Texture Analysis in Musculoskeletal Ultrasonography: A Systematic Review

Background: The objective of this systematic review was to summarize the findings of texture analyses of musculoskeletal ultrasound images and synthesize the information to facilitate the use of texture analysis on assessing skeletal muscle quality in various pathophysiological conditions. Methods: Medline, PubMed, Scopus, Web of Science, and Cochrane databases were searched from their inception until January 2025 using the PRISMA Diagnostic Test Accuracy and was registered at PROSPERO CRD42025636613. Information related to patients, interventions, ultrasound settings, texture analyses, muscles, and findings were extracted. The quality of evidence was evaluated using QUADAS-2. Results: A total of 38 studies using second-order and higher-order texture analysis met the criteria. The results indicated that no studies used an established reference standard (histopathology) to evaluate the accuracy of ultrasound texture analysis in diagnosing muscle quality. Alternative reference standards were compared, including various physiological, pathological, and pre-post intervention comparisons using over 200+ texture features of various muscles on diverse pathophysiological conditions. Conclusions: The findings of these included studies demonstrating that ultrasound texture analysis was able to discriminate changes in muscle quality using texture analysis between patients with pathological conditions and healthy conditions, including popular gray-level co-occurrence matrix (GLCM)-based contrast, correlation, energy, entropy, and homogeneity. Studies also demonstrated that texture analysis can discriminate muscle quality in various muscles under pathophysiological conditions although evidence is low because of bias in subject recruitment and lack of comparison with the established reference standard. This is the first systematic review of the use of texture analysis of musculoskeletal ultrasonography in assessing muscle quality in various muscles under diverse pathophysiological conditions.