An overview of musculoskeletal ultrasound. Techniques, applications, and diagnostic value in musculoskeletal disorders

Nº de DOI:10.34896/RSI.2025.42.95.001

AUTHORS

1. Leandro Olivero Hurtado Herdoiza. General Practitioner. Attached to the San Vicente de Paúl Basic Hospital. Independent Researcher at the Matilde Hidalgo of Procel Research and Teaching Department. Graduate of the State University of Guayaquil. (⁠Arenillas-Ecuador). https://orcid.org/0000-0001-9932-300X
2. Elías Josue Del Pezo Matovelle. General Practitioner. Attached to APROFE. Graduate of the University of Guayaquil. (⁠Guayaquil-Ecuador). https://orcid.org/0009-0003-2558-177X
3. Luis Alejandro Guevara Vergara. General Practitioner. Attached to Monte Sinaí General Hospital. Graduate of the University of Guayaquil. (⁠Guayaquil -Ecuador). https://orcid.org/0009-0003-5078-3998
4. Sofia Elizabeth Cadena Farinango. General Practitioner. Attached to Carlos Andrade Marín Hospital. Graduate of the University of the Americas. (⁠Quito -Ecuador). https://orcid.org/0009-0003-4872-7014
5. Ronie Hugo Crespo Tonato. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the Regional Autonomous University of Los Andes. (Salcedo -Ecuador). https://orcid.org/0009-0003-4070-9575

ABSTRACT

As research continues to delineate its capabilities, this paper aims to provide a comprehensive overview of the techniques employed in musculoskeletal ultrasound, explore its diverse clinical applications, and evaluate its diagnostic accuracy and impact in managing musculoskeletal disorders, emphasizing its integral role in modern musculoskeletal medicine.

KEY WORDS

Musculoskeletal ultrasound, ultrasound assessment of musculoskeletal, diagnostic imaging, ultrasound techniques, soft tissue disorders, tendon injuries, joint effusion and diagnostic accuracy.

RESUMEN

A medida que la investigación continúa delineando sus capacidades, este artículo tiene como objetivo proporcionar una descripción general integral de las técnicas empleadas en la ecografía musculoesquelética, explorar sus diversas aplicaciones clínicas y evaluar su precisión diagnóstica y su impacto en el manejo de los trastornos musculoesqueléticos, enfatizando su papel integral en la medicina musculoesquelética moderna.

PALABRAS CLAVE

Ecografía musculoesquelética, evaluación ecográfica del aparato locomotor, diagnóstico por imagen, técnicas ecográficas, patologías de tejidos blandos, lesiones tendinosas, derrame articular y precisión diagnóstica.

INTRODUCTION

Musculoskeletal ultrasound (MSK US) has emerged as a vital imaging modality in the evaluation and management of various musculoskeletal disorders, offering real-time, dynamic, and high-resolution visualization of soft tissue structures. As a non-invasive technique, MSK US provides distinct advantages over traditional imaging methods such as MRI and CT, including portability, cost-effectiveness, and the ability to perform immediate, bedside assessments that facilitate prompt clinical decision-making. Fundamental principles of musculoskeletal ultrasound imaging revolve around the transmission and reception of high-frequency sound waves, which generate detailed images of muscles, tendons, ligaments, nerves, and joint structures; optimizing probe selection, settings, and scanning protocols tailored to different anatomical regions is essential for accurate diagnosis. Clinicians frequently utilize MSK US in diagnosing conditions such as tendinopathies, ligament injuries, bursitis, and soft tissue masses, often guiding interventional procedures like injections and aspirations with enhanced precision. The diagnostic value of MSK US lies in its high sensitivity and specificity for soft tissue injuries, enabling differentiation among various pathologies such as tears, tendinopathies, and inflammatory conditions, thereby significantly influencing treatment strategies and patient outcomes.

OBJECTIVE

To provide a comprehensive overview of the techniques used in musculoskeletal ultrasound, explore its various clinical applications, and evaluate its diagnostic accuracy and impact on the management of musculoskeletal disorders, emphasising its integral role in modern musculoskeletal medicine.

METHODOLOGY

The methodology for this scientific review article, adopts a systematic and structured approach to identify, evaluate, and synthesize current literature on the use of ultrasound in the assessment of musculoskeletal (MSK) conditions. A comprehensive search is conducted across major scientific databases including PubMed, Scopus, Web of Science, and Embase to retrieve peer-reviewed articles published in English over the past 15 years. Search terms include combinations of keywords and MeSH terms such as “musculoskeletal ultrasound”, “ultrasound assessment of musculoskeletal”, “diagnostic imaging”, “ultrasound techniques”, “soft tissue disorders”, “tendon injuries”, “joint effusion” and “diagnostic accuracy.” Boolean operators are used to refine search results and ensure comprehensive coverage of the topic.

Studies are eligible for inclusion if they describe the techniques of musculoskeletal ultrasound, its clinical applications in diagnosing musculoskeletal disorders (e.g., tendonitis, bursitis, ligament tears, joint inflammation), and its comparative diagnostic performance versus other imaging modalities such as MRI or CT. The review includes original research articles, systematic reviews, meta-analyses, and clinical guidelines that evaluate the utility, sensitivity, specificity, or overall diagnostic value of MSK ultrasound in clinical practice.

The data are synthesized thematically and presented in narrative form, supported by summary tables and comparative analyses where appropriate. The review also examines advancements in ultrasound technology, such as high-frequency transducers and portable devices, and their impact on point-of-care applications. By integrating findings across diverse clinical scenarios, this article aims to provide a comprehensive overview of the current role, strengths, and limitations of musculoskeletal ultrasound in modern diagnostic practice, and to highlight areas where further research is warranted.

RESULTS

Techniques in Musculoskeletal Ultrasound:

What are the fundamental principles of musculoskeletal ultrasound imaging?

Musculoskeletal ultrasound imaging is grounded in several fundamental principles that collectively ensure its diagnostic efficacy and patient safety. At its core, this modality provides high-resolution, real-time visualization of muscles, tendons, ligaments, joints, nerves, and associated soft tissues, making it invaluable for both assessment and monitoring of musculoskeletal conditions^1,2. Central to safe practice is the application of the ALARA (As Low As Reasonably Achievable) principle, which guides practitioners to minimize ultrasound exposure while still achieving optimal image quality; this principle is closely linked with understanding and regulating the Mechanical Index (MI), an indicator of potential bioeffects, to further safeguard patient well-being during examination³. Moreover, technical proficiency in image optimization, including machine settings and proper patient positioning, is essential to ensure that clinicians obtain accurate, reproducible images without unnecessary or repeated scanning³. These core concepts are interconnected, as effective musculoskeletal ultrasound not only relies on a comprehensive anatomical understanding and visualization of both primary and peritendinous structures but also on the consistent application of safety and technical best practices^3,4. Thus, ongoing education and adherence to established guidelines are crucial interventions to promote high-quality imaging outcomes while prioritizing patient safety.

How are ultrasound probes and settings optimized for musculoskeletal assessments?

Optimizing ultrasound probes and settings for musculoskeletal assessments is a multifaceted process that hinges on careful alignment between the probe’s characteristics and the anatomical context of the examination. The selection of a probe must account for both tissue type and imaging depth, as musculoskeletal structures such as tendons, ligaments, and superficial muscles require high-resolution detail, which is best achieved with certain transducer types⁵. Linear array transducers, in particular, are preferred due to their capacity to deliver crisp, high-frequency images, making them exceptionally well-suited for evaluating superficial structures like tendons and ligaments⁶. The choice of probe, therefore, is not only about physical compatibility but also dictates the ultimate diagnostic quality, as improper selection may obscure critical anatomical details or pathology⁵. Furthermore, ultrasound systems offer a suite of adjustable settings—including frequency, gain, and focus—that must be tailored to the specific musculoskeletal target to maximize image clarity⁶. The synergy between appropriate probe selection and meticulous adjustment of imaging parameters is essential to ensure comprehensive assessment of musculoskeletal elements, thus facilitating more accurate diagnoses and informed clinical decisions. As imaging technology advances, regular training and protocol refinement are necessary to guarantee that sonographers and clinicians remain adept at leveraging these tools for optimal patient care.

What protocols are followed for scanning different anatomical regions?

MRI protocols for scanning different anatomical regions are meticulously tailored to account for the unique imaging requirements of each body area, ensuring optimal diagnostic outcomes and clinical utility⁷. These protocols act as comprehensive guides for both the scanner and the operator, specifying which sequences, coil configurations, and technical parameters are appropriate for the anatomical region under examination^7,8. For example, scanning the heart, lumbosacral plexus, knee, and brain not only involves the use of distinct coil types—such as a 30-channel body coil for the heart or a 64-channel head/neck coil for the brain—but also necessitates dedicated imaging sequences and scan parameters optimized for tissue contrast, spatial resolution, and acquisition speed⁸. Furthermore, established guidelines and master protocols—often named and coded according to the imaging phase, such as arterial or delayed—are used to ensure consistency and clarity in imaging workflows, particularly for complex regions like the abdomen^7,9. Despite these standardized approaches, variations can occur based on the scanning center’s practices and the specific clinical question, which may affect the comprehensiveness and reproducibility of the examination⁷. This interconnectedness between protocol structure, anatomical specificity, and institutional practices underscores the need for ongoing review, harmonization of guidelines, and improved labeling standards to optimize image quality, streamline workflows, and facilitate advanced applications such as AI-driven analysis⁷.

Clinical Applications of Musculoskeletal Ultrasound:

In which musculoskeletal conditions is ultrasound most commonly utilized?

Musculoskeletal ultrasound has become an indispensable imaging modality in the evaluation and management of a wide range of musculoskeletal conditions, with its application spanning across traumatic, inflammatory, and degenerative disorders of soft tissues and joints^10,11. Most notably, it is frequently employed to diagnose and monitor tendonitis, not only providing dynamic assessment but also helping clinicians guide treatment decisions in conditions affecting the tendons, such as the Achilles tendon and the rotator cuff^10,12,13. In addition to its pivotal role in tendon-related pathologies, ultrasound is highly valuable for identifying ligament injuries and sprains, offering real-time visualization of ligament integrity and associated abnormalities^12,13,14. Furthermore, the modality is extensively utilized for the evaluation of joint inflammation, allowing for the detection of synovitis, effusions, and other intra-articular changes, which can be crucial in the management of both acute and chronic joint conditions^12,14. Beyond tendons, ligaments, and joints, musculoskeletal ultrasound is also commonly used to diagnose soft tissue injuries such as muscle tears, reflecting its growing utility in sports medicine and rehabilitation settings^13,14. Given its broad scope and noninvasive nature, the integration of musculoskeletal ultrasound into clinical practice necessitates ongoing education for practitioners and investment in advanced equipment to ensure optimal patient care across the interconnected domains of musculoskeletal health.

How does ultrasound assist in guiding interventional procedures?

Building on the comprehensive visualization of musculoskeletal structures, ultrasound significantly enhances the guidance of interventional procedures by providing real-time imaging that allows clinicians to accurately identify target tissues and pathological areas for treatment¹⁵. This dynamic imaging capability is crucial for the precise localization of nerves, blood vessels, and other soft tissues, which not only improves the effectiveness of interventions but also minimizes the risk of complications arising from inadvertent injury to critical structures^15,16. The interconnection between accurate anatomical visualization and safe procedural guidance is further strengthened by ultrasound’s ability to enable accurate needle placement and continuous monitoring of the needle’s advancement, ensuring that therapeutic agents are delivered directly to the intended site without damaging adjacent tissues^15,16. Moreover, this real-time feedback loop supports the immediate confirmation of correct needle position before the administration of treatment, further reducing procedural errors and improving patient safety^15,16. These features collectively contribute to increased efficacy and safety in musculoskeletal interventions, facilitating the avoidance of complications and enhancing overall patient outcomes. To fully leverage these advantages, ongoing training and wider adoption of ultrasound guidance in interventional procedures should be prioritized, ensuring that clinicians can utilize this technology to its full potential for precise and safe patient care.

What are the advantages of ultrasound compared to other imaging modalities in musculoskeletal disorders?

Compared to other imaging modalities such as MRI and X-rays, musculoskeletal ultrasound offers a range of unique advantages that enhance both diagnostic accuracy and patient care, particularly when evaluating soft tissue structures like muscles, tendons, ligaments, and joints¹⁴. One of the core benefits is that ultrasound is a non-invasive technique that does not involve radiation exposure, making it especially advantageous for repeated assessments and follow-up examinations, which is crucial for chronic musculoskeletal conditions or monitoring therapeutic progress^13,14,17. This safety profile intersects with its patient-friendly nature, as ultrasound examinations are less likely to cause discomfort or claustrophobia, a common issue with MRI, and are preferred by many patients for conditions such as shoulder pain [18]. Furthermore, ultrasound enables real-time, dynamic imaging, allowing clinicians to assess musculoskeletal structures during movement and directly interact with patients to focus the examination on symptomatic areas, leading to a more comprehensive and tailored evaluation^14,18. This immediate feedback loop not only improves diagnostic accuracy but also fosters clearer communication between the clinician and patient regarding the source and nature of symptoms¹⁴. Additionally, ultrasound is a cost-effective and widely available modality, making it accessible to a broader range of patients and reducing the financial burden on healthcare systems compared to MRI or CT scans^13,14. These interconnections between safety, accessibility, dynamic assessment, and patient-centered care underscore the imperative for clinicians to integrate musculoskeletal ultrasound more broadly into diagnostic pathways, ensuring that patients benefit from its distinctive advantages in both routine and specialized musculoskeletal evaluations^13,14.

Diagnostic Value of Musculoskeletal Ultrasound:

How accurate is musculoskeletal ultrasound in detecting soft tissue injuries?

Musculoskeletal (MSK) ultrasound has emerged as a highly precise modality for the evaluation of soft tissue injuries, particularly in the context of tendon and ligament damage. Its real-time imaging capabilities allow for dynamic assessment, enabling clinicians to visualize both the anatomical structure and movement of soft tissues during examination. This advantage is especially relevant in acute injury scenarios, where subtle abnormalities such as partial tears or fiber disruptions might be missed by static imaging techniques. The interconnection between clinical assessment and radiological findings is strengthened by MSK ultrasound’s ability to provide immediate and detailed feedback, which can directly inform treatment decisions and rehabilitation strategies. Furthermore, the accuracy of MSK ultrasound supports its integration with other diagnostic tools, creating a comprehensive approach to patient care and reducing the need for more costly or invasive procedures. Given its high diagnostic accuracy and versatility, it is essential for healthcare systems to prioritize both the training of practitioners in MSK ultrasound and the integration of this technology into standard musculoskeletal injury protocols to optimize patient outcomes¹⁹.

What is the role of ultrasound in differentiating between various pathologies?

Building on musculoskeletal ultrasound’s capacity to visualize a breadth of soft tissue structures, the broader role of ultrasound in differentiating between various pathologies is rooted in its ability to distinguish between tissue types and abnormal materials with high specificity and sensitivity²⁰. This makes ultrasound invaluable not only in musculoskeletal contexts but also in abdominal and pelvic assessments, where it can provide detailed, real-time images to clarify whether a lesion is cystic, solid, or mixed, and thus guide further diagnostic workup²¹. Elastography, an advanced ultrasound technique, measures tissue stiffness and further enhances differentiation, allowing clinicians to distinguish malignant tumors from benign or healthy tissue, and even evaluate fibrosis in organs such as the liver²². The integration of these features—conventional imaging, elastography, and the ability to differentiate between fluid, soft tissue, and foreign bodies—demonstrates the interconnected utility of ultrasound across multiple domains, from rheumatology to oncology and hepatology²⁰. Ultimately, this versatility and the non-invasive, real-time nature of ultrasound demand that healthcare systems continue to invest in operator training and technology adoption, ensuring that clinicians can leverage its full diagnostic potential for a diverse patient population²¹.

How does musculoskeletal ultrasound impact patient management and outcomes?

The integration of musculoskeletal ultrasound into clinical practice has significantly transformed patient management by enabling more accurate diagnoses and facilitating targeted treatment plans²³. The real-time visualization provided by ultrasound not only improves the efficiency of diagnosing a wide range of musculoskeletal conditions but also allows clinicians to make immediate and informed decisions regarding patient care, bridging the gap between diagnosis and intervention²³. This capability is especially valuable in primary care settings, where it reduces the necessity for specialist referrals and expedites the initiation of management strategies, ultimately streamlining the patient pathway and reducing wait times for definitive care²³. Additionally, musculoskeletal ultrasound empowers healthcare providers to precisely monitor treatment progress and adapt management protocols as conditions evolve, ensuring that therapeutic interventions remain aligned with the patient’s clinical course²³. The ability to assess healing, detect complications, and evaluate the effectiveness of treatments in real time not only enhances patient outcomes but also fosters a more proactive and responsive approach to patient care, underlining the crucial role of musculoskeletal ultrasound across diagnostic, therapeutic, and monitoring domains²³. To maximize these benefits, ongoing training in ultrasound interpretation and continued technological advancements are essential, promoting its broader adoption and integration into multidisciplinary musculoskeletal care.

DISCUSSION 

The comprehensive overview presented in this paper underscores the pivotal role of musculoskeletal ultrasound (MSK US) as a versatile and invaluable imaging modality in the diagnosis and management of various musculoskeletal disorders. Its ability to deliver high-resolution, real-time visualization of soft tissues, combined with its safety profile—being non-invasive and free from ionizing radiation—positions MSK US as an indispensable tool in both clinical and research settings. The emphasis on technical proficiency, including optimal probe selection, machine settings, and adherence to safety principles like ALARA, highlights the importance of ongoing training and standardization to ensure consistent, accurate, and reproducible results across different practitioners and institutions. Moreover, the dynamic assessment capabilities of MSK US enable clinicians to evaluate tissue function during movement, enhancing diagnostic precision and informing targeted treatment strategies. Its utility in guiding interventional procedures further amplifies its clinical value by improving safety and efficacy. However, despite these strengths, there are limitations to consider. Operator dependence remains a significant challenge, as image quality and diagnostic accuracy heavily rely on the clinician’s expertise and familiarity with anatomy. Variations in imaging protocols and equipment settings across institutions can impact consistency, suggesting a need for standardized guidelines and continued education. Additionally, while advanced techniques such as elastography hold promise for differentiating tissue characteristics, their broader adoption is hindered by limited availability and the need for specialized training. Future research should focus on establishing standardized protocols, integrating artificial intelligence to assist in image interpretation, and expanding the application scope of MSK US in areas like oncology and rheumatology. Exploring the potential of portable ultrasound devices for point-of-care assessments could further enhance accessibility, especially in resource-limited settings. Overall, while MSK US offers numerous advantages, addressing its current limitations through technological advancements and educational initiatives will be essential to fully harness its diagnostic and therapeutic potential, ultimately improving patient outcomes in musculoskeletal care.

CONCLUSIONS

1. Musculoskeletal ultrasound (MSK-US) has emerged as a powerful, versatile, and increasingly essential imaging modality in the diagnosis and management of a wide range of musculoskeletal disorders. This review demonstrates that MSK-US offers numerous advantages, including real-time imaging, dynamic assessment, high-resolution visualization of soft tissue structures, cost-effectiveness, and the absence of ionizing radiation. These features make it especially valuable in both outpatient and point-of-care settings. The technique proves highly effective in evaluating tendons, ligaments, muscles, bursae, and superficial joints, often rivaling or even surpassing MRI in certain diagnostic scenarios—particularly for detecting tendon tears, effusions, and guiding interventional procedures.
2. Clinically, MSK-US contributes significantly to early diagnosis, therapeutic decision-making, and monitoring of treatment outcomes in conditions such as rotator cuff injuries, lateral epicondylitis, carpal tunnel syndrome, bursitis, and inflammatory arthritis. Additionally, its capacity for dynamic evaluation allows clinicians to assess pathology during movement, providing diagnostic insights not available through static imaging methods. The review also highlights the growing use of ultrasound guidance in musculoskeletal interventions, improving the precision and safety of procedures like injections, aspirations, and biopsies.
3. However, despite its advantages, musculoskeletal ultrasound has limitations, primarily related to its operator dependency, learning curve, and reduced efficacy in visualizing deep or complex anatomical structures compared to modalities like MRI or CT. Variability in technique and interpretation across practitioners remains a challenge, as does the lack of standardization in training and credentialing globally.

FUTURE DIRECTIONS

1. Looking ahead, the field of musculoskeletal ultrasound is poised for continued growth and refinement. Future research should focus on the development of standardized protocols and training programs to reduce operator variability and improve diagnostic reliability. Technological advancements, such as machine learning-assisted interpretation, portable high-resolution devices, and 3D ultrasound capabilities, hold great promise for enhancing diagnostic accuracy and accessibility.
2. Further studies are also needed to compare MSK-US with other imaging modalities across specific pathologies to better define its role in diagnostic algorithms. Large-scale, multicenter trials evaluating patient outcomes, cost-effectiveness, and integration into clinical workflows will be essential to inform evidence-based guidelines. In parallel, efforts should be made to expand the use of MSK-US in primary care, emergency medicine, sports medicine, and rheumatology, where its real-time and dynamic capabilities can provide immediate value.

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