Skip to main content

Prevalence of morphological and mechanical stiffness alterations of mid Achilles tendons in asymptomatic marathon runners before and after a competition



To determine the prevalence of morphological and mechanical stiffness alterations at the mid Achilles tendon in asymptomatic marathon runners before and after a competition. To assess the relationship between pre-existing Achilles tendon alterations and pain after running.

Materials and methods

All marathon runners from a local running club who were participating in the Melbourne Marathon 2013 (full marathon category) were invited for conventional ultrasound and sonoelastography 1 week leading up to the marathon and again within 3 days post-marathon. Another group of active, healthy individuals not involved in running activities were recruited as controls. Intratendinous morphological (tendon thickness, hypoechogenicities), Doppler as well as stiffness properties of the Achilles were recorded. Achilles tendon pain was evaluated using the visual analogue scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A).


Twenty-one asymptomatic runners (42 Achilles tendons) and 20 healthy controls (40 Achilles tendons) were examined. On the pre-marathon evaluation, runners showed significantly more morphological changes on B-mode ultrasound compared to the controls (p < 0.001). Marathon running induced a significant reduction in tendon stiffness (p = 0.049) and an increase in Doppler signals (p = 0.036). Four runners (4/21, 19 %) reported Achilles tendon pain after the race [VAS 4.0 (±1.9), VISA 74.2 (±10.1)]. Reduced tendon stiffness at baseline was associated with post-marathon Achilles tendon pain (p = 0.016).


Marathon runners demonstrate a higher prevalence of morphological alterations compared to non-runners. Marathon running caused a significant change in Achilles tendon stiffness and Doppler signals. Pre-existing soft Achilles tendon properties on sonoelastography may be a predisposing risk for development of symptoms post-running.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. Kvist M. Achilles tendon injuries in athletes. Sports Med. 1994;18(3):173–201.

    CAS  PubMed  Article  Google Scholar 

  2. Muraoka T, Muramatsu T, Fukunaga T, Kanehisa H. Geometric and elastic properties of in vivo human Achilles tendon in young adults. Cells Tissues Organs. 2004;178(4):197–203.

    PubMed  Article  Google Scholar 

  3. Kubo K, Kanehisa H, Fukunaga T. Effects of different duration isometric contractions on tendon elasticity in human quadriceps muscles. J Physiol. 2001;536(Pt 2):649–55.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  4. Arampatzis A, Karamanidis K, Morey-Klapsing G, De Monte G, Stafilidis S. Mechanical properties of the triceps surae tendon and aponeurosis in relation to intensity of sport activity. J Biomech. 2007;40(9):1946–52.

    PubMed  Article  Google Scholar 

  5. Rosager S, Aagaard P, Dyhre-Poulsen P, Neergaard K, Kjaer M, Magnusson SP. Load-displacement properties of the human triceps surae aponeurosis and tendon in runners and non-runners. Scand J Med Sci Sports. 2002;12(2):90–8.

    CAS  PubMed  Article  Google Scholar 

  6. Magnusson SP, Kjaer M. Region-specific differences in Achilles tendon cross-sectional area in runners and non-runners. Eur J Appl Physiol. 2003;90(5–6):549–53.

    PubMed  Article  Google Scholar 

  7. Kongsgaard M, Aagaard P, Kjaer M, Magnusson SP. Structural Achilles tendon properties in athletes subjected to different exercise modes and in Achilles tendon rupture patients. J Appl Physiol. 1985;99(5):1965–71. 2005.

    Article  Google Scholar 

  8. Kubo K, Kanehisa H, Kawakami Y, Fukunaga T. Influence of static stretching on viscoelastic properties of human tendon structures in vivo. J Appl Physiol. 1985;90(2):520–7. 2001.

    Google Scholar 

  9. Peltonen J, Cronin NJ, Stenroth L, Finni T, Avela J. Achilles tendon stiffness is unchanged one hour after a marathon. J Exp Biol. 2012;215(Pt 20):3665–71.

    PubMed  Article  Google Scholar 

  10. Peltonen J, Cronin NJ, Avela J, Finni T. In vivo mechanical response of human Achilles tendon to a single bout of hopping exercise. J Exp Biol. 2010;213(Pt 8):1259–65.

    PubMed  Article  Google Scholar 

  11. Drakonaki EE, Allen GM, Wilson DJ. Ultrasound elastography for musculoskeletal applications. Br J Radiol. 2012;85(1019):1435–45.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  12. Klauser AS, Faschingbauer R, Jaschke WR. Is sonoelastography of value in assessing tendons? Semin Musculoskelet Radiol. 2010;14(3):323–33.

    PubMed  Article  Google Scholar 

  13. De Zordo T, Chhem R, Smekal V, Feuchtner G, Reindl M, Fink C, et al. Real-time sonoelastography: findings in patients with symptomatic Achilles tendons and comparison to healthy volunteers. Ultraschall Med. 2010;31(4):394–400.

    PubMed  Article  Google Scholar 

  14. Klauser AS, Miyamoto H, Tamegger M, Faschingbauer R, Moriggl B, Klima G, et al. Achilles tendon assessed with sonoelastography: histologic agreement. Radiology. 2013;267(3):837–42.

    PubMed  Article  Google Scholar 

  15. Shalabi A. Magnetic resonance imaging in chronic Achilles tendinopathy. Acta Radiol Suppl (Stockholm). 2004(432):1-45.

  16. Fredberg U, Bolvig L. Significance of ultrasonographically detected asymptomatic tendinosis in the patellar and achilles tendons of elite soccer players: a longitudinal study. Am J Sports Med. 2002;30(4):488–91.

    PubMed  Google Scholar 

  17. Boesen AP, Boesen MI, Torp-Pedersen S, Christensen R, Boesen L, Holmich P, et al. Associations between abnormal ultrasound color Doppler measures and tendon pain symptoms in badminton players during a season: a prospective cohort study. Am J Sports Med. 2012;40(3):548–55.

    PubMed  Article  Google Scholar 

  18. Ooi CC, Schneider ME, Malliaras P, Chadwick M, Connell D. Diagnostic performance of Axial-strain sonoelastography in confirming clinically diagnosed Achilles tendinopathy: comparison with conventional B-mode US and Color Doppler imaging. Ultrasound Med Biol. 2014. doi:10.1016/j.ultrasmedbio.2014.08.019.

    PubMed  Google Scholar 

  19. 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(5):335–41.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  20. Warden SJ, Kiss ZS, Malara FA, Ooi AB, Cook JL, Crossley KM. Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med. 2007;35(3):427–36.

    PubMed  Article  Google Scholar 

  21. Archambault JM, Wiley JP, Bray RC, Verhoef M, Wiseman DA, Elliott PD. Can sonography predict the outcome in patients with achillodynia? J Clin Ultrasound. 1998;26(7):335–9.

    CAS  PubMed  Article  Google Scholar 

  22. Cook JL, Ptazsnik 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(10):700–3.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  23. Farris DJ, Trewartha G, McGuigan MP. The effects of a 30-min run on the mechanics of the human Achilles tendon. Eur J Appl Physiol. 2012;112(2):653–60.

    PubMed  Article  Google Scholar 

  24. Arampatzis A, De Monte G, Karamanidis K, Morey-Klapsing G, Stafilidis S, Bruggemann GP. Influence of the muscle-tendon unit’s mechanical and morphological properties on running economy. J Exp Biol. 2006;209(Pt 17):3345–57.

    PubMed  Article  Google Scholar 

  25. Wren TA, Lindsey DP, Beaupre GS, Carter DR. Effects of creep and cyclic loading on the mechanical properties and failure of human Achilles tendons. Ann Biomed Eng. 2003;31(6):710–7.

    PubMed  Article  Google Scholar 

  26. Schechtman H, Bader DL. Fatigue damage of human tendons. J Biomech. 2002;35(3):347–53.

    CAS  PubMed  Article  Google Scholar 

  27. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409–16.

    CAS  PubMed  Article  Google Scholar 

  28. Shaikh Z, Perry M, Morrissey D, Ahmad M, Del Buono A, Maffulli N. Achilles tendinopathy in club runners. Int J Sports Med. 2012;33(5):390–4.

    CAS  PubMed  Article  Google Scholar 

  29. Boesen MI, Boesen A, Koenig MJ, Bliddal H, Torp-Pedersen S. Ultrasonographic investigation of the Achilles tendon in elite badminton players using color Doppler. Am J Sports Med. 2006;34(12):2013–21.

    PubMed  Article  Google Scholar 

  30. Malliaras 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(11):2210–5.

    PubMed  Article  Google Scholar 

  31. Fahlstrom M, Alfredson H. Ultrasound and Doppler findings in the Achilles tendon among middle-aged recreational floor-ball players in direct relation to a match. Br J Sports Med. 2010;44(2):140–3.

    CAS  PubMed  Article  Google Scholar 

  32. Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 2010;6(5):262–8.

    PubMed  Article  Google Scholar 

  33. Kannus P. Etiology and pathophysiology of chronic tendon disorders in sports. Scand J Med Sci Sports. 1997;7(2):78–85.

    CAS  PubMed  Article  Google Scholar 

  34. Arya S, Kulig K. Tendinopathy alters mechanical and material properties of the Achilles tendon. J Appl Physiol. 2010;108(3):670–5.

    PubMed  Article  Google Scholar 

  35. Wang HK, Lin KH, Su SC, Shih TT, Huang YC. Effects of tendon viscoelasticity in Achilles tendinosis on explosive performance and clinical severity in athletes. Scand J Med Sci Sports. 2012;22(6):e147–55.

    PubMed  Article  Google Scholar 

  36. Gibbon WW, Cooper JR, Radcliffe GS. Sonographic incidence of tendon microtears in athletes with chronic Achilles tendinosis. Br J Sports Med. 1999;33(2):129–30.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  37. Movin T, Guntner P, Gad A, Rolf C. Ultrasonography-guided percutaneous core biopsy in Achilles tendon disorder. Scand J Med Sci Sports. 1997;7(4):244–8.

    CAS  PubMed  Article  Google Scholar 

  38. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford). 2006;45(5):508–21.

    CAS  Article  Google Scholar 

Download references


This study was supported by a RANZCR (Royal Australian and New Zealand College of Radiologists) Research Grant in 2013. The authors would like to thank Dr Andrew Dixon and Ms Donna Jones for their assistance in recruiting runners to participate in this research study and all the runners and controls for their enthusiasm and commitment to this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations


Corresponding author

Correspondence to C. C. Ooi.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ooi, C.C., Schneider, M.E., Malliaras, P. et al. Prevalence of morphological and mechanical stiffness alterations of mid Achilles tendons in asymptomatic marathon runners before and after a competition. Skeletal Radiol 44, 1119–1127 (2015).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Ultrasonography
  • Elasticity imaging techniques
  • Sonoelastography
  • Achilles tendon
  • Marathon runners