
of anatomical items relevant to the practice of rheumatology: upper
extremity, head, neck, spine, and general concepts. Clin Rheumatol
35:3025–3030
20. Hernández-Díaz C, Alvarez-Nemegyei J, Navarro-Zarza JE,
Villaseñor-Ovies P, Kalish RA, Canoso JJ, Vargas A, Chiapas-
Gasca K, Biundo JJ, de Toro Santos FJ, McGonagle D, Carette S,
Saavedra MÁ (2017) A survey of anatomical items relevant to the
practice of rheumatology: pelvis, lower extremity, and gait. Clin
Rheumatol 36:2813–2819
21. Millender LH, Nalebuff EA, Holdsworth DE (1973) Posterior
interosseous nerve syndrome secondary to rheumatoid synovitis. J
Bone Joint Surg Am 55:375–377
22. Shah KN, Hodax JD, Katarincic JA (2016) Evaluating a flexor
tendon laceration with the tenodesis effect. J Pediatr 176:214–
214.e1
23. Waldman S (2007) Atlas of pain management injection techniques.
Saunders Elsevier, Philadelphia
24. Koran LM (1975) The reliability of clinical methods, data and
judgments (second of two parts). N Engl J Med 293(14):695–701
25. Koran LM (1975) The reliability of clinical methods, data and
judgments (first of two parts). N Engl J Med 293:642–646
26. Canoso JJ (2012) Should rheumatologists palpate the breast? Letter
J Rheumatol 39:1296
Publisher’s note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.