Ultrasound-guided musculoskeletal interventions and professional boundaries: an international expert opinion

Abstract

The growth of musculoskeletal ultrasound (US) has led to an increasing trend of US-guided interventions also/sometimes being performed by allied health professionals who lack formal comprehensive medical training. This international expert opinion - developed through structured consultation among 20 Physical and Rehabilitation Medicine (PRM) physicians from 14 countries across five continents - addresses the patient safety, ethical, and medicolegal concerns arising from non-physicians performing such interventions. A narrative literature synthesis was conducted and iteratively reviewed by all contributing authors whereas formal consensus methodology was not employed. Having reviewed the international regulatory landscape, including regulations from the United States, Europe (Germany, France, Italy, Spain, Scandinavian countries, and the United Kingdom), and the Asia-Pacific region; we highlight inconsistencies that may compromise patient welfare. We call upon PRM associations to develop unified position statements establishing minimum competency standards. Policy recommendations would include establishing international complication registries, implementing enforceable supervision protocols, strengthening informed consent requirements, and ensuring transparent provider identification. Through these measures, professional organizations, regulators, and healthcare institutions can promote patient safety, transparency, and consistent standards worldwide.

Introduction

The integration of diagnostic and interventional ultrasound (US) into musculoskeletal medicine represents a paradigm shift in clinical practice. In the hands of appropriately trained physicians, US has evolved beyond a mere imaging modality to become an indispensable clinical tool that complements physical examination and guides therapeutic decision-making.¹ Herein, it is noteworthy that US augments the clinical awareness/judgement of physicians who bear medicolegal responsibility for patient care. While acknowledging the value of multidisciplinary collaboration, US-guided interventions being performed by allied health professionals – who lack formal medical training – raises profound concerns regarding patient safety, professional boundaries, ethical standards and medicolegal liability. Interventions performed without physician oversight demands urgent attention from the medical community.

US-guided injections constitute medical interventions that require comprehensive knowledge of regional basic/applied anatomy, (patho)physiology of the disease, pharmacokinetics and pharmacodynamics of the administered medications, and identification/management of (un)expected complications.^{1, 2} Professional organizations including the American Academy of Physical Medicine and Rehabilitation have established that physiatrists are trained and qualified to perform a broad range of interventional procedures including ultrasound-guided injections.³ The EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) guidelines emphasize the necessity of appropriate medical training for interventional US.⁴ This position reflects not merely the acquisition of US technical skills, but rather the physician’s unique capacity to synthesize clinical history, physical examination findings, laboratory results, and imaging data into coherent diagnostic and comprehensible therapeutic decisions.⁵ The concept of US guidance for interventions encompasses the entire continuum of care; initial clinical decision-making (including the diagnosis as well as the details of the injection), procedural precision, unique ability to prognosticate and systematic patient follow-up. These are responsibilities that indisputably extend well beyond the training scope of non-physician practitioners.

This document represents an international expert opinion authored by physiatrists. Its purpose is to document professional standards, ethical considerations, and patient safety principles related to US-guided musculoskeletal interventions.

Methods

This document was developed as an international expert opinion by a group of 20 Physical and Rehabilitation Medicine (PRM) physicians representing 14 countries across five continents. Contributing authors were selected based on their documented expertise in musculoskeletal US, interventional physiatry, or rehabilitation medicine policy, with particular emphasis on publication record and clinical experience in US-guided procedures.

An initial manuscript was drafted based on a narrative review of the literature, which included a search of PubMed, Google Scholar, and relevant organizational websites for guidelines, position statements, regulatory documents, and peer-reviewed studies related to US-guided musculoskeletal interventions, professional scope of practice, and patient safety. The draft was circulated to all co-authors for iterative review, critique, and revision through multiple rounds of electronic correspondence. All authors contributed to refining the positions, adding regional regulatory information, and approving the final version.

We acknowledge that formal consensus methodology, such as a Delphi process or nominal group technique, was not employed. Accordingly, this document is classified as an international expert opinion (Level V evidence per the Oxford Centre for Evidence-Based Medicine) rather than a formal consensus statement. We recognize this as a limitation and suggest that a future formal consensus process involving a broader range of stakeholders, including allied health professional representatives, would be a valuable next step.

Regulatory landscape and patient safety

The global regulatory framework governing US-guided interventions reveals concerning inconsistencies. In the United States, the American Institute of Ultrasound in Medicine has established training guidelines stipulating that US-guided interventions require physician oversight and competency documentation.⁶ The AMSSM (American Medical Society for Sports Medicine) position statement explicitly characterizes these procedures as medical acts requiring physician expertise.² The European Society of Radiology has emphasized that several major European countries, including Germany, France, Italy, and parts of Eastern Europe, restrict US examinations and/or interventional procedures to physicians only.⁷ The EFSUMB guidelines on interventional US further emphasize the necessity of appropriate medical training and institutional credentialing.⁴

The situation in the United Kingdom and several Commonwealth nations warrants particular scrutiny. In the United Kingdom, the Royal College of Radiologists has positioned diagnostic and interventional US as medical acts requiring appropriate training, clinical governance, and professional accountability.⁸ In Australia and New Zealand, professional organizations have issued guidance on non-physician performance of US-guided procedures, and such regulatory gaps create uncertainty among non-physician practitioners regarding their scope of practice.⁹ These regulatory gaps have the untoward potential of causing adverse events, including infections, neurovascular injuries, and systemic complications that would definitely demand medical approach which extends beyond non-physician capabilities.

However, it is necessary to remember that findings from research studies, even those of high quality, cannot always be generalized and need to be confirmed by real-world data.¹⁰ In fact, research studies usually involve selected samples, the setting in which the study is performed is often specialized, and clinicians are usually aware that their intervention is being evaluated. Real-world studies, based on large datasets obtained from different sources (e.g., health databases, health insurance systems, or claims) in countries where the new approach is implemented, may verify the effectiveness and safety of the new approach in broader patient populations and real-world settings.

Legal and ethical considerations

The legal dimensions of this issue extend beyond professional disagreement to fundamental questions of patient rights and medical ethics. US-guided procedures are invasive medical acts that most jurisdictions reserve for licensed physicians. When non-physicians perform these procedures, they may expose themselves, their institutions, and their patients to significant legal liability. Effective informed consent requires that patients understand who will be performing their procedure and the qualifications of that provider.

From an ethical standpoint, the performance of US-guided interventions by inadequately trained practitioners (or without sufficiently trained physician oversight) violates several core principles. Patient autonomy is compromised when individuals are not fully informed about provider credentials. The principle of beneficence is undermined when patients are exposed to unnecessary risks. Justice is also violated when patients unknowingly receive care that deviates from established standards. Most critically, the management of serious procedural complications, such as anaphylaxis, pneumothorax, or neurovascular injuries, requires physician expertise that is fundamental to ensuring patient safety during interventional procedures.¹¹ Patient safety requires attention to multiple factors including system design, competent workforce development, effective teamwork, and patient engagement.¹²

Call for international action

We call upon authoritative international bodies of musculoskeletal medicine to develop unified position statements that explicitly define musculoskeletal therapeutic injections as medical acts requiring physician oversight. Such statements can also reference existing guidelines from professional organizations while establishing minimum competency standards that transcend jurisdictional variations. Rather than endorsing inappropriate scope expansion, we advocate strengthening collaborative frameworks between medical specialties and allied health professions. Physicians should retain responsibility for the diagnosis as well as interventional treatments of patients with musculoskeletal diseases universally. Table I summarizes our key policy recommendations for establishing appropriate boundaries regarding US-guided interventional practice.

Table I. —Policy recommendations for ultrasound-guided ınterventional practice.

Domain	Recommendation
Informed consent	Strengthen legal standards for informed consent to require explicit disclosure of provider training and qualifications for all interventional procedures
Provider identification	Implement comprehensive provider identification requirements ensuring patients can distinguish between physician and non-physician providers through clear identification badges and consent/procedure documentation
Professional standards	International organizations should develop authoritative position statements, with input from legal and ethics consultants, that can serve as reference standards in medico-legal proceedings
Complication registry	Establish complication registries with mandatory reporting requirements to systematically track procedural outcomes and identify safety concerns

All recommendations represent level V evidence (expert opinion) per the Oxford Centre for Evidence-Based Medicine.

Conclusions

Having devoted our careers to advancing musculoskeletal medicine/US, we firmly believe that maintaining rigorous clinical standards serves the interests of all stakeholders. Patient safety must always supersede clinical demand, professional ambition or scope expansion. True progress in our field emerges via disciplined interprofessional collaboration with clearly defined boundaries, not through blurring the lines between distinct clinical competencies or medical practice. Defined roles ensure that patient care is overseen by qualified professionals, reducing misdiagnosis and inappropriate interventions.

In closing, this expert opinion reflects the collective views of an international group of Physical and Rehabilitation Medicine physicians with high level of expertise in musculoskeletal and interventional US – education and research alike. The recommendations are based on existing international guidelines, ethical frameworks, and collective clinical experience across diverse healthcare systems.