Skeletal Radiology

, Volume 39, Issue 6, pp 509–521 | Cite as

Longitudinal microvascularity in Achilles tendinopathy (power Doppler ultrasound, magnetic resonance imaging time–intensity curves and the Victorian Institute of Sport Assessment–Achilles questionnaire): a pilot study

  • Paula J. RichardsEmail author
  • Iain W. McCall
  • Christopher Day
  • John Belcher
  • Nicola Maffulli
Review Article



To evaluate the imaging of the natural history of Achilles tendinopathy microvascularisation in comparison with symptoms, using a validated disease-specific questionnaire [the Victorian Institute of Sport Assessment–Achilles (VISA-A)].


A longitudinal prospective pilot study of nine patients with post-contrast magnetic resonance imaging (MRI), time–intensity curve (TIC) enhancement, ultrasound (US) and power Doppler (PD) evaluation of tendinopathy of the mid-Achilles tendon undergoing conservative management (eccentric exercise) over 1 year.


There were five men and four women [mean age 47 (range 30–62) years]. Six asymptomatic tendons with normal US and MRI appearance showed less enhancement than the tibial metaphysis did and showed a flat, constant, but very low rate of enhancement in the bone and Achilles tendon (9–73 arbitrary TIC units). These normal Achilles tendons on imaging showed a constant size throughout the year (mean 4.9 mm). At baseline the TIC enhancement in those with tendinopathy ranged from 90 arbitrary units to 509 arbitrary units. Over time, 11 abnormal Achilles tendons, whose symptoms settled, were associated with a reduction in MRI enhancement mirrored by a reduction in the number of vessels on power Doppler (8.0 to 2.7), with an improvement in morphology and a reduction in tendon size (mean 15–10.6 mm). One tendon did not change its abnormal imaging features, despite improving symptoms. Two patients developed contralateral symptoms and tendinopathy, and one had more abnormal vascularity on power Doppler and higher MRI TIC peaks in the asymptomatic side.


In patient with conservatively managed tendinopathy of the mid-Achilles tendon over 1 year there was a reduction of MRI enhancement and number of vessels on power Doppler, followed by morphological improvements and a reduction in size. Vessels per se related to the abnormal morphology and size of the tendon rather than symptoms. Symptoms improve before the Achilles size reduces and the restoration of normal imaging over time.


Achilles tendinopathy Power Doppler Magnetic resonance imaging (MRI) Time–intensity curves 



We thank Shearing Healthcare for the donation of some gadolinium. Shearing Healthcare had no direct input to, control of, or influence on, the study, design or results. We thank Dr. Richard’s long-suffering secretary, Cynthia Jackson, for preparing this document.


  1. 1.
    Richards PJ, Dheer AK, McCall IW. Achilles tendon (TA) size and power Doppler ultrasound (PD) changes compared to MRI: a preliminary observational study. Eur Radiol. 2000;10:G18.Google Scholar
  2. 2.
    Husson JL, De Korvin B, Polard JL, Attali JY, Duvauferrier R. Study of the correlation between MRI and surgery of Achilles tendon pathology. Acta Orthop Belg. 1994;60:408–12.PubMedGoogle Scholar
  3. 3.
    Fornage BD. Achilles tendon: US examination. Radiology. 1986;159:759–64.PubMedGoogle Scholar
  4. 4.
    Neuhold A, Stiskal M, Kainberger F, Schwaighofer B. Degenerative Achilles tendon disease: assessment by magnetic resonance and ultrasonography. Eur J Radiol. 1992;14:213–20.CrossRefPubMedGoogle Scholar
  5. 5.
    Astrom M, Gentze C-F, Nilsson P, Rausing A, Sjoberg S, Westlin N. Imaging in chronic Achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol. 1996;25:615–20.CrossRefPubMedGoogle Scholar
  6. 6.
    Maffulli N, Regine R, Angelillo M, Capasso G, Filice S. Ultrasound diagnosis of Achilles tendon pathology in runners. Br J Sports Med. 1987;21:158–62.CrossRefPubMedGoogle Scholar
  7. 7.
    Gibbon WW, Cooper JR, Radcliffe GS. Distribution of sonographically detected tendon abnormalities in patients with a clinical diagnosis of chronic Achilles tendinosis. J Clin Ultrasound. 2000;28(2):61–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Quinn SF, Murry WT, Clark RA, Cochran CF. Achilles tendon: MR Imaging at 1.5T. Radiology. 1987;164:767–70.PubMedGoogle Scholar
  9. 9.
    Karjalainen PT, Soila K, Aronen HJ, Pihlajamk HK, Tynninen O, Paavonen T, et al.. MR imaging of overuse injuries of the Achilles tendon. AJR Am J Neuroradiol. 2000;175:251–60.Google Scholar
  10. 10.
    Rubin JM, Bude RO, Carson PL, Bree Rl, Adler RS. Power Doppler US: a potentially useful alternative to mean frequency-based colour Doppler US. Radiology. 1994;190:853–6.PubMedGoogle Scholar
  11. 11.
    Öhberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med. 2002;36:173–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Weskott HP. Amplitude Doppler US: slow blood flow detection tested with a flow phantom. Radiology. 1997;202:125–30.PubMedGoogle Scholar
  13. 13.
    Theobald P, Benjamin M, Nokes L, Pugh N. Review of the vascularisation of the human Achilles tendon. Injury. 2005;36:1267–72.CrossRefPubMedGoogle Scholar
  14. 14.
    Movin T, Kristoffersen-Wiberg M, Shalabi A, Gad A, Aspelin R, Rolf C. Intratendinous alterations as imaged by US and contrast medium enhanced MRI in chronic achilldynia. Foot Ankle. 1998;19:311–7.PubMedGoogle Scholar
  15. 15.
    Richards PJ, Win T, Jones PW. The distribution of microvascular response in Achilles tendonopathy assessed by colour and power Doppler. Skeletal Radiol. 2005;34:336–42.CrossRefPubMedGoogle Scholar
  16. 16.
    Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, et al. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med. 2001;35:335–41.CrossRefPubMedGoogle Scholar
  17. 17.
    Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med. 2003;13:11–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26:360–6.PubMedGoogle Scholar
  19. 19.
    Backhaus M, Kamradt T, Sandrock D, Loreck D, Fritz J, Wolf KJ, et al. Arthritis of the finger joints. Arthritis Rheum. 1999;42:1232–54.CrossRefPubMedGoogle Scholar
  20. 20.
    Lang P, Honda G, Roberts T, Vahlensieck M, Johnston JO, Rosenauw W, et al. Musculoskeletal neoplasm: perineoplastic edema versus tumour on dynamic postcontrast MRI images with spatial mapping of instantaneous enhancement rates. Radiology. 1995;197:831–9.PubMedGoogle Scholar
  21. 21.
    Blankstein A, Cohen I, Diamant L, Heim M, Dudkiewicz I, Israeli A, et al. Achilles tendon pain and related pathologies: diagnosis by ultrasonography. Isr Med Assoc J. 2001;3:575–8.PubMedGoogle Scholar
  22. 22.
    Martinoli C, Pretrolesi F, Crespi G, Bianchi S, Gandolfo N, Valle M, et al. Power Doppler sonography: clinical applications. Eur J Radiol. 1998;27:2133–40.CrossRefGoogle Scholar
  23. 23.
    Ying M, Yeung E, Li B, Li W, Lui M, Tsoi C. Sonographic evaluation of the size of Achilles tendon: the effect of exercise and dominance of the ankle. Ultrasound Med Biol. 2003;29:637–42.CrossRefPubMedGoogle Scholar
  24. 24.
    Soila K, Karjalainen PT, Aronen HJ, Pihlajamaki HK, Tirman PJ. High resolution MRI of the asymptomatic Achilles tendon. AJR Am J Roentgenol. 1999;173:323–8.PubMedGoogle Scholar
  25. 25.
    Bertolotto M, Perrone R, Martinoli C, Rollandi GA, Patetta R, Derchi LE. High resolution ultrasound anatomy of normal Achilles tendon. Br J Radiol. 1995;68:986–91.CrossRefPubMedGoogle Scholar
  26. 26.
    Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. 1989;71(1):100–1.PubMedGoogle Scholar
  27. 27.
    Schmidt-Rohlfing B, Graf J, Schneider U, Niethard FU. The blood supply of the Achilles tendon. Int Orthop. 1992;16:29–31.CrossRefPubMedGoogle Scholar
  28. 28.
    Shalibi A, Kristoffersen-Wiberg M, Papadoginnakis N, Aspelin P, Movin T. Dynamic contrast-enhanced MRI imaging and histopathology in chronic Achilles tendinosis: a longitudanal MR study of 15 patients. Acta Radiol. 2002;43:198–206.Google Scholar
  29. 29.
    Rolf C, Movin T. Etiology, histopathology, and outcome of surgery in achillondynia. Foot Ankle Int. 1997;18:565–9.PubMedGoogle Scholar
  30. 30.
    Kvist M, Jozsa L, Jarvinen M. Vascular changes in the ruptured Achilles tendon and paratenon. Int Orthop. 1992;16:377–82.CrossRefPubMedGoogle Scholar
  31. 31.
    Maffulli N, Barrass V, Ewen SWB. Light microscopic histology of Achilles tendon ruptures. Am J Sports Med. 2000;28:857–63.PubMedGoogle Scholar
  32. 32.
    Movin T, Gad A, Reinhott FP, Rolf C. Tendon pathology in long-standing achillodynia: biopsy findings in 40 patients. Acta Orthop Scand. 1997;68:170–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Astrom M, Westlin N. Blood flow in the human Achilles tendon assessed by laser Doppler flowmetry. J Orthop Res. 1994;12:246–52.CrossRefPubMedGoogle Scholar
  34. 34.
    Knobloch K, Kraemer R, Lichtenberg A, Jagodzinski M, Gossling T, Richter M, et al. Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes. Am J Sports Med. 2006;34:92–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Alfredson H, Bjur D, Thorsen K, Lorentzon R, Sandstrom P. High intratendinous lactate levels in painful chronic Achilles tendinosis. An investigation using microdialysis technique. J Orthop Res. 2003;20:934–8.CrossRefGoogle Scholar
  36. 36.
    Astrom M, Westlin N. Blood flow in chronic Achilles tendinopathy. Clin Orthop Relat Res. 1994;308:166–72.PubMedGoogle Scholar
  37. 37.
    Peers KHE, Brys PPM, Lysen RJJ. Correlation between power Doppler US and clinical severity in Achilles tendinopathy. Int Orthop. 2003;27:180–3.PubMedGoogle Scholar
  38. 38.
    Mallinaris P, Richards PJ, Garau G, Maffulli N. Achilles tendon Doppler flow may be associated with mechanical loading among active athletes. Am J Sports Med. 2008;36:2210–6.CrossRefGoogle Scholar
  39. 39.
    Van Snellenberg W, Wiley JP, Brunet G. Achilles tendon pain intensity and level of neovascularisation in athletes as determined by color Doppler ultrasound. Scand J Med Sci Sports. 2007;17:530–4.PubMedGoogle Scholar
  40. 40.
    Cook JL, Kiss ZS, Ptasznik R, Malliaras P. Is vascularity more evident after exercise? Implications for tendon imaging. AJR Am J Neuroradiol. 2005;185:1138–40.Google Scholar
  41. 41.
    Zanetti M, Metzdork A, Kendert HP, Zollinger H, Vienne P, Siefert B, et al. Achilles tendons: clinical relevance of neovascularisation diagnosed with power Doppler US. Radiology. 2003;227:556–60.CrossRefPubMedGoogle Scholar
  42. 42.
    Reiter M, Ulreich N, Dirisamer A, Tscholakoff D, Bucek RA. Colour and power Doppler sonography in symptomatic achilles tendon disease. Int J Sports Med. 2004;25:301–5.CrossRefPubMedGoogle Scholar
  43. 43.
    Khan KM, Forster BB, Robinson J, Cheong Y, Louis L, Maclean L, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med. 2003;37:149–53.CrossRefPubMedGoogle Scholar
  44. 44.
    Haims AH, Schweitzer ME, Patel RS, Hecht P, Wapner KL. MR imaging of the Achilles tendon: overlap of findings in symptomatic and asymptomatic individuals. Skeletal Radiol. 2000;29:640–5.CrossRefPubMedGoogle Scholar
  45. 45.
    Bjordal JM, Lopes-Martins IVV. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. Br J Sports Med. 2006;40:76–80.CrossRefPubMedGoogle Scholar
  46. 46.
    Öhberg L, Alfredson H. Sclerosing therapy in chronic Achilles tendon insertional pain—results of a pilot study. Knee Surg Sports Traumatol Arthroscopy. 2003;11:339–43.CrossRefGoogle Scholar
  47. 47.
    Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the achilles tendon: a pilot study. AJR Am J Neuroradiol. 2007;189:215–20.Google Scholar
  48. 48.
    Mafi N, Lorentzon R, Alfredson H. Superior short-tem results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001;9:42–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Cowper SE, Robin HS, Steinberg SM. Scleromyxoedema-like cutaneous diseases in renal-dialysis patients. Lancet. 2000;356:1000–1.CrossRefPubMedGoogle Scholar
  50. 50.
    Broome DR, Girguis MS, Baron PW, Cottrell AC, Kjellin I, Kirk GA. Gadodiamide-associated nephrogenic systemic fibrosis: why radiologists should be concerned. AJR Am J Neuroradiol. 2007;188:586–92.Google Scholar
  51. 51.
    Shalabi A, Movin T, Kristoffersen-Wilberg M, Aspelin P, Svensson L. Reliability in the assessment of tendon volume and intratendinous signal of the Achilles tendon on MRI: a methodological description. Knee Surg Sports Traumatol Arthrosc. 2005;13:492–8.CrossRefPubMedGoogle Scholar
  52. 52.
    Cook JL, Ptaznik R, Kiss ZS, Malliaras P, Morris ME, De Luca J. High reproducibility of patellar tendon vascularity assessed by colour Doppler ultrasonography: a reliable measurement tool for quantifying tendon pathology. Br J Sports Med. 2005;39:700–3.CrossRefPubMedGoogle Scholar
  53. 53.
    Farrant JM, O’Connor PJ, Grainger AJ. Role of tendon position during Doppler sonography for neovascular tendinopathy (abstract). Skeletal Radiol. 2006;35:422.Google Scholar
  54. 54.
    Cook JL, Khan KM, Harcourt PR, Kiss ZS, Fehrmann MW, Griffiths L, et al. Patella tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Clin J Sport Med. 1998;8:73–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Sconfienza L, Silvestri E, Lacelli F, Bartolini B, Martinoli C, Garlaschi G. Evaluation of normal and pathologic appearance of achilles tendon with elastosonography: present and future applications (abstract). Skeletal Radiol. 2006;35:428.Google Scholar
  56. 56.
    Black J, Cook J, Kiss ZS, Smith M. Intertester reliability of sonography in patellar tendinopathy. J Ultrasound Med. 2004;23:671–5.PubMedGoogle Scholar

Copyright information

© ISS 2009

Authors and Affiliations

  • Paula J. Richards
    • 1
    • 2
    • 3
    Email author
  • Iain W. McCall
    • 2
    • 4
  • Christopher Day
    • 1
  • John Belcher
    • 5
  • Nicola Maffulli
    • 2
  1. 1.University Hospital of North Staffordshire NHS Trust (UHNS)Stoke on TrentUK
  2. 2.Keele UniversityKeeleUK
  3. 3.X-ray DepartmentNorth Staffs. Royal InfirmaryStoke on TrentUK
  4. 4.North Staffordshire NHS TrustStoke on TrentUK
  5. 5.Department of Primary Care and Public Health, North Wales Clinical SchoolCardiff UniversityCardiffUK

Personalised recommendations