Own the turf or lose it: Ultrasound‐guided procedures and the future of shoulder repair

To highlight why the current arthroscopy-centred paradigm may be insufficient for rotator cuff disease and to propose a surgeon-led transition towards office-based, ultrasound-guided 'micro' interventions. The central question is whether earlier, less invasive image-guided procedures can preserve tissue biology and improve value while maintaining patient safety. This commentary synthesises five decades of arthroscopic shoulder surgery principles with contemporary rotator cuff care pathways and the rapid expansion of musculoskeletal ultrasound outside the operating room. Emerging enabling technologies, including navigation, dedicated micro-instruments, and standardised procedural workflows, are considered to outline a plausible near-term shift in first-line procedural care. Arthroscopy has transformed shoulder surgery, yet its foundational approach has changed little: fluid distension for visualisation, tissue ablation to create a view, and dependence on costly operating-room infrastructure. In rotator cuff disease, clinical practice often tolerates prolonged delay, during which imaging, injections, and adjunctive therapies repeatedly consume resources while tendon and muscle degeneration progress. This delay can culminate in complex salvage procedures once reparative biology is compromised. In parallel, ultrasound has become ubiquitous and increasingly capable of supporting interventional solutions beyond diagnosis and injections. As barriers to adoption decrease, first-line procedures may move upstream, potentially shifting the scope of practice away from surgeons unless they actively shape standards and evidence. The appropriate response is not territorialism but leadership. Shoulder surgeons should treat ultrasound literacy as foundational, adopt a deliberate micro-interventional mindset, develop and validate safety-first workflows, and generate comparative evidence that patients and health systems require. If surgeons lead this transition, earlier intervention may preserve biology and value; if not, the next paradigm will be defined elsewhere.