Ultrasound-guided versus landmark-guided injections in musculoskeletal practice: a scoping review of clinical efficacy, educational needs, and economic considerations

Intra-articular corticosteroid injections are commonly used to manage musculoskeletal pain, but accurate placement is essential for efficacy and safety. Ultrasound-guided (US) injections offer real-time visualization, improving precision, with an unproven effect on complication rates compared with landmark-guided (LMG) techniques. Despite their growing use, the cost-effectiveness and training requirements of the ultrasound guidance remain unclear or unexplored. The purpose of the study is to map and characterize the available evidence comparing ultrasound-guided injections to landmark-guided approaches across major joints, while addressing education and cost considerations. A scoping review was conducted following PRISMA-ScR guidance. Five databases were searched (PubMed, Embase, Cochrane, Scopus, Web of Science) on June 24, 2025. Full search strings for each database are provided in Supplementary File 1. Records were de-duplicated and screened in Rayyan.ai by two independent reviewers at title/abstract and full-text stages; Rayyan was used only for de-duplication and screening organization, not for eligibility decisions or data extraction. Pre-defined outcomes were pain (VAS/NRS), validated function scores, injection accuracy, and cost. 29 studies were included and stratified by joint: shoulder (16), knee (6), elbow (4), with 3 studies providing a cost analysis perspective. Effectiveness varied across studies, ranging from no significant difference to large statistical and clinical significance as seen in Tables 1, 2 and 3. Cost findings were derived from a small number of studies using non-comparable models and were not synthesizable. US-guided injections reliably improve placement accuracy and may provide short-term symptomatic benefit at selected sites, but comparative clinical superiority is not established at longer follow-up and cost-effectiveness remains undetermined. Adequately powered randomized trials with standardized outcomes and uniform economic analyses are research priorities. Use of US in clinical practice remains dependent on the patient focused anatomy, clinician requirements, and facility’s economic considerations.