Echo intensity is not an accurate surrogate marker of intramuscular fat and fibrosis: A systematic review with meta-analyses

Background: Intramuscular fat and fibrous tissue deposition increase with ageing, disuse, and disease and contribute to impaired muscle function and reduced 'muscle quality'. Magnetic resonance imaging (MRI) and biopsy provide reference measures of muscle composition, but their cost, invasiveness, and limited accessibility restrict routine use. B-mode ultrasonography has emerged as a practical, low-cost alternative, with ultrasound-derived echo intensity widely interpreted as a surrogate measure (index) of intramuscular fat, fibrosis, and 'muscle quality'. However, such interpretation warrants further scrutiny. Aim: To quantify the relationship between ultrasound-derived echo intensity and reference measures of intramuscular fat and fibrous tissue and determine whether these relationships vary across muscles or according to anatomical and methodological factors. Methods: A systematic search of six databases was conducted (last search: August 2026). Human and animal studies reporting correlations between echo intensity and measures of intramuscular fat or fibrous tissue using MRI, histology, or chemical analysis were synthesised using multilevel random-effects meta-analysis with study-level cluster-robust inference. Correlations were Fisher z-transformed and back-transformed for interpretation. Exploratory analyses examined fat compartment, muscle, muscle architecture, health status, study model, and distance-correction procedures. Results: Twenty-eight studies met the eligibility criteria. For intramuscular fat, 204 effects from 23 independent studies yielded a weak-to-moderate pooled correlation with echo intensity (r=0.54, 95% CI: 0.45-0.61; 95% PI: - 0.02-0.84; P<0.01), with substantial heterogeneity (I^2=74.5%). The wide prediction interval suggests the true correlation could range from negligible to strong. No significant moderation effects were observed for study model (animal vs. human: r=0.46 vs. 0.55; P=0.26), health status (clinical vs. healthy: r=0.64 vs. 0.49; P=0.11), probe-to-muscle distance correction (corrected vs. raw echo intensity: r=0.57 vs. 0.53; P=0.25), or muscle architecture (non-pennate vs. pennate: r=0.63 vs. 0.53; P=0.56), although some categories contained few studies and effects. Model-based inference indicated significant moderation effect of lipid compartment (intramyocellular lipid vs. total intramuscular fat vs. extramyocellular lipid: r=0.10 vs. 0.57 vs. 0.49; P<0.001) but this effect was not significant under cluster-robust inference (P=0.50). For fibrous tissue, six effects from four studies yielded a weak, non-significant pooled correlation (r=0.34, 95% CI -0.39, 0.81], 95% PI [-0.85, 0.96]; P=0.24). Conclusions: Echo intensity is weakly-to-moderately associated with intramuscular fat, and this varied substantially across studies and muscles, whereas evidence for intramuscular fibrous tissue is limited and uncertain. These findings provide limited support for interpreting echo intensity as a surrogate measure or an index of intramuscular fat or fibrosis or, on this basis, as an index of 'muscle quality'.