Shear Wave Elastography in Musculoskeletal Imaging: A Narrative Review.

Shear wave elastography (SWE) is an increasingly investigated ultrasound-based technique in musculoskeletal imaging that provides quantitative information on tissue stiffness and biomechanical properties. This narrative review aims to summarize the basic principles, technical considerations, current clinical applications, limitations, and future perspectives of SWE in musculoskeletal imaging. Unlike conventional grayscale and Doppler ultrasonography, which mainly assess morphology and vascularity, SWE may provide additional functional information in major musculoskeletal tissues, including tendons and ligaments, skeletal muscles, peripheral nerves, fibrocartilaginous structures, plantar fascia, and selected soft tissue lesions. Current evidence suggests potential roles for SWE in detecting early biomechanical alterations, assessing disease severity, differentiating symptomatic from asymptomatic tissues, and monitoring response to treatment or rehabilitation. However, musculoskeletal tissues are anisotropic, viscoelastic, and position-dependent; as a result, SWE measurements are influenced by acquisition-related factors, tissue biomechanics, positioning and loading conditions, region of interest (ROI) placement, tissue depth, and device-related variability. For this reason, SWE findings should not be interpreted as standalone diagnostic criteria but should be considered together with clinical findings, conventional ultrasonography, MRI, electrophysiology, histopathology, and patient-centered outcomes when appropriate. This review highlights the need for tissue-specific measurement protocols, standardized reporting, normative reference data, inter-vendor harmonization, and longitudinal validation against clinically meaningful outcomes before SWE can be more reliably integrated into routine musculoskeletal imaging and rehabilitation practice.