Background <p>Ultrasound (US) examination can now be considered a fundamental imaging modality in the diagnosis and monitoring of patients with rheumatoid arthritis (RA). Despite its widespread use, there is still a lack of standardization in examination protocols, and the clinical interpretation of ultrasound findings remains controversial.</p> Objective <p>The aim of this narrative review is to identify clinical scenarios in which musculoskeletal ultrasound may provide key information supporting therapeutic decision-making in rheumatoid arthritis.</p> Methods <p>A narrative literature review was performed based on studies identified in MEDLINE/PubMed and Embase. The study focused on evaluating the usefulness of US examination in RA based on randomized clinical trials, observational studies, and clinically relevant reports published over the last two decades.</p> Results <p>The presented study results indicate that routine use of US during treatment conducted in accordance with the treat-to-target (T2T) strategy does not have a significant impact on the clinical outcomes obtained. At the same time, US may play a key role in the decision-making process regarding treatment modification, as its results are less influenced by subjective factors and enable the identification of subclinical inflammation, which is associated with an increased risk of disease exacerbation in the following months.</p> Conclusion <p>Ultrasound should be regarded as a precise diagnostic tool in the evaluation of patients with RA rather than a substitute for clinical assessment. It should be employed primarily in situations where uncertainty exists regarding further therapeutic management, as its added clinical value is greatest in such contexts.</p>