Background Post-stroke muscle stiffness is a major challenge in the rehabilitation of stroke survivors, with no gold standard in clinical assessment. Muscle stiffness is typically evaluated by the Modified Ashworth Scale or the Tardieu Scale; however, these can have low reliability and sensitivity. Ultrasound elastography is an advanced imaging technology that can quantitatively measure the stiffness of a tissue and has been shown to have good construct validity when compared to clinically assessed muscle stiffness and functional motor recovery. Objective The purpose of this article is to systematically review the literature regarding the change in muscle stiffness as measured by ultrasound elastography in stroke survivors. Methods Scopus, PubMed, Embase, CINAHL, MEDLINE and Cochrane Library were searched for relevant studies that assessed the change in stiffness of post-stroke muscle stiffness measured by ultrasound elastography following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results In total, 29 articles were identified, using either strain elastography and shear wave elastography to measure the stiffness of muscles in stroke survivors, most frequently in the biceps and medial gastrocnemius muscles. The stiffness was typically higher in the paretic compared to the non-paretic or healthy control. Other variations that increased the stiffness include increasing the joint angle and introducing a passive stretch or muscle activation. The paretic muscle has also been assessed pre- and post-treatment demonstrating a decrease in stiffness. Conclusion Ultrasound elastography is a promising imaging technology for determining the muscle stiffness in stroke survivors with need for a standardized imaging protocol.

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