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.

OBJECTIVE:The suprascapular nerve (SSN) provides major motor and sensory innervation to the shoulder. Its accurate identification on ultrasound is challenging because of its small size, low contrast and proximity to structures with similar echotexture. This study aimed to develop and evaluate a deep learning-based approach for multi-class segmentation of the SSN and adjacent structures in dynamic supraclavicular ultrasound. METHODS:Dynamic ultrasound videos (n = 80) from 42 healthy adults were manually annotated for the SSN, brachial plexus, subclavian artery and omohyoid muscle. A Double U-Net architecture was implemented, incorporating a VGG-19 pre-trained encoder in the first stage and a randomly initialized encoder in the second stage, together with Atrous Spatial Pyramid Pooling and Squeeze-and-Excitation blocks. Ablation experiments examined the effects of encoder choice, architectural design, annotation strategy, loss function and output weighting. Segmentation performance was evaluated using Dice similarity coefficients on an independent test set. RESULTS:The Double U-Net significantly outperformed the baseline U-Net across all annotated structures. For SSN segmentation, the mean Dice coefficient improved from 0.51 ± 0.19 to 0.68 ± 0.11 (p = 0.03), with greater stability across test videos. A pre-trained VGG-19 encoder showed higher Dice scores than alternative encoders, without statistical significance (p = 0.12). Ablation analyses confirmed complementary contributions of both stages (p = 0.52). Multi-structure supervision yielded modest benefit, with optimal performance when all four structures were annotated (Dice 0.68 ± 0.11). Focal loss achieved the highest average Dice score, and optimal performance was obtained by emphasizing the final output with limited intermediate supervision (α:β = 0.1:0.9). CONCLUSION:The proposed Double U-Net enables reliable multi-class segmentation of the SSN and surrounding structures in dynamic supraclavicular ultrasound, supporting its potential clinical application in suprascapular neuropathy.

Abstract Knee pain is one of the most prevalent musculoskeletal complaints and a leading cause of disability, particularly in middle-aged and older adults. Owing to the knee’s complex anatomy and its essential role in weight bearing and locomotion, an accurate diagnosis of knee disorders remains challenging. Although radiography and magnetic resonance imaging are indispensable for structural evaluation, musculoskeletal ultrasound (US) has gained recognition as an effective first-line imaging modality because of its real-time visualization, dynamic assessment capability, absence of ionizing radiation, and cost-effectiveness. This guideline follows the EURO-MUSCULUS/USPRM framework to present a standardized, anatomy-based approach to knee ultrasonography, with emphasis on optimal patient positioning and systematic examination of the anterior, medial, lateral, and posterior compartments. Key anatomical structures – including the suprapatellar recess, quadriceps and patellar tendons, medial/lateral collateral ligaments, menisci, iliotibial band, posterior cruciate ligament, and the semimembranosus-gastrocnemius bursa – are detailed alongside their corresponding sonographic landmarks. Common knee pathologies, such as joint effusion, synovial hypertrophy, tendinopathy, ligament and meniscal tears, iliotibial band syndrome, and Baker’s cysts, are illustrated with characteristic grayscale and Doppler US features. In addition, practical guidance on US-guided knee interventions, including suprapatellar joint injection, bursal injections, and Baker’s cyst aspiration, is provided. By integrating standardized scanning protocols with interventional techniques, this guideline seeks to improve diagnostic reproducibility, enhance recognition of common knee pathologies, and promote the routine clinical adoption of musculoskeletal US in knee assessment.

BACKGROUND:Alterations in shoulder muscle thickness and strength are believed to be associated with rotator cuff (RC) tendinopathy. Previous studies have mainly focused on measuring the supraspinatus tendon thickness in relevant patients with shoulder pain. This study examined differences in shoulder muscle thickness and RC strength in the symptomatic and asymptomatic shoulders of patients with RC tendinopathy. METHODS:Thirty-five patients with unilateral RC tendinopathy were included in this study. Muscle thickness of the supraspinatus, infraspinatus, deltoid, and combined middle trapezius+rhomboid was measured via ultrasonography, while RC strength (internal rotator [IR] and external rotator [ER]) at 60°/s and 180°/s was assessed using an isokinetic device. FINDINGS:No significant differences were found in muscle thickness (supraspinatus p = .342; infraspinatus, p = .746; deltoid p = .112; middle trapezius+rhomboid, p = .378), RC strength (ER 60°/s p = .283; IR 60°/s p = .337; ER 180°/s p = .334; IR 180°/s p = .141), or ER/IR strength ratios (60°/s p = .857; 180°/s p = .379) between symptomatic and asymptomatic shoulders. Significant correlations ranging from weak-to-high were found between supraspinatus, infraspinatus, and deltoid thickness and RC strength (r = 0.354-0.732, p < .05). A moderate correlation was observed between middle trapezius+rhomboid thickness and shoulder ER strength (r = 0.620-0.625, p < .001), but no correlation with IR strength (p > .05). INTERPRETATION:Patients with RC tendinopathy exhibited similar shoulder muscle thickness, ER and IR strength, and ER/IR strength ratios between symptomatic vs. asymptomatic shoulders. Additionally, shoulder muscle thickness appears to be associated with shoulder rotator strength.

This case highlights the diagnostic value of high-resolution ultrasonography in identifying postoperative injury of the posterior branch of the medial antebrachial cutaneous nerve (MABCN) following cubital tunnel surgery. A 45-year-old man developed localized pain, warmth, and paresthesia extending from the medial epicondyle to the proximal anterior forearm one month after ulnar nerve decompression and anterior transposition. Physical examination revealed focal allodynia and a positive Tinel sign. Because previous surgery may substantially alter the anatomical location of the surrounding nerves, electrodiagnostic localization can be technically challenging and less reliable. Ultrasonography therefore played a key diagnostic role. The images demonstrated the normal sonoanatomy of the MABCN and its anatomical relationship with the basilic vein and ulnar nerve, followed by pathologic findings of focal enlargement of the posterior branch adjacent to postoperative scar tissue. These imaging features, together with a positive sonographic Tinel sign, supported the diagnosis of localized nerve irritation. Ultrasound-guided hydrodissection using 5% dextrose and methylcobalamin resulted in marked clinical improvement, with the Visual Analog Scale pain score decreasing from 9 to 2. This case is particularly illustrative because postoperative injury of the MABCN may mimic recurrent cubital tunnel syndrome yet typically produces purely sensory symptoms confined to the medial elbow region. Targeted ultrasonographic evaluation can reveal subtle postoperative nerve pathology and guide effective ultrasound-guided intervention.

Sciatic neuropathy is most commonly attributed to spinal or muscular causes, whereas vascular-related compression remains underrecognized. We report a case of sciatic nerve entrapment caused by an anomalous inferior gluteal artery in the deep gluteal region, who presented with persistent right gluteal and posterior thigh pain for more than two years, refractory to multiple conservative treatments. Physical examination demonstrated marked allodynia and a well-defined Tinel-like sign, with radiating symptoms extending to the lower limb, suggesting a peripheral etiology. High-resolution ultrasonography identified an aberrant inferior gluteal artery, which crossed over and compressed the sciatic nerve, forming an accompanying artery of the sciatic nerve. Doppler imaging confirmed the vascular nature of the structure, while long-axis views demonstrated focal nerve compression with segmental swelling. Magnetic resonance imaging further corroborated the diagnosis. Ultrasound-guided hydrodissection using 5% dextrose and lidocaine was performed, resulting in significant symptom relief. Pain scores improved from 7 to 3 after treatment, with resolution of symptoms at two-month follow-up. This case highlights a rare neurovascular cause of sciatic nerve entrapment and underscores the importance of ultrasonography in identifying anatomical variations. Recognition of vascular contributions to deep gluteal syndrome may improve diagnostic accuracy and guide targeted interventions.

Posterior interosseous nerve (PIN) syndrome is an uncommon neuropathy that may mimic lateral epicondylitis. High-resolution ultrasound aids its diagnosis by revealing nerve swelling, while ultrasound-guided injection is increasingly employed for decompression. Nevertheless, the influence of injection axis on injectate distribution remains unclear. This study aimed to compare the spread characteristics and accuracy of short-axis vs. long-axis ultrasound-guided injections at the proximal and distal PIN using cadaveric validation.Kindly check and confirm the city name is correctly identified in affiliation [6].It is correctly identified. Ten cadaveric limbs were randomized to short-axis (n = 5) or long-axis (n = 5) injections. Ultrasound parameters, including fascicle count, cross-sectional area, and surrounding muscle or tendon thickness, were recorded. Proximal and distal injections were performed separately with 5 mL of injectate. Subsequent dissection assessed target infiltration and spread dimensions (length, width). Ultrasound findings were comparable between the groups with no significant differences in cross-sectional area or muscle/tendon thickness. On dissection, all injections achieved successful proximal and distal PIN infiltration. At the proximal level, short-axis injections produced significantly greater infiltration width (43.6 ± 6.2 mm vs. 24.3 ± 13.2 mm, p = 0.032), while infiltration length was not significantly different (88.8 ± 17.4 mm vs 77.1 ± 37.1 mm, p = 0.690). At the distal level, both infiltration length (81.0 ± 24.4 mm vs. 67.7 ± 37.4 mm, p = 0.548) and width (28.2 ± 10.9 mm vs. 22.5 ± 8.8 mm, p = 0.548) were numerically greater with short-axis injections, although the differences did not reach statistical significance. Both short- and long-axis ultrasound-guided injections consistently achieved target infiltration of the PIN. The short-axis approach provided broader proximal spread, which may enhance circumferential perineural coverage, whereas the distal injections showed no significant differences between techniques. These findings support the reliability of both approaches, while highlighting a potential advantage of short-axis guidance at the proximal forearm.

Wrist and hand disorders are among the common musculoskeletal complaints, with high-resolution ultrasonography now regarded as an indispensable tool for their evaluation and management. Building upon the EURO-MUSCULUS/USPRM framework and the educational principles of the Ultrasound Musculoskeletal Workshop in Taiwan and the Neuromuscular Ultrasound Workshop in Taiwan programs, this guideline provides a standardized, anatomy-based approach to diagnostic and interventional ultrasound (US) of the wrist and hand. The protocol outlines systematic scanning of the six extensor compartments, scapholunate ligament, triangular fibrocartilage complex, carpal tunnel, Guyon's canal, A1 pulley, and digital collateral ligaments. It also integrates patient positioning, transducer orientation, and dynamic maneuvers to optimize visualization. Tripartite visual documentation, comprising cadaveric dissections, schematic anatomical illustrations, and paired US images from both high-end and handheld devices, supports reproducible interpretation. Common pathologies - including De Quervain tenosynovitis, scapholunate ligament injuries, triangular fibrocartilage complex disorders, trigger finger and trigger thumb, and carpal tunnel syndrome - are characterized with their key sonographic features and functional correlates. Practical pearls for US-guided interventions are outlined for De Quervain tenosynovitis, scapholunate joint, A1 pulley, and carpal tunnel. Emphasizing the principle of "diagnosis ahead of intervention"; this guideline aims to enhance consistency, safety, and clinical effectiveness in the US-based assessment, diagnosis, and treatment of wrist and hand disorders. It provides an image-anatomy framework suitable for future integration into artificial intelligence-assisted systems as well.

OBJECTIVES:This observational study aimed to define a standardized sonographic approach for evaluating the elementary lesions of the tendon-bone junction (TBJ) in insertional Achilles tendinopathy (IAT). METHODS:Using high-frequency transducers, we matched the histological microarchitecture and the anatomical features of the TBJ of the Achilles tendon in patients with a clinical diagnosis of IAT. Colour/power Doppler assessments have been performed as well. RESULTS:Fifty-eight patients, with a mean age of 54 years (54.50 ± 11.72) and a gender distribution of 32 males (55.17%) and 26 females (44.83%), were enrolled in this observational study. Five elementary lesions of IAT were sonographically defined: bone spur, calcified longitudinal fissuration, intra-tendinous bony formation, tendon-bone disjunction, and fibrocartilage hyperemia. Moreover, specific sonographic signs have been identified to differentiate bony spurs in the growing phase and end-stage. CONCLUSIONS:Using high-frequency B-mode and high-sensitive Doppler imaging, detailed sonographic assessment of the TBJ can be performed in IAT patients. The aforementioned 5 elementary lesions can be considered as a standardized approach for prompt examination of this complex/anatomical region. ADVANCES IN KNOWLEDGE:Recent advances in ultrasound equipment allow for accurate assessment of the TBJ of the AT. The present observational study defined 5 elementary sonographic lesions of the IAT as bone spur, calcified longitudinal fissuration, intra-tendinous bony formation, tendon-bone disjunction, and fibrocartilage hyperemia. Pertinent ultrasound-guided procedures targeting the TBJ are also discussed.

This prospective study evaluated the diagnostic performance of deep learning models in predicting subacromial impingement syndrome (SIS) during dynamic shoulder ultrasonography, comparing a faster region-based convolutional neural network (Faster R-CNN) with a self-transfer learning CNN (STL-CNN). The utility of integrating a one-dimensional convolutional neural network (1D-CNN) for SIS classification was also examined. Participants underwent shoulder abduction and adduction during ultrasound imaging. Faster R-CNN and STL-CNN were trained to localize anatomical landmarks, and the better-performing model was paired with a 1D-CNN to differentiate SIS. Subacromial motion metrics—including acromiohumeral distance (AHD), horizontal AHD (hAHD), and vertical AHD (vAHD)—were used as classification features. Among 59 SIS patients and 59 controls, Faster R-CNN demonstrated significantly lower mean distance errors than STL-CNN for the greater tuberosity (0.1302 cm vs. 0.4835 cm, p = 0.03) and lateral acromion (0.0585 cm vs. 0.2634 cm, p = 0.02). vAHD yielded superior discrimination compared with AHD and hAHD. Using Faster R-CNN–derived trajectories, the 1D-CNN achieved 94

Objectives: In this systematic review, we discuss the literature regarding the accuracy and efficacy of ultrasound (US)-, fluoroscopy (FL)-, and landmark (LM)-guided intra-articular hip injections. Materials and methods: A systematic review was performed following the Cochrane process from April 2023 to August 2023 utilizing PubMed, Embase, Web of Science, and Scopus databases. Branched logic was used to include any articles that were published prior to April 2023 containing the key terms “hip” AND “ultrasound” AND “injections”. Two authors screened studies for eligibility, and any disagreements were resolved through discussion with a third reviewer. Risk-of-bias assessments were performed. Results: A total of five studies were included in the review. Individual studies demonstrated amounted to 100% (17/17) versus 85.4% (53/62) versus 70% (52/74) for US-, FL- and LM-guided intra-articular injections/arthrocentesis, respectively. All studies, except for one, addressing either the injection accuracy or improvement in pain showed improved outcomes in the US-guided injection/aspiration groups. Conclusion: This systematic review provides preliminary evidence for slightly better accuracy with US-guided intra-articular hip injections/arthrocentesis versus FL- or LM-guided intra-articular hip injections/aspirations. It contributes to the current literature by evaluating multiple measurable outcomes, including procedural accuracy, changes in pain scores, patient-reported procedural discomfort, and improvements in range of motion.