Abstract
Ultrasound is increasingly used in neurological rehabilitation, most visibly to improve the accuracy and safety of botulinum toxin (BoNT) and phenol administration for spasticity. However, its potential to contribute to wider clinical decision-making remains underdeveloped, particularly through characterisation of structural muscle–tendon unit (MTU) changes that may help clinicians interpret the relative neural and structural contributors to stiffness and contracture. This position paper argues that ultrasound should be conceptualised not only as a procedural adjunct but also as a clinical decision-support tool. We synthesise current evidence supporting muscle ultrasound for tissue characterisation and intervention guidance, outline barriers to implementation, and distinguish established procedural applications from the emerging use of ultrasound for tissue-informed clinical decision support. The modified Heckmatt scale is presented as one feasible method for tissue characterisation within this broader ultrasound toolkit, while recognising that validated thresholds linking ultrasound findings to specific treatment decisions have not yet been established. Further methodological standardisation, competency development and prospective evaluation are required before these emerging applications can be incorporated consistently into routine clinical pathways.