Updates in ultrasound-guided musculoskeletal interventions

Abstract

Musculoskeletal ultrasound (MSK-US) has evolved from a diagnostic tool into a key modality for guiding minimally invasive interventions across the musculoskeletal system. Its real-time imaging, portability, and absence of ionizing radiation make it a cost-effective and safe alternative to fluoroscopy and CT for numerous procedures, including biopsies, aspirations, injections, and percutaneous releases. Recent technological advances in ultrasound, including high-frequency probes, microvascular imaging, needle-tracking systems, and robotic probe steering, have improved precision and expanded its application to complex regions such as the spine and peripheral nerves. Minimally invasive ultrasound-guided techniques now play an important role in treating conditions such as De Quervain’s disease, trigger finger, Dupuytren’s contracture, carpal tunnel syndrome, and epicondylitis, offering outcomes comparable to surgery with reduced morbidity. Novel biological treatments, including platelet-rich plasma and mesenchymal stem cell therapies, show regenerative potential but require further validation. Despite ongoing debate about the long-term safety of corticosteroids and local anesthetics, ultrasound guidance continues to expand its role in interventional and regenerative medicine. The integration of advanced imaging technologies with standardized protocols and specialized training is expected to further consolidate ultrasound-guided interventions as a cornerstone of modern musculoskeletal care, improving both procedural safety and patient outcomes.

Introduction

In recent years, musculoskeletal ultrasound (MSK-US) has become an increasingly important modality, not only for diagnostic imaging but also for image-guided procedures, thanks to its lack of ionizing radiation, real-time imaging capabilities, and the portability of modern ultrasound devices.¹ Specifically, ultrasound guidance is now well established for various procedures, including tumor biopsies, diagnostic aspirations, and percutaneous therapeutic drainages of abscesses, hematomas, cysts, or fluid collections, as well as therapeutic injections targeting joints, nerves, and tendons. Techniques such as barbotage for calcific tendinopathy (Figure 1A and B) and hydrodilatation for adhesive capsulitis (Figure 2) have also gained acceptance, solidifying MSK-US as the primary imaging modality for evaluating and managing tendinous, articular, and soft-tissue disorders.

Figure 1.

Calcific tendinopathy of the supraspinatus tendon treated with barbotage. (A) Calcification within the supraspinatus tendon (white arrow) with “toothpaste-like” density, representing an evolutionary phase amenable to barbotage. (B) A 20-gauge needle was advanced under real-time ultrasound guidance directly into the calcific deposit (white arrow), followed by fragmentation and saline lavage.

Figure 2.

Patient with adhesive capsulitis showing thickening of the axillary pouch. Capsular hydrodistension performed using a 22-gauge needle (white arrow) and saline solution. Hyaluronic acid can be used as an alternative to saline.

This consolidation reflects several factors: the strong evidence supporting ultrasound as an effective diagnostic tool for a wide range of musculoskeletal diseases²; its favorable cost-effectiveness and shorter examination time compared to MRI; and the high diagnostic agreement between these modalities, especially in evaluating soft-tissue conditions involving the shoulder, foot, and ankle, as well as assessing peripheral nerves, foreign bodies, and periprosthetic soft tissues.³ Another important aspect is the increasing integration of MSK-US among both radiologists and non-radiologist clinicians across various specialties.⁴

In most clinical settings, ultrasound-guided interventions show greater accuracy and procedural precision compared to palpation-based approaches that depend solely on external anatomical landmarks.¹ Because it is a portable, non-ionizing imaging technique, MSK-US is a cost-effective and accessible alternative to expensive modalities like MRI and CT. Its immediate availability at the point of care enables timely diagnosis and treatment, making it especially valuable in pediatric, emergency, and resource-limited healthcare environments where quick and equitable access to musculoskeletal imaging is crucial.⁵

Methods

A focused literature search was performed using PubMed to identify relevant studies on ultrasound-guided musculoskeletal interventions. The search strategy included combinations of the following keywords, with Boolean operators where appropriate: “musculoskeletal ultrasound-guided interventions,” “musculoskeletal injections,” and related terms. The search was limited to articles published in English over the last 10 years. Additional relevant studies were identified through manual screening of reference lists.

Inclusion criteria comprised clinical studies, review articles, and technical reports focusing on ultrasound-guided interventional procedures for musculoskeletal conditions, selected based on their relevance to current clinical practice and technical applicability. Exclusion criteria included articles not directly related to the topic, non-English publications, and studies with insufficient methodological detail. Titles and abstracts were screened for relevance, followed by full-text evaluation of selected articles.

This review provides a comprehensive, practice-oriented overview of ultrasound-guided musculoskeletal interventions, combining well-established techniques with recent advancements and highlighting areas where evidence remains evolving or controversial. It was conducted as a focused narrative review; therefore, a formal systematic review protocol was not applied. This approach allows for an integrative presentation of current techniques and emerging applications in MSK-US interventions.

Ultrasound imaging in ultrasound-guided procedures: minimum requirements and modern equipment

Modern musculoskeletal interventional ultrasound fundamentally relies on the performance and versatility of imaging equipment. A minimum-standard setup should include a broadband linear transducer operating between 10 and 15 MHz, offering adequate spatial resolution for assessing superficial joints and soft-tissue structures. Additionally, a low-frequency curvilinear probe (3-6 MHz) is essential when imaging deep-seated regions, intra-pelvic targets, or patients with high body mass index.⁶

Contemporary ultrasound platforms must enable real-time imaging, B-mode and Doppler functionalities, and at least basic compound imaging to optimize tissue contrast and needle visibility. In contrast, advanced or high-end consoles integrate harmonic imaging, beam steering, tissue elastography (Figure 3), and dedicated needle-tracking systems, all of which substantially enhance procedural precision and operator confidence.⁷

Figure 3.

Elastography of a hypoechoic mass within the muscle belly (white arrow). Different areas of the lesion exhibit varying stiffness, represented by color (blue: softer tissue; red: stiffer tissue).

Probe selection is equally critical: while a standard linear array suffices for most interventions, small-footprint “hockey-stick” transducers (5-13 MHz) are useful when working within restricted anatomical spaces such as small joints, tendons, or peri-neural regions.⁸ Adequate Doppler sensitivity is required to identify low-flow vascular structures, and newer systems equipped with microvascular imaging modes (eg, SMI, eFlow) improve distinction between vascular, inflammatory, and fibrotic lesions.⁷

From an operational perspective, portable point-of-care systems are increasingly implemented for bedside and intraoperative applications, offering high mobility and favorable cost-effectiveness. Conversely, premium-grade consoles continue to represent the gold standard for complex interventional procedures, given their superior spatial resolution, ergonomic transducer design, and multi-probe compatibility.¹ Regardless of the level of technology, strict adherence to aseptic technique and ergonomic workflow, including sterile probe sheaths, foot-switch activation, and efficient disinfection protocols, is vital for maintaining safety and procedural efficiency.⁹ Ultimately, the ideal ultrasound system for interventional MSK practice must harmonize mobility, image fidelity, and functional versatility, ensuring that both portable and high-end platforms comply with current clinical performance standards.¹⁰

Ultrasound-guidance today

In recent years, ultrasound-guided interventions have increasingly moved from mainly extremity areas to more complex areas like the spine.

Established fields

Musculoskeletal ultrasound offers real-time, dynamic imaging of muscles, tendons, ligaments, joints, and periosteal tissues, enabling early detection and precise characterization of various conditions, including traumatic injuries, arthritis, synovitis, and fractures, all without exposing patients to ionizing radiation. Beyond diagnostic use, MSK-US is a valuable tool for therapeutic guidance and ongoing monitoring. It allows for accurate image-guided procedures, such as injections and aspirations, and supports assessment of treatment effectiveness, like tendon healing and synovial inflammation evaluation. This facilitates personalized rehabilitation and pain management plans tailored to each patient’s needs. Ultrasound has become a primary modality for diagnosing and treating a wide array of musculoskeletal disorders. Under real-time sonographic guidance, multiple procedures can be performed: barbotage, hydrodilation, tumor biopsies (Figure 4A and B), percutaneous fluid drainages (eg, Baker’s cysts, hematomas, abscesses), intra-articular and bursal injections (Figure 5), nerve blocks, and intra-tendinous or intramuscular injections.^11,12 More complex procedures, such as foreign body removal can also be guided with ultrasound, and are gaining momentum.

Figure 4.

Ultrasound-guided biopsy of a muscle mass using a 14-gauge needle (white arrow) (A). Color Doppler evaluation showing increased intra- and peri-lesional vascularity (B).

Figure 5.

Ultrasound-guided hyaluronic acid injection for hip osteoarthritis using a 22G needle. The needle is advanced into the anterior capsular recess at the femoral head-neck junction (white arrow).

Collectively, these clinical applications have established MSK-US as the preferred imaging and interventional method for tendinous, articular, and soft-tissue conditions, providing high procedural accuracy, reduced morbidity, and greater patient comfort compared to traditional open surgical techniques.¹³

New frontiers

Spine injections

Within the spine, the use of ultrasound-guided interventions, including needle insertions, facet joint injections (Figure 6A-C), and epidural access techniques, has been increasingly documented in the literature, providing a radiation-free and real-time alternative to traditional fluoroscopic or CT-guided methods.¹⁴ Furthermore, the development of intraoperative ultrasound-based registration and navigation technologies signifies an emerging area of innovation in image-guided spinal procedures, emphasizing a rapidly advancing research trend.

Figure 6.

Ultrasound-guided facet joint injection showing needle placement (white arrows) for therapeutic delivery (A, B, C).

US-MRI fusion imaging

Although US-MRI fusion imaging is not a novel technology, its application in musculoskeletal interventions is still evolving and not yet widely adopted in routine clinical practice, with growing interest in selected indications. Ultrasound/MRI fusion has emerged as a valuable technique for spinal interventions, offering precise needle guidance without the use of fluoroscopy.¹⁵ In this method, recent MRI scans are imported into the ultrasound system, and key bony landmarks, such as spinous processes, facet joints, the sacrum, and iliac crests, are identified to align the imaging planes. The software then synchronizes real-time ultrasound with the MRI, creating a 3D fusion that provides accurate spatial orientation. Needle placement can be visualized directly on ultrasound or further enhanced using radiofrequency-equipped needles, which track the tip continuously. This approach allows safe and precise targeting of nerve roots and facet joints, with reported accuracy of 1-2 mm for fixed structures.¹⁶ Early evidence suggests that pain relief from ultrasound/MRI fusion-guided injections is comparable to that achieved with conventional fluoroscopy, while providing the benefits of radiation-free imaging and real-time procedural verification.¹⁵

Ultrasound-guided neuromodulation

Ultrasound imaging precisely locates peripheral nerves and ganglia, aiding in the percutaneous insertion of stimulation leads or electrodes for neuromodulation, such as peripheral nerve stimulation (PNS). A feasibility study indicated that ultrasound-guided percutaneous PNS targeting the brachial plexus in patients undergoing outpatient shoulder surgery was technically feasible and may be linked to lower postoperative pain medication use.¹⁷ Similarly, a pilot study of ultrasound-guided percutaneous neuromodulation of the sciatic nerve in people with chronic low back pain showed improvements in muscle strength, hip joint mobility, and pain levels.¹⁸

Compared with fluoroscopy or CT, ultrasound provides real-time visualization of neural structures along with surrounding soft tissues and vascular landmarks, thereby enhancing electrode placement accuracy and reducing the risk of injury to nearby non-target structures. As a result, ultrasound guidance is a valuable and increasingly popular technique for neuromodulation in musculoskeletal and pain management applications. However, larger randomized controlled trials are still needed to confirm therapeutic effectiveness and to establish standardized procedural protocols.¹⁹

Future perspectives

Exciting new advances are also shaping the future of ultrasound guidance beyond traditional areas: robotic probe steering, automated insonification optimization, and improved microvascular imaging are being tested to enhance anatomical detail in difficult regions such as vertebral anatomy.²⁰

Robotic probe steering allows semi- or fully automated control of the ultrasound transducer through a computer-controlled robotic arm. After the operator initially positions it near the target anatomy, the system adjusts angle, tilt, and contact pressure to improve image quality. Studies have shown that robotic ultrasound probe positioning with high accuracy and automated force/pose control is achievable.²¹

In interventional procedures such as spine interventions, deep bone biopsies, or small/deep joint procedures, precise probe control is essential. These regions are susceptible to acoustic shadowing, complex geometry, and limited visibility of the injection needle. Robotic steering maintains a stable imaging plane and real-time needle visualization at difficult angles or depths, enhancing guidance accuracy, reducing operator fatigue, and potentially lowering the risk of vascular or neural injury.²¹

However, clinical evidence remains scarce. Most studies are preclinical or involve phantom or cadaver models, focusing on technical feasibility; large-scale trials showing improved patient outcomes or fewer complications are absent.²²

Designed to reduce operator dependence, software-driven methods like automated insonification optimization adjust imaging settings such as gain, focus, depth, contrast, dynamic range, and frequency during the scan to produce consistent, high-quality images without constant manual adjustments.²⁰ These systems help decrease operator variability, enhance visualization of small nerves, low-flow vessels, and calcifications, and allow the operator to concentrate on the procedure. Although promising, strong clinical evidence for these technologies is still limited.

Enhanced microvascular imaging (EMVI) is an advanced ultrasound method that provides clear imaging of small vessels and slow blood flows that are usually not detectable with standard color or power Doppler. Superb microvascular imaging (SMI), a version of EMVI, employs sophisticated filtering algorithms to distinguish slow blood flow from tissue movement and clutter, thereby enhancing the visualization of microvascular networks.²³

In interventional practice, EMVI assists in the detailed mapping of microvessels and neovascularization, promoting safer and more accurate needle placement. During spinal, deep muscular, or tendinous procedures, it guides needle paths to avoid vital vessels, helps distinguish inflamed or neovascularized tissue from fibrotic or necrotic areas, and allows monitoring changes in neoangiogenesis over time.²⁴

Future developments, such as integration with needle-tracking systems, robotic probe steering, and AI-based real-time analysis, could further enhance procedural accuracy, decrease complications, and allow access to difficult-to-reach areas. However, strong clinical evidence confirming real patient outcome improvements remains limited.

Ultrasound-guided surgery in musculoskeletal interventions

The use of intraoperative ultrasound guidance has become increasingly important in musculoskeletal surgery. The development of high-frequency linear probes and high-definition displays allows real-time visualization of muscles, tendons, ligaments, and nearby blood vessels, greatly improving surgical accuracy. This technology facilitates minimally invasive tendon repairs, treatment of muscle cysts or masses, and safe access to deep joints, while decreasing the risk of injury to vital structures and enhancing postoperative recovery. The rising use of ultrasound-guided procedures in the musculoskeletal field reflects a broader trend toward safer, more precise, and patient-specific treatments.

De quervain’s disease

De Quervain’s disease (DQD), or De Quervain’s tenosynovitis, is a common cause of wrist pain caused by inflammation of the tendons located in the first dorsal compartment (FDC). Its pathophysiology is similar to that of trigger finger, as irritation of the tendon and its surrounding sheath results in pain, swelling, and limited function during normal hand use. Although open surgical decompression is traditionally seen as the standard treatment, it comes with drawbacks like scarring and adhesion formation.²⁵ Recent advances in minimally invasive treatments, especially ultrasound-guided procedures, aim to reduce these complications while providing effective treatment. Ultrasound-guided release of the first dorsal extensor compartment allows precise visualization of nearby structures, controlled division of the retinaculum, and decreased postoperative complications compared to the traditional open method.²⁵

Trigger finger

Trigger finger, or stenosing tenovaginitis, results from impaired gliding of the flexor tendon due to thickening and constriction at the A1 pulley. Ultrasound offers an accurate assessment of both the tendon’s resting and dynamic characteristics, allowing precise evaluation of tendon movement and pulley anatomy. Although open A1 pulley release remains the gold standard for resistant cases, interest in ultrasound-guided percutaneous techniques has increased due to their potential to improve accuracy and reduce tissue damage.²⁶ Minimally invasive ultrasound-guided release has shown high reliability and safety, with complete pulley division achieved without major complications or iatrogenic injuries.²⁷ Minor postoperative issues, such as localized pain or transient synovitis, are usually self-limiting and similar to those seen after traditional open surgery.²⁶ In comparative studies, pain levels immediately after surgery were similar between open and ultrasound-guided procedures; however, at 1 month, patients treated with the ultrasound-guided method reported significantly lower pain scores (P = 0.02). Functional outcomes were comparable between groups, but recovery was notably faster in the ultrasound-guided percutaneous group.²⁷

Dupuytren

Dupuytren’s contracture results from excessive collagen deposition within the palmar fascia, leading to fibrous cord formation and progressive limitation of finger extension.²⁸ Disease progression causes fascial retraction with fixed flexion deformities, primarily affecting the metacarpophalangeal (MCP) joint and, less frequently, the proximal interphalangeal (PIP) joint, most commonly in the ulnar digits.²⁹

Percutaneous needle aponeurotomy (PNA) is the most widely used minimally invasive treatment, aiming to divide pathological cords while minimizing soft-tissue trauma. Compared with open surgery, PNA offers faster recovery, fewer perioperative risks, and lower costs, with proven safety and effectiveness.^30,31 However, the blind technique increases the risk of tendon and neurovascular injury, incomplete release, and high recurrence rates exceeding 80% at 5 years.³²

Ultrasound-guided PNA improves visualization of cords and neurovascular structures, enhancing procedural accuracy and safety, with excellent clinical outcomes reported.³³ Similarly, ultrasound guidance may optimize collagenase clostridium histolyticum (CCH) injections by enabling precise enzyme delivery and potentially improving treatment efficacy.³⁴

Median nerve compression

Carpal tunnel release can be performed using open, endoscopic, or ultrasound-guided techniques.^35,36 Ultrasound-guided carpal tunnel release (USCTR) is a minimally invasive approach that allows real-time visualization of the median nerve, adjacent vascular structures, and anatomical variants such as a persistent median artery, often associated with a bifid median nerve. Percutaneous techniques help preserve functionally important median nerve branches, including the palmar cutaneous and thenar motor branches, which are at risk during open or endoscopic procedures. Reduced soft-tissue disruption lowers the risk of iatrogenic injury and supports faster functional recovery with improved cosmetic outcomes.^37–39

Both retrograde and anterograde ultrasound-guided approaches have been developed to enhance safety while achieving effective decompression, representing a safe and cost-effective option for patients with moderate to severe carpal tunnel syndrome unresponsive to conservative treatment.³⁶

Median nerve compression at the elbow, presenting as pronator syndrome, is typically caused by entrapment at the pronator teres or lacertus fibrosus.⁴⁰ Ultrasound-guided percutaneous release under WALANT (Wide Awake Local Anesthesia No Tourniquet) enables precise division of compressive structures with continuous neurovascular monitoring, minimal scarring, and rapid recovery.^37–39

Epicondylitis

Epicondylitis is a common degenerative tendinopathy that can resolve spontaneously, with diagnosis mainly based on clinical evaluation.⁴¹ Conservative treatment is the first option, but in resistant cases, open or arthroscopic tenotomy of the epicondylar muscles may be considered. Ultrasound-guided percutaneous tenotomy at the common epicondylar tendon near the enthesis has shown success rates similar to traditional surgery while minimizing tissue trauma and scar formation (Figure 7A).⁴²

Figure 7.

Increased vascularity of the wrist and finger extensor tendons on color Doppler, an ultrasound finding consistent with epicondylitis (A). Percutaneous ultrasound-guided tendon dry needling with a small-gauge needle (white arrow) (B).

Percutaneous ultrasound-guided tendon dry needling, also known as tendon fenestration, is a minimally invasive alternative for treating chronic lateral epicondylitis.⁴² Using a small-gauge needle without skin incision or tissue removal, this technique encourages faster recovery, reduces procedural costs, and allows an earlier return to work compared to open-release surgery (Figure 7B). Clinical outcomes, including pain, physical function, patient-reported improvement, and satisfaction, are similar to those of surgical release. These findings support recommending ultrasound-guided tendon dry needling as a first-line treatment before considering surgery for chronic lateral epicondylitis.⁴²

Tenotomy of the LHBT

The long head of the biceps tendon (LHBT) plays an important role in rotator cuff (RC) problems, as degenerative LHBT injuries often occur alongside RC tears and can cause ongoing shoulder pain even if the tendon remains intact.^43,44 This is mainly because it is richly supplied by sensory sympathetic fibers, making the LHBT a key pain-sensitive structure. Spontaneous tendon rupture in RC patients often leads to pain relief, supporting the use of arthroscopically guided tenotomy when spontaneous rupture does not happen or during RC repair surgery.^45,46

Evidence regarding ultrasound-guided percutaneous LHBT tenotomy remains limited.^47–49 Recent cadaveric studies have shown its feasibility, enabling rapid and complete tendon division through a small skin incision,^47,48 although some concerns about iatrogenic injury to the tendon or cartilage have been reported.⁴⁹ Current guidelines from the European Society of Musculoskeletal Radiology recognize the technique as feasible, though clinical validation is still needed.⁵⁰

Chronic exertional compartment syndrome

Chronic exertional compartment syndrome (CECS) of the forearm is an exercise-induced condition characterized by cramping and pain that usually develops within minutes of activity, requiring the individual to stop the sport. It is most often seen in motorcycling disciplines such as motocross, enduro, and circuit racing,⁵¹ though other activities like rock climbing, rowing, windsurfing, and jet skiing may also be involved, but less frequently.

Diagnosis depends on a combination of clinical signs and elevated intramuscular pressure measurements. Management can be conservative or surgical, with fasciotomy recommended in refractory cases.⁵² Traditional open fasciotomy is effective but more invasive, while ultrasound-guided fasciotomy offers a minimally invasive alternative. This method provides precise visualization of underlying anatomical structures while reducing the surgical field, promoting quicker recovery and an earlier return to athletic activity, making it especially suitable for elite athletes.⁵²

Radial and ulnar nerve release

Radial nerve entrapment may occur at several anatomical sites, most commonly at the lateral intermuscular septum of the distal arm and at the arcade of Frohse. Compression at the lateral intermuscular septum typically results in pain and functional impairment. A minimally invasive ultrasound-guided percutaneous decompression under WALANT enables accurate nerve release while preserving function, with Doppler-guided hydrodissection further enhancing safety by reducing the risk of iatrogenic injury.⁵³ Although this approach minimizes soft-tissue disruption compared with open surgery, clinical evidence remains limited, with no large-scale trials available.^53,54

Entrapment at Frohse’s arcade, though uncommon, may cause exertional or nocturnal dorsal forearm pain and weakness of wrist and finger extensors.⁵⁴ A fully ultrasound-guided percutaneous release allows precise division of the superficial fascia over the supinator while avoiding adjacent neurovascular structures, offering a less invasive alternative to open decompression.

Similarly, ulnar nerve compression at the elbow can be managed with ultrasound-guided percutaneous release. In situ decompression has been associated with rapid recovery, effective symptom relief, and fewer complications than neurolysis with transposition, supporting this technique as a viable option for selected patients.⁵⁵

Radiosynoviorthesis

Radiosynoviorthesis involves the therapeutic ablation of synovial tissue through the intra-articular administration of radionuclides. This approach is indicated for patients with monoarthritis or oligoarthritis who fail to respond to systemic medical therapy over a 6-month period or to an adequate intra-articular corticosteroid regimen.⁵⁶ The radiopharmaceuticals consist of fine colloidal particles labeled with β-emitting isotopes. Once injected, these particles are engulfed by superficial synovial macrophages, inducing localized necrosis, subsequent sclerosis, and fibrosis of the inflamed synovium, ultimately reducing joint effusion and providing symptomatic relief from pain.⁵⁷

Ultrasound-guided radiofrequency ablation for knee osteoarthritis and neoplasms

Knee arthroplasty remains the standard care for patients with advanced osteoarthritis who have not responded to conservative treatments. However, many patients are ineligible for surgery due to comorbidities or other contraindications, creating a demand for alternative options. Ultrasound-guided radiofrequency ablation (RFA) of the genicular nerves has become a minimally invasive choice for patients with severe pain and functional impairment that do not improve with conservative management or intra-articular injections.⁵⁸ After a positive diagnostic genicular nerve block with local anesthetic, RFA can offer targeted nerve modulation, leading to significant pain relief and better quality of life.⁵⁸

Furthermore, RFA is a safe and effective short-term treatment for refractory Sportsman’s Hernia, superior to anesthetic/steroid injections, targeting tendon inflammation and ilioinguinal nerve compression, potentially resolving symptoms without surgery.⁵⁹

Radiofrequency ablation is also increasingly used in oncology for both benign and malignant tumors, including hepatocellular carcinoma, metastatic liver lesions, thyroid nodules, parathyroid adenomas, and musculoskeletal soft-tissue tumors.^60,61 The moving-shot technique under ultrasound guidance provides continuous real-time monitoring, allowing for precise ablation in anatomically delicate areas while reducing injury to nearby structures.^62,63 Early evidence shows that this approach is safe, effective, and minimally invasive, achieving significant volume reduction and aesthetic improvement in benign soft-tissue neoplasms within 6 months, with no documented complications or local recurrence.^64,65

Ultrasound-guided cryoneurolysis

Ultrasound-guided cryoneurolysis has emerged as a promising interventional technique for the management of chronic, refractory peripheral mononeuropathies. By delivering localized freezing to the affected nerves, this approach aims to provide sustained pain relief while minimizing tissue trauma.⁶⁶ Ultrasound guidance allows continuous visualization of the needle and cryoprobe, ensuring accurate placement, access to small or anatomically complex structures, and the use of smaller instruments, which enhances both safety and procedural precision. Early clinical reports indicate that cryoneurolysis is generally well-tolerated, with few adverse events, and can serve as a viable option for patients who have not responded to conventional therapies.⁶⁶ Despite these encouraging results, robust randomized studies are still lacking, particularly regarding optimal freezing temperatures, duration of analgesia, and the potential benefits of repeated treatments. Future investigations should focus on prospective, controlled trials to establish standardized protocols and clarify the long-term efficacy of ultrasound-guided cryoneurolysis.^66,67

Ultrasound-guided alcohol neurolysis

Ultrasound-guided alcohol ablation is a minimally invasive technique used to treat chronic neuropathic pain by chemically neurolysing targeted nerves. It has been extensively applied in the management of Morton’s neuroma, where precise localization of the affected interdigital nerve allows injection of low-concentration alcohol under high-resolution ultrasound guidance, achieving significant pain relief with minimal complications.⁶⁸

Ultrasound-guided high-intensity focused ultrasound

Ultrasound-guided high-intensity focused ultrasound (USgHIFU) is a noninvasive thermoablative technique that enables precise local tumor ablation. It has shown safety and effectiveness in managing inoperable neoplastic disease, alleviating symptoms and reducing tumor volume, though evidence remains limited due to a lack of randomized controlled trials.^69,70 By inducing early sterile inflammation, it could also support long-term antitumor immunity.⁷¹ Further randomized studies are needed to confirm its benefits and optimize clinical protocols.

Ultrasound-guided extracorporeal shock wave therapy

Extracorporeal shockwave therapy (ESWT) is a noninvasive treatment modality increasingly used in musculoskeletal disorders, based on the delivery of acoustic waves that induce mechanical and biological responses in target tissues. These effects include stimulation of cellular activity, neovascularization, and tissue regeneration through mechanotransduction processes.⁷² ESWT is commonly applied in chronic, refractory conditions such as plantar fasciitis, calcific shoulder tendinopathy, Achilles tendinopathy, and lateral epicondylitis, often as a second-line therapy when conservative treatments fail.⁷³ While evidence supports its efficacy in selected conditions, outcomes remain variable depending on indication and treatment protocols, highlighting the need for standardized approaches.^72,73

From science to practice

Over the past decade, several innovations in MSK-US have moved from experimental ideas to widely used clinical practices. Procedures that were initially studied in small feasibility studies, such as ultrasound-guided percutaneous needle tenotomy, platelet-rich plasma (PRP) injections, percutaneous irrigation for calcific tendinopathy, and targeted peripheral nerve blocks, are now routine procedures at many centers.⁷⁴ This shift was made possible by advances in imaging technology, including high-frequency linear probes, better needle visualization, and microvascular imaging, combined with improved procedural protocols validated through multicenter clinical trials. For instance, ultrasound-guided corticosteroid injections and PRP therapy for tendinopathies show higher accuracy and better clinical outcomes compared to landmark-based techniques.¹⁰ Additionally, over the last 10 years, the scope of interventions has expanded to include areas such as spinal injections, bone biopsies, hydrodissection of peripheral nerves, and minimally invasive synovial cyst drainage, which previously mostly relied on CT or fluoroscopic guidance.⁷⁵ Essentially, the transition from “science to practice” highlights a clear pathway: techniques initially tested in controlled research settings are now translated into standardized, reproducible procedures that are part of the standard care in musculoskeletal intervention. This illustrates how technological progress, clinical validation, and operator training together drive the adoption of evidence-based interventional ultrasound.

New therapeutic agents. Are they effective?

In recent years, biological therapies in the musculoskeletal field have attracted significant attention because of their potential to improve endogenous tissue regeneration through targeted delivery of growth factors, cells, and biomaterials. Simultaneously, advancements in MSK-US have raised its importance from just diagnostic imaging to a crucial tool for interventional guidance.

Along with procedural guidance, MSK-US enables objective, long-term evaluation of treatment results, such as tendon thickness, echotexture, fibrillar alignment, Doppler signal, and tissue integration.

Despite these advances, clinical use remains limited by methodological differences: biological preparations are often non-standardized, injection protocols vary, imaging follow-up lacks consistency, and links with molecular biomarkers are rare.

Hyaluronic acid

Hyaluronic acid (HA) injections under ultrasound guidance are increasingly used in musculoskeletal medicine for both intra-articular and peritendinous applications. In individuals with knee osteoarthritis, ultrasound-guided HA administration has been shown to reduce pain and improve functional outcomes over the medium term, sometimes providing superior symptom relief compared to corticosteroids.⁷⁶ Similarly, in hip osteoarthritis, HA injections performed with real-time ultrasound guidance offer pain reduction, functional improvement, and a favorable safety profile, while also decreasing the need for additional analgesics.⁷⁷ For tendinopathies, including those affecting the supraspinatus, Achilles, and patellar tendons, peritendinous HA injections guided by ultrasound are associated with pain relief, reduction in tendon thickness, and decreased neovascularization.⁷⁸ Single-dose HA injections have also demonstrated functional benefits in insertional Achilles tendinopathy.⁷⁹ Beyond these applications, HA may be considered for other enthesopathies and joints, such as the glenohumeral and ankle, though further controlled studies are necessary to establish optimal protocols and long-term efficacy.

Platelet-rich plasma

In recent years, the clinical use of PRP has increased for the treatment of musculoskeletal soft-tissue injuries. PRP consists of injecting concentrated autologous platelets at the injury site to promote bone and soft-tissue healing.⁸⁰ Its role in tendinopathies remains controversial, as clinical responses vary by tendon and biological effects typically emerge only after several months.⁸¹ Platelets release multiple bioactive factors, including platelet-derived growth factor, transforming growth factor, vascular endothelial growth factor, epidermal growth factor, insulin-like growth factor, and fibronectin, which support angiogenesis, collagen synthesis, and tissue remodeling.^82,83 Despite these theoretical advantages, systematic reviews show limited evidence that PRP is superior to standard treatments for most musculoskeletal conditions.⁸⁴ Some benefit has been reported in non-surgical RC disease, but overall data do not support routine use given costs and invasiveness.⁸⁵ PRP appears safe, yet its efficacy is inconsistent in knee osteoarthritis and patellar tendinopathy, where it should not be considered first-line therapy.^80,84 Conversely, ultrasound-guided PRP injections demonstrate sustained pain relief in chronic plantar fasciitis compared with corticosteroids.^80,84 Evidence for other indications remains limited, underscoring the need for high-quality studies.¹⁰

Prolotherapy

Prolotherapy is a regenerative injection technique in which hyperosmolar solutions, such as dextrose, are delivered into tendons, ligaments, or periarticular tissues under ultrasound guidance. The procedure aims to promote tissue healing and reduce pain by triggering a controlled local inflammatory response. Prolotherapy is generally safe and may provide clinical benefits in conditions such as patellar tendinopathy, Osgood-Schlatter disease, and Achilles tendinopathy. However, current evidence is limited, with few high-quality randomized studies, and in some cases its effects are not superior to placebo or other treatments.⁸ While it can offer a less invasive and cost-effective option for selected patients, prolotherapy should be considered a second-line therapy when standard conservative measures fail.⁸

Mesenchymal stem cell

Mesenchymal stem cell (MSC) therapy is a promising regenerative approach for tendon disorders. Preclinical studies have demonstrated that MSCs can differentiate into tenocytes, secrete extracellular matrix components, and aid in tendon tissue regeneration.⁸² The meta-analysis showed significant improvements in pain, joint function, and radiological or arthroscopic outcomes, with dose-dependent responses observed.^86,87 The therapeutic effects seem to result from both the differentiation ability of MSCs and their paracrine and immunomodulatory actions, which involve releasing cytokines and growth factors like vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF).⁸⁸ Reported adverse events were mild and mostly not related to the treatment itself.^{74,  86} Still, concerns about long-term safety and potential teratogenicity persist.⁸⁹ Due to methodological limitations and the limited number of studies available, large-scale randomized controlled trials are needed to confirm the efficacy and safety of MSC-based therapies for tendon disorders.^90,91

Growth factors

Insulin-like growth factor-I (IGF-I), transforming growth factor-β (TGF-β), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and extracellular vesicles (EVs) are key mediators in tendon repair, each playing distinct roles at different healing stages. IGF-I is released immediately after injury, enhancing cellular proliferation and reducing inflammatory activity.⁹² VEGF is also expressed early, promoting angiogenesis and increasing local metabolic activity, supporting other growth factors; however, prolonged VEGF signaling may impair tendon remodeling.⁹³ PDGF, one of the first cytokines identified in tendon regeneration, exerts strong chemotactic and proliferative effects on fibroblasts and tenocytes. Nevertheless, excessive activity can amplify inflammation and reduce adhesion formation.⁹⁴ TGF-β remains active throughout most of the healing process and is vital for coordinating cellular proliferation, activating other trophic factors, and reducing inflammatory responses.⁹⁵ Overall, these mediators coordinate cellular signaling and extracellular matrix remodeling essential for effective tendon recovery.

Traditional drugs: safety and concerns

Corticosteroids and local anesthetics

Intra-articular corticosteroids show conflicting evidence about their effects on cartilage. In vitro and animal studies indicate dose- and time-dependent toxicity: low doses or single injections may be neutral or even beneficial, while high doses or repeated treatments are linked to cartilage damage, including loss of proteoglycans, depletion of type II collagen, and chondrocyte death.⁹⁶ For example, doses above 3 mg per injection or cumulative doses exceeding 18-24 mg have been associated with visible cartilage injury.⁹⁶ However, the clinical significance in humans remains uncertain; a randomized trial using 40 mg of triamcinolone every 3 months for 2 years did not show significant joint space narrowing compared to placebo.⁹⁷

Local anesthetics such as lidocaine and bupivacaine are cytotoxic to chondrocytes depending on dose, duration, and agent, with ropivacaine generally exhibiting lower toxicity.⁹⁸ Prolonged exposure, such as through intra-articular pumps, increases the risk of chondrolysis, while the effects of single injections are less clearly defined.⁹⁹

Data on tendon-specific damage from corticosteroid and local anesthetic injections are scarce. Structural failure of tendons, ligaments, or fascia, including partial or complete rupture, is an uncommon but clinically meaningful adverse effect of corticosteroid injections.¹⁰⁰ While the overall incidence is low, estimated at around 0.1% in a meta-analytic assessment, isolated case reports have described these complications across a wide range of anatomical sites.¹⁰⁰ Available evidence suggests a higher likelihood of occurrence in the setting of multiple corticosteroid injections administered to the same anatomical region.⁹⁶

Conclusions

In recent years, interventional MSK-US has become a precise, safe, and minimally invasive technique, increasingly replacing or reducing the need for fluoroscopy and CT in many procedures. Its uses range from traditional interventions on tendons, joints, and soft tissues to more complex procedures like spinal injections, bone biopsies, and peripheral neuromodulation.

The integration of advanced technologies, including high-frequency probes, microvascular imaging, needle tracking, and portable or robotic systems, has significantly improved procedural accuracy and patient safety. However, a thorough understanding of the limitations of pharmacologic therapies and emerging treatment options remains crucial. The choice among corticosteroids, local anesthetics, PRP, or new drugs should be based on strong clinical evidence, carefully considering the possible risks of tissue damage or procedural complications.

Finally, strategies aimed at reducing invasiveness, including ultrasound-guided alternatives to open surgery, represent a rapidly advancing field. The synergy between technological innovation, specialized training, and standardized protocols is expected to further incorporate interventional ultrasound into daily clinical practice, enhancing efficacy, safety, and patient comfort.

Conflicts of interest

The authors declare no conflicts of interest.

Funding

The authors declare no sources of funding related to this work.