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Regional shear wave elastography of Achilles tendinopathy in symptomatic versus contralateral Achilles tendons

  • Ultrasound
  • Published:
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Abstract

Objectives

Ultrasound often corroborates clinical diagnosis of Achilles tendinopathy (AT). Traditional measures assess macromorphological features or use qualitative grading scales, primarily focused within the free tendon. Shear wave imaging can non-invasively quantify tendon elasticity, yet it is unknown if proximal structures are affected by tendon pathology. The purpose of the study was to determine the characteristics of both traditional sonographic measures and regional shear wave speed (SWS) between limbs in patients with AT.

Methods

Twenty patients with chronic AT were recruited. Traditional sonographic measures of tendon structure were measured. Regional SWS was collected in a resting ankle position along the entire length of the tendon bilaterally. SWS measures were extracted and interpolated across evenly distributed points corresponding to the free tendon (FT), soleus aponeurosis (SA), and gastrocnemius aponeurosis (GA). Comparisons were made between limbs in both traditional sonographic measures and regional SWS.

Results

Symptomatic tendons were thicker (10.2 (1.9) vs. 6.8 (1.8) mm; p < 0.001) and had more hyperemia (p = 0.001) and hypoechogenicity (p = 0.002) than the contralateral tendon. Regional SWS in the FT was lower in the symptomatic limb compared to the contralateral limb (11.53 [10.99, 12.07] vs. 10.97 [10.43, 11.51]; p = 0.03). No differences between limbs were found for the SA (p = 0.13) or GA (p = 0.99).

Conclusions

Lower SWS was only observed in the FT in AT patients, indicating that alterations in tendon elasticity associated with AT were localized to the FT and did not involve the proximal passive tendon structures.

Key Points

• Baseline characteristics of a pilot sample of 20 subjects suffering from chronic Achilles tendinopathy showed differences in conventional sonographic measures of tendon thickness, qualitatively assessed hypoechogenicity, hyperemia, and quantitative measures of shear wave speed.

• Regional shear wave speeds were lower in the free tendon but not in the proximal regions of the soleus or gastrocnemius aponeuroses in Achilles tendinopathy patients.

• Using shear wave imaging to estimate tendon stiffness may prove beneficial for clinical validation studies to address important topics such as return to activity and the effectiveness of rehabilitation protocols.

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Abbreviations

AT:

Achilles tendinopathy

FT:

Free tendon

GA:

Gastrocnemius aponeurosis

SA:

Soleus aponeurosis

SWS:

Shear wave speed

References

  1. Kakouris N, Yener N, Fong DTP (2021) A systematic review of running-related musculoskeletal injuries in runners. J Sport Health Sci 10:513–522

    Article  Google Scholar 

  2. Florit D, Pedret C, Casals M, Malliaras P, Sugimoto D, Rodas G (2019) Incidence of tendinopathy in team sports in a multidisciplinary sports club over 8 seasons. J Sports Sci Med 18:780–788

    Google Scholar 

  3. De Jonge S, Van Den Berg C, De Vos RJ et al (2011) Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med 45:1026–1028

    Article  Google Scholar 

  4. Waldecker U, Hofmann G, Drewitz S (2012) Epidemiologic investigation of 1394 feet: coincidence of hindfoot malalignment and Achilles tendon disorders. Foot Ankle Surg 18:119–123

    Article  Google Scholar 

  5. Millar NL, Silbernagel KG, Thorborg K et al (2021) Tendinopathy. Nat Rev Dis Prim 7:1

    Article  Google Scholar 

  6. Peltz CD, Haladik JA, Divine G, Siegal D, Van Holsbeeck M, Bey MJ (2013) ShearWave elastography: repeatability for measurement of tendon stiffness. Skelet Radiol 42:1151–1156

    Article  CAS  Google Scholar 

  7. Dirrichs T, Schrading S, Gatz M, Tingart M, Kuhl CK, Quack V (2019) Shear wave elastography (SWE) of asymptomatic Achilles tendons: a comparison between semiprofessional athletes and the nonathletic general population. Acad Radiol 26:1345–1351

    Article  Google Scholar 

  8. Payne C, Watt P, Cercignani M, Webborn N (2018) Reproducibility of shear wave elastography measures of the Achilles tendon. Skelet Radiol 47:779–784

    Article  Google Scholar 

  9. Dorado Cortez C, Hermitte L, Ramain A, Mesmann C, Lefort T, Pialat JB (2016) Ultrasound shear wave velocity in skeletal muscle: a reproducibility study. Diagn Interv Imaging 97:71–79

    Article  Google Scholar 

  10. Šarabon N, Kozinc Ž, Podrekar N (2019) Using shear-wave elastography in skeletal muscle: a repeatability and reproducibility study on biceps femoris muscle. PLoS One 14:e0222008

    Article  Google Scholar 

  11. Mendes B, Firmino T, Oliveira R et al (2018) Hamstring stiffness pattern during contraction in healthy individuals: analysis by ultrasound-based shear wave elastography. Eur J Appl Physiol 118:2403–2415

    Article  Google Scholar 

  12. DeWall RJ, Slane LC, Lee KS, Thelen DG (2014) Spatial variations in Achilles tendon shear wave speed. J Biomech 47:2685–2692

    Article  Google Scholar 

  13. Slane LC, DeWall R, Martin J, Lee K, Thelen DG (2015) Middle-aged adults exhibit altered spatial variations in Achilles tendon wave speed. Physiol Meas 36:1485–1496

    Article  Google Scholar 

  14. Slane LC, Martin J, DeWall R, Thelen D, Lee K (2017) Quantitative ultrasound mapping of regional variations in shear wave speeds of the aging Achilles tendon. Eur Radiol 27:474–482

    Article  Google Scholar 

  15. Chernak LA, Dewall RJ, Lee KS, Thelen DG (2013) Length and activation dependent variations in muscle shear wave speed. Physiol Meas 34:713–721

    Article  CAS  Google Scholar 

  16. Le Sant G, Ates F, Brasseur JL, Nordez A (2015) Elastography study of hamstring behaviors during passive stretching. PLoS One 10:e0139272

    Article  Google Scholar 

  17. Wang AB, Perreault EJ, Royston TJ, Lee SSM (2019) Changes in shear wave propagation within skeletal muscle during active and passive force generation. J Biomech 94:115–122

    Article  Google Scholar 

  18. Corrigan P, Zellers JA, Balascio P, Silbernagel KG, Cortes DH (2019) Quantification of mechanical properties in healthy Achilles tendon using continuous shear wave elastography: a reliability and validation study. Ultrasound Med Biol 45:1574–1585

    Article  Google Scholar 

  19. Gatz M, Betsch M, Bode D et al (2020) Intra individual comparison of unilateral achilles tendinopathy using B-mode, power doppler, ultrasound tissue characterization and shear wave elastography. J Sports Med Phys Fitness 60:1462–1469

    Article  Google Scholar 

  20. Gatz M, Betsch M, Dirrichs T et al (2020) Eccentric and isometric exercises in Achilles tendinopathy evaluated by the VISA-A score and shear wave elastography. Sports Health 12:373–381

    Article  Google Scholar 

  21. Dirrichs T, Quack V, Gatz M, Tingart M, Kuhl CK, Schrading S (2016) Shear wave elastography (SWE) for the evaluation of patients with tendinopathies. Acad Radiol 23:1204–1213

    Article  Google Scholar 

  22. Prado-Costa R, Rebelo J, Monteiro-Barroso J, Preto AS (2018) Ultrasound elastography: compression elastography and shear-wave elastography in the assessment of tendon injury. Insights Imaging 9:791–814

    Article  Google Scholar 

  23. Dirrichs T, Quack V, Gatz M et al (2018) Shear wave elastography (SWE) for monitoring of treatment of tendinopathies: a double-blinded, longitudinal clinical study. Acad Radiol 25:265–272

    Article  Google Scholar 

  24. Gatz M, Schweda S, Betsch M et al (2021) Line- and point-focused extracorporeal shock wave therapy for Achilles tendinopathy: a placebo-controlled RCT study. Sports Health 13:511–518

    Article  Google Scholar 

  25. Martin JA, Biedrzycki AH, Lee KS et al (2015) In vivo measures of shear wave speed as a predictor of tendon elasticity and strength. Ultrasound Med Biol 41:2722–2730

    Article  Google Scholar 

  26. Robinson JM, Cook JL, Purdam C et al (2001) The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 35:335–341

    Article  CAS  Google Scholar 

  27. Ryan M, Wong A, Rabago D, Lee K, Taunton J (2011) Ultrasound-guided injections of hyperosmolar dextrose for overuse patellar tendinopathy: a pilot study. Br J Sports Med 45:972–977

    Article  Google Scholar 

  28. Kot BCW, Zhang ZJ, Lee AWC, Leung VYF, Fu SN (2012) Elastic modulus of muscle and tendon with shear wave ultrasound elastography: variations with different technical settings. PLoS One 7:e44348

    Article  CAS  Google Scholar 

  29. Matthews W, Ellis R, Furness JW, Rathbone E, Hing W (2020) Staging Achilles tendinopathy using ultrasound imaging: the development and investigation of a new ultrasound imaging criteria based on the continuum model of tendon pathology. BMJ Open Sport Exerc Med 6:e000699

    Article  Google Scholar 

  30. Konor MM, Morton S, Eckerson JM, Grindstaff TL (2012) Reliability of three measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther 7:279–287

    Google Scholar 

  31. Slane LC, Thelen DG (2015) Achilles tendon displacement patterns during passive stretch and eccentric loading are altered in middle-aged adults. Med Eng Phys 37:712–716

    Article  Google Scholar 

  32. Splittgerber LE, Ihm JM (2019) Significance of asymptomatic tendon pathology in athletes. Curr Sports Med Rep 18:192–200

    Article  Google Scholar 

  33. Giombini A, Dragoni S, Di Cesare A, Di Cesare M, Del Buono A, Maffulli N (2013) Asymptomatic Achilles, patellar, and quadriceps tendinopathy: a longitudinal clinical and ultrasonographic study in elite fencers. Scand J Med Sci Sports 23:311–316

    Article  CAS  Google Scholar 

  34. Comin J, Cook JL, Malliaras P et al (2013) The prevalence and clinical significance of sonographic tendon abnormalities in asymptomatic ballet dancers: a 24-month longitudinal study. Br J Sports Med 47:89–92

    Article  Google Scholar 

  35. Kulig K, Chang Y-J, Winiarski S, Bashford GR (2016) Ultrasound-based tendon micromorphology predicts mechanical characteristics of degenerated tendons. Ultrasound Med Biol 42:664–673

    Article  Google Scholar 

  36. Krupenevich RL, Beck ON, Sawicki GS, Franz JR (2022) Reduced Achilles tendon stiffness disrupts calf muscle neuromechanics in elderly gait. Gerontology 68:241–251

    Article  Google Scholar 

  37. Klein EE, Weil L, Weil LS, Fleischer AE (2013) Body mass index and Achilles tendonitis: a 10-year retrospective analysis. Foot Ankle Spec 6:276–282

    Article  Google Scholar 

  38. Child S, Bryant AL, Clark RA, Crossley KM (2010) Mechanical properties of the Achilles tendon aponeurosis are altered in athletes with achilles tendinopathy. Am J Sports Med 38:1885–1893

    Article  Google Scholar 

  39. Obst SJ, Heales LJ, Schrader BL et al (2018) Are the mechanical or material properties of the Achilles and patellar tendons altered in tendinopathy? A systematic review with meta-analysis. Sports Med 48:2179–2198

    Article  Google Scholar 

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Funding

Funding for this work was provided by the Radiological Society of North America (Scholar Grant) RSCH1317, the University of Wisconsin Madison Radiology Department Research and Development Fund (#1204-001), and the Clinical and Translational Science Award (CTSA) program, previously through the National Center for Research Resources (NCRR) grant 1UL1RR025011, and now by the National Center for Advancing Translational Sciences (NCATS), grant 9U54TR000021.

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Authors and Affiliations

  1. Department of Kinesiology, University of Wisconsin-Madison, Madison, WI, USA

    Scott K. Crawford

  2. Department of Orthopedics & Rehabilitation, University of Wisconsin-Madison, Madison, WI, USA

    Scott K. Crawford, Bryan C. Heiderscheit & John J. Wilson

  3. Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA

    Darryl Thelen

  4. Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA

    Darryl Thelen & Bryan C. Heiderscheit

  5. Department of Radiology, School of Medicine and Public Health, University of Wisconsin-Madison, E3/311, 600 Highland Ave, Madison, WI, 53792, USA

    Janice M. Yakey & Kenneth S. Lee

  6. Badger Athletic Performance Program, University of Wisconsin-Madison, Madison, WI, USA

    Bryan C. Heiderscheit

Authors
  1. Scott K. Crawford
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  2. Darryl Thelen
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Corresponding author

Correspondence to Kenneth S. Lee.

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Guarantor

The scientific guarantor of this publication is Kenneth S. Lee.

Conflict of interest

The authors of this manuscript declare relationships with the following companies:

Kenneth S. Lee

Grant: NBA/GE Collaborative

Royalties: Elsevier

In Kind Research support: Supersonic Imagine

John J. Wilson

Grant: DePuy-Mitek

No other authors have conflicts of interest related to this work.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

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Institutional Review Board approval was obtained.

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• observational

• performed at one institution

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Crawford, S.K., Thelen, D., Yakey, J.M. et al. Regional shear wave elastography of Achilles tendinopathy in symptomatic versus contralateral Achilles tendons. Eur Radiol 33, 720–729 (2023). https://doi.org/10.1007/s00330-022-08957-3

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  • DOI: https://doi.org/10.1007/s00330-022-08957-3

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