Tendon Thickness Measurements Research Articles

Normative data on lower extremity entheseal tendon thicknesses in healthy children: an ultrasound study correlating age, sex, anthropometry

Abstract Objectives This study aims to establish normative data on lower extremity entheseal tendon thicknesses in healthy children and examine correlations with age, gender, and anthropometric measures using musculoskeletal ultrasound. The secondary objective of the study is to investigate the power Doppler properties of entheseal tendons. Methods A total of 192 healthy children, aged 5–18 years, participated in this cross-sectional study. Participants underwent detailed physical and ultrasonographic examinations. Entheseal tendon thickness measurements were taken from five specific regions: distal quadriceps tendon (DQT), proximal patellar ligament (PPL), distal patellar ligament (DPL), Achilles tendon (AT), and plantar fascia (PF). Correlations between thicknesses and age, weight, height, and body mass index (BMI) were analyzed. Intra-tendinous vascularity was evaluated using power Doppler. Interobserver and intraobserver agreements were assessed using intraclass correlation coefficients (ICC). Results Normative data on lower extremity entheseal tendon thicknesses according to age, weight, height, and BMI have been established. Significant positive correlations were found between thicknesses and age, weight, height, and BMI. Weight was identified as the most influential factor, particularly for the DPL and AT. Right side tendons (AT and PF) are statistically thicker. Minimal Doppler activity was detected in 10.6% of the entheseal DQTs in the group of children aged 5–9 years. The study achieved high to excellent interobserver and intraobserver agreement. Conclusion This study examined the ultrasonographic characteristics of lower extremity entheseal tendons in healthy children using B-mode and power Doppler, provided normative data on their thicknesses, and demonstrated significant correlations between thicknesses and age, sex, and anthropometry.

Evaluation of the Relationship between Acromiohumeral Distance and Supraspinatus Tendon Thickness Measured by Ultrasonography and Rotator Cuff Pathologies, Pain, and Function.

In this study, we aimed to evaluate acromiohumeral distance (AHD) and supraspinatus tendon (ST) thickness measurements and their relationship with pain and function in ST pathologies. The study included 111 patients and 25 healthy controls (HC). Patients were divided into 3 groups according to their diagnosis: non-tear tendinopathy (NTT), partial thickness tear (PTT), and full thickness tear (FTT). The AHD and ST thickness of the participants were measured with ultrasound. The pain and functional status of the patients were evaluated with the Numeric Rating Scale (NRS), The QuickDASH shortened version of the DASH Outcome Measure - Disabilities of the Arm Shoulder and Hand (QDASH), and Simple Shoulder Test (SST). The AHD value was significantly higher in the NTT group (p=0.000). The AHD value was significantly lower in the FTT group (p=0.000). ST thickness value was significantly lower in the PTT group compared to the NTT group (p=0.000). There was a positive correlation between ST thickness and BMI (r=0.553,p<0.01). There was a negative correlation between ST thickness and SST and a positive correlation between ST thickness (r=-0.223,p<0.05) and QDASH (r=0.276,p<0.05). We found that AHD and SST thicknesses significantly differed in the NTT, PTT, FTT, and HC groups. This difference may be important for diagnosis. In addition, the effect of obesity on ST thickness and the relationship between ST thickness and functional scores may be considered. Weight control may be effective at this point. acromiohumeral distance, supraspinatus tendon thickness, ultrasound.

Clinical and Ultrasonographic Effectiveness of Two Different Splints Used for the Treatment of Lateral Epicondylitis: A Prospective Randomized Controlled Study

ObjectiveThis study compares the clinical and ultrasonographic efficacy of 2 splint types, the lateral epicondylitis band (LEB) and the wrist extensor splint (WES), for treatment of lateral epicondylitis (LE). DesignRandomized controlled single-blind trial. SettingOutpatient clinic. Participants159 participants diagnosed with unilateral LE based on clinical and ultrasonographic findings, and 2-12 weeks from symptom onset, were included (N=159). InterventionsOne group received joint-protection education-only (wait-and-see), while the other 2 groups were fit with splints: one the LEB and the other the WES. Both splint groups received joint-protection education. Main Outcome MeasuresThe primary outcome measure was the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire. Secondary outcome measures were the Visual Analog Scale (VAS) for pain, hand grip strength by dynamometry, algometric measurements, patient satisfaction, and selected ultrasonographic parameters (maximum tendon thickness measurements (MTTM) in the capitellar-radiocapitellar region and total ultrasonography scale score [TUSS]). All outcomes were assessed at baseline, 3-weeks, and 6-weeks post intervention initiation. ResultsParticipants’ mean age was 46.85±8.63 years. Of the participants, 40.88% (n=65) were male and 59.12% (n=94) were female. The baseline median (1Q-3Q) values of PRTEE-total scores were 58.5 (51-68) for the LEB, 63.5 (56.25-70.25) for the WES and 57 (48-68) for the education-only groups. At 6-weeks, the PRTEE-total scores had decreased by 44 points for those randomized to the LEB, 46 points to the WES and 7 points in the education-only groups(P<.001). While the LEB and WES approaches were superior to the wait-and-see approach in algometric measurements, VAS, and PRTEE scores (P<.05), no significant changes were found in MTTM and TUSS values. The LEB group was superior to the WES group in hand grip strength and patient satisfaction (P<.05). ConclusionUsing either splint for 6 weeks can be considered effective for the relief of pain and increased functionality in persons with subacute LE, although the LEB had a more positive effect on grip strength and patient satisfaction than the WES.

Measuring Ultrasonographic Thickness of the Achilles Tendon Insertion Is Less Reliable Than the Midportion in Healthy Tendons and Patients With Tendinopathy.

Ultrasound is the preferred imaging method in the diagnostic process of Achilles tendinopathy (AT). Ultrasound tissue characterization (UTC) is a frequently used, standardized and valid method to assess tendon geometry in AT patients. It is unknown whether UTC is reliable for measuring Achilles tendon thickness. The aim of the study was to assess intra- and inter-rater reliability of Achilles tendon thickness measurements using UTC in both asymptomatic individuals and patients with AT, and to evaluate if the reliability of thickness measurements differs between the midportion and insertional area. Exactly 50 patients with AT and 50 asymptomatic individuals were included. Using the conventional US and standardized UTC procedure maximum thickness was measured in the midportion and insertion region. To determine inter- and intra-rater reliabilities, the intraclass correlation coefficient (ICC) was used. The ICC values for inter- and intra-rater reliability were classified as "excellent," for the AT group (0.93 [95% CI: 0.88-0.96] and 0.95 [0.92-0.97]) and asymptomatic participants (0.91 [0.87-0.94] and 0.94 [0.92-0.96]). The reliability of measuring tendon thickness in the midportion region was "excellent," with both inter-rater (0.97 [0.95-0.98]) and intra-rater (0.98 [0.96-0.99]) ICC values indicating high levels of agreement. In the insertional region, ICC values for inter-rater (0.79 [0.69-0.87]) and intra-rater (0.89 [0.84-0.93]) reliability were "moderate to good." We showed excellent reliability for measuring the US thickness of the midportion and good reliability of measuring the insertional region in patients with AT. Significantly lower ICCs were observed for the reliability of thickness measurements in the insertional region when compared with the midportion.

Use of Weight-Bearing Computed Tomography (WBCT) Imaging in the Assessment of the Achilles Tendinopathy: A Prospective Comparative and Controlled Study

Category: Hindfoot; Sports Introduction/Purpose: Insertional and non-insertional Achilles tendinopathy (AT) are prevalent diseases in the active, working-age population. Ultrasound (US) and magnetic resonance imaging (MRI) are frequently utilized in the assessment and grading of AT. Use of these imaging modalities are limited by operator interpretation/variability and costs, respectively. Also, these assessments are performed in the non-weight bearing positioning of the lower extremity, thus poorly evaluating the functional position of the loaded tendon. Validation of weight-bearing computed tomography (WBCT) for Achilles tendon imaging could provide a novel and functional means of quantifying tendon pathology. The study’s purposes were to: 1) Correlate Achilles tendon tissue structural findings when assessed by WBCT and US imaging, and 2) Compare WBCT Achilles tendon tissue changes between AT patients and controls. Methods: This was a prospective-comparative IRB-approved cohort study including 10 adults with AT (Age = 54.7 ± 10.3 years, BMI = 40.65 ± 10.07 kg/m2, 8F/2M), 10 age-matched controls (Age = 54.6 ± 11.33 years, BMI = 37.9 ± 9.55 kg/m2, 8F/2M), and 4 younger controls (Age = 32.25 ± 8.3 years, BMI = 24.32 ± 5.14 kg/m2, 2F/2M). WBCT scans (Curvebeam HiRise/PedCAT) and US imaging (Butterfly iQ+) of the Achilles tendon were collected. Tendons were manually segmented in WBCT images (3D Slicer software) and tendon thickness was measured at the maximum anterior-posterior (AP) diameter of the tendon (insertion and midportion regions). Radiodensity was quantified by the average Hounsfield Units (HU) of each tendon region and normalized to the radiodensity of each participant’s talus (segmented using Disior Bonelogic). US measures of the tendon thickness were similarly completed by independent observers who were blinded to the WBCT measurement. Intraclass correlation coefficient (ICC) assessed correlation between WBCT and US findings. Paired T-tests compared WBCT HU between patients and controls. P-values &lt; 0.05 were considered significant. Results: There was excellent correlation (ICC= 0.83-0.94, Table 1) between WBCT and US imaging regarding tendon thickness, with WBCT overestimating thickness by only 0.27-0.55mm (4-9% of total tendon thickness). These findings could be explained by decreased US tendon thickness measurements secondary to the tendon’s compression by the US probe. WBCT imaging demonstrated a higher radiodensity (HU) within the Achilles tendon (for both insertion and midportion regions) in AT patients when compared to controls (Table 2), with p-values of 0.009 and 0.001 for insertional and midportion regions, respectively. Findings are consistent with tendinopathic differentiation of the Achilles tendon substance in the AT patients. Color-coded maps demonstrating HU distributions across the Achilles tendon were created to facilitate interpretation of tissue characteristics (Fig. 1). Conclusion: In this prospective, comparative, and controlled study, we observed a high correlation between US and WBCT imaging in the assessment of Achilles tendon thickness in AT patients and controls. We also found that WBCT HU distribution in the Achilles tendon was significantly increased in the AT patients when compared to controls. Findings are likely explained by tendinopathic tissue changes in the diseased tendons, potentially related to the well-known chondroid metaplasia observed in Achilles tendinopathy pathological process. WBCT imaging and color-coded maps can represent a promising tool in the assessment of AT patients.

Ultrasound-guided injection of platelet-rich plasma (PRP) in rotator cuff tendinopathy: effect on patients\u2019 symptoms and supraspinatus tendon thickness

BackgroundRotator cuff tendinopathy is considered a major cause of shoulder pain and disability that is increasing substantially with age affecting more than half of the general population by the age of 60 years. This study aims to assess the effect of ultrasound-guided injection of platelet-rich plasma on patient symptoms and supraspinatus tendon thickness in cases of rotator cuff tendinopathy.ResultsThis was a single-arm interventional study conducted on 30 patients with age ranging between 27 and 54 years old. Following US-guided injection of PRP, patients were evaluated clinically using the Shoulder Pain and Disability Index (SPADI) scoring system and radiologically using ultrasonographic supraspinatus tendon thickness measurements at 4, 8, 12, and 24 weeks. Our study showed remarkably noticeable changes when comparing the pre-injection and post-injection SPADI scoring system. There is highly statistically significant pain and disability score and percentage improvement, yet on the other hand, the radiological improvement shows no statistically significant difference found between baseline tendon thickness and its follow-up at 4, 8, and 12 weeks while only there was a statistically significant decrease in tendon thickness found at 24 weeks with P value = 0.043.ConclusionsThe ultrasound-guided PRP injection for supraspinatus tendinopathy cases is a safe, cheap, and easily prepared outpatient procedure which showed competitive, promising, and well-proved results when compared to other modality outcomes such as conventional surgeries, arthroscopic procedures, and physiotherapy.

The Role of the Vascular and Structural Response to Activity in the Development of Achilles Tendinopathy: A Prospective Study

Background: Several risk factors have been suggested in the development of Achilles tendinopathy, but large-scale prospective studies are limited. Purpose: To investigate the role of the vascular response to activity of the Achilles tendon, tendon thickness, ultrasound tissue characterization (UTC) of tendon structure, and foot posture as possible risk factors in the development of Achilles tendinopathy. Study Design: Cohort study; Level of evidence, 2. Methods: The study began with 351 first-year students at Ghent University. After 51 students were excluded, 300 were tested in the academic years 2013-2014 and 2014-2015 and were followed prospectively for 2 consecutive years by use of a multilevel registration method. Of those, 250 students were included in the statistical analysis. At baseline, foot posture index and UTC were investigated bilaterally. Blood flow and tendon thickness were measured before and after a running activity. Cox regression analyses were performed to identify significant contributors to the development of Achilles tendinopathy. Results: During the 2-year follow-up, 27 of the included 250 participants developed Achilles tendinopathy (11%). Significant predictive effects were found for female sex and blood flow response after running (P = .022 and P = .019, respectively). The risk of developing Achilles tendinopathy increased if the blood flow increase after running was reduced, regardless of sex, foot pronation, and timing of flow measurements. The model had a predictive accuracy of 81.5% regarding the development of Achilles tendinopathy, with a specificity of 85.0% and a sensitivity of 50.0%. Conclusion: This prospective study identified both female sex and the diminished blood flow response after running as significant risk factors for the development of Achilles tendinopathy. UTC of tendon structure, Achilles tendon thickness, and foot posture did not significantly contribute to the prediction of Achilles tendinopathy. A general evaluation of tendon structure by UTC, measurement of tendon thickness, or determination of the foot posture index will not allow clinicians to identify patients at risk for developing Achilles tendinopathy. Furthermore, it may be possible to improve blood flow after activity by using noninvasive techniques (such as prostaglandins, compression stockings, heat, massage, and vibration techniques). These techniques may be useful in the prevention and management of Achilles tendinopathy, but further research is needed.

Elbow problems in paraplegic spinal cord injured patients: frequency and related risk factors—a preliminary controlled study

Cross-sectional controlled study. To evaluate the elbow joint with ultrasound in paraplegic patients, determine the related factors and compare it with healthy controls. A training and research rehabilitation hospital in Istanbul. A total of 30 paraplegic patients and 20 healthy controls were included in the study. Patients demographic data, pain in the elbow joint, level and duration of injury, ambulation status, type of wheelchair used, daily duration of wheelchair and other ambulation equipment usage, transfers being dependent or independent, daily number of push-ups were recorded. Elbow joints were evaluated with ultrasound for presence of fluid and thickness of the triceps tendon. Mean triceps tendon thickness values of the right side were larger in spinal cord injury (SCI) patients when compared with those of healthy controls'. Joint effusion on the right elbow joint was also found to be more common in SCI patients than in normal subjects. Triceps tendon thickness measurements were not found to be correlated with demographic and clinical factors. Seven paraplegic patients (23%) reported that they have pain in the elbow. In this preliminary study, our results showed that right elbow effusion was more frequent and right triceps tendon was thicker in SCI patients when compared with healthy subjects.

Common extensor tendon thickness measurements at the radiocapitellar region in diagnosis of lateral elbow tendinopathy

The aim of this study was to determine the value of measuring common extensor tendon (CET) thickness at the radiocapitellar and capitellar regions with qualitative ultrasonographic findings in the diagnosis of lateral elbow tendinopathy. The study included 164 lateral elbow tendinopathy patients (84 bilateral, 80 unilateral) matched by age, gender, and body mass index with 80 normal subjects. CET was examined using gray-scale and Doppler ultrasonography for tendinopathy, and tendon thickness was measured at two landmark locations: capitellar and radiocapitellar. In tendinopathy, tendon thickness including the dominant capitellar region, increased in every measured location. In the capitellar region of the dominant elbow, the cut-off thickness was 5.15 mm, and in the radiocapitellar region, this value was 4.05 mm. For the non-dominant elbow, the cut-off thickness was 4.61 mm, whereas in the radiocapitellar region, this value was 3.51 mm. The greatest risk of tendinopathy was at the radiocapitellar region on the dominant side. The overall sensitivity and specificity of gray-scale findings were 54% and 88%, respectively, and the addition of Doppler readings did not alter these values. When capitellar measurements were added, the values increased to 79% and 80% for sensitivity and specificity, respectively. These values further increased to 93% and 91%, respectively, when radiocapitellar measurements were included. A second tendon thickness measurement at the radiocapitellar region of CET in addition to the capitellar region is recommended on the grounds that combined qualitative and quantitative evaluation of CET increases the diagnostic per- formance of ultrasonography in lateral elbow tendinopathy.

Musculoskeletal sonography in juvenile systemic lupus erythematosus

To demonstrate the role of sonography in depicting periarticular changes in juvenile systemic lupus erythematosus (SLE) and to find out whether certain tendons in juvenile SLE patients were different from those of healthy controls. Thirty juvenile SLE patients (27 female, 3 male) were recruited for this study. Sonographic evaluations were performed in the knee, ankle, elbow, wrist, and metacarpophalangeal (MCP) joints on the nondominant sides of the individuals. For comparison, 32 healthy volunteers were included as a control group. Knee effusion was observed more frequently in the juvenile SLE group compared with the control group (P = 0.00). When tendon thickness measurements were compared between the groups, flexor and extensor tendons of the third finger (at MCP joint level) of juvenile SLE patients were found to be thinner (P = 0.04 and P = 0.03, respectively). Tendon thickness values did not correlate with disease duration or SLE disease activity index scores (P > 0.05). The main findings of our study were relevant with 1) increased involvement of the knee, ankle, hand extensor tendons, wrist, elbow, and hand flexor tendons (in decreasing order of frequencies) in juvenile SLE, and 2) decreased extensor/flexor tendon thicknesses in the hands of juvenile SLE patients. Physicians should be aware of the potentially disabling scenario of tendon pathologies. Defining the extent of joint and tendon pathologies in juvenile SLE may guide us in the management of the disease.

Musculoskeletal sonography in juvenile systemic lupus erythematosus

Results Knee effusion was observed more frequently in the JSLE group in comparison with the control subjects (p = 0.00). When tendon thickness measurements were compared between the groups, flexor and extensor tendons of the third digit (at MCP joint level) of JSLE patients were found to be thinner (p values being 0.04 and 0.03, respectively). Tendon thickness values did not correlate with disease duration and SLE disease activity index scores (p values > 0.05).

β2‐Microglobulin Amyloidosis in Hemodialysis and Peritoneal Dialysis Patients

Beta(2)-microglobulin (beta(2)-M) amyloidosis is an important cause of morbidity in patients on dialysis. In this cross-sectional study, we evaluated supraspinatus tendon thickness (as a measure of shoulder involvement from beta(2)-M amyloidosis) in patients who are on hemodialysis (HD) compared with those on continuous ambulatory peritoneal dialysis (CAPD). In 27 patients on HD who were treated with high-flux dialyzers, 31 patients on CAPD, and 31 healthy volunteers, we performed bilateral shoulder magnetic resonance imaging and measured the supraspinatus tendon thickness using electronic calipers. There were no statistically significant differences in age or dialysis duration between the HD and CAPD patients. Each patient was asked about the presence or absence of shoulder pain. The supraspinatus tendon thickness in HD patients (mean thickness 6.6 +/- 1.3 mm, range 3.20-8.80 mm, N = 53) and CAPD patients (6.8 +/- 0.9 mm, range 4.9-8.8 mm, N = 61) was not significantly different (P = 0.289); however, the mean thickness in either group was higher than in the healthy controls (5.5 +/- 0.6 mm, range 4.3-6.8 mm, N = 61) (HD patients vs. controls: P = 0.000; CAPD patients vs. controls: P = 0.000). Patients with shoulder pain had higher mean supraspinatus tendon thickness measurements than patients without shoulder pain (P = 0.042). The thickness of supraspinatus tendons is not significantly different between patients on CAPD and HD. An association exists between shoulder pain and mean supraspinatus tendon thickness. This hidden complication of ESRD should be further studied in larger populations of dialysis patients.

Ultrasonography in Evaluation of Achilles and Patella Tendon Thickness

Despite the general acknowledgement that measurement of tendon thickness by ultrasonography (US) is an integral part of clinical examination of tendons in both symptomatic and asymptomatic athletes, there is no consensus on where and how the tendons should be measured. This study aims to evaluate the Achilles and patellar tendons by ultrasonography with the intention of establishing a consensus for measuring the thickness of Achilles and patellar tendons in future studies. This study includes three sub-studies, evaluating: 1. Achilles and patellar tendon thickness in relation to the distance from the attachment at the calcaneus or patella, 2. longitudinal versus transversal US scan for measurement of the tendon thickness by examining the tendons in both longitudinal and transversal scan planes twice by the same observer, and 3. differences in tendon thickness using three different US measurement methods, when measuring both the sagittal AP thickness and the "true" thickness (measured perpendicular to the greatest width) twice by the same observer. A total of 209 tendons were included. Normal Achilles tendons have the same thickness in the distal 5 cm-long section. Patellar tendons are more cone-shaped proximally. There is no significant difference between the longitudinal and transversal scan except when applied on abnormal patellar tendons. The tendon thickness and coefficient of variation is smaller when measuring the true thickness compared to the AP thickness. The true tendon thickness is less than the AP thickness, because the AP-thickness is dependent upon the rotation of the tendon. Moreover, the true thickness is a more precise measurement. In future measurements, the true thickness of tendons could be measured in either transversal or longitudinal scan. When measuring abnormal patellar tendons, however, it is necessary to apply a longitudinal scan as this is the only method allowing the examiner to record the distance from the point where the thickness is measured to the bony attachment. The measurement can thereby be repeated at exactly the same point during subsequent controls.

Sonographic evaluation of the tendons in familial Mediterranean fever and Behçet’s disease

Objectives There have been some studies on the burden of certain rheumatological disorders on the tendons; however, patients with familial Mediterranean fever (FMF) and Behçet's disease (BD) have not, up to now, been studied in this regard in the literature. Thus, this current study centers on ensuing changes in the tendons of these patients. Methods The study comprised 32 patients with FMF (13 male, 19 female), 31 with BD (18 male, 13 female) and 35 control subjects (17 male, 18 female). Sonographical evaluations were performed from the triceps, quadriceps and Achilles tendons on the non-dominant extremities of the individuals using a linear array probe of 8–16 MHz. Results The mean triceps tendon (TT) thickness value of FMF patients was greater than that of BD patients ( P = 0.03) or the controls' ( P = 0.02). The mean quadriceps tendon (QT) thickness value of BD patients was greater than that of FMF patients ( P = 0.00) or the controls' ( P = 0.01). The mean Achilles tendon (AT) thickness value of BD patients was greater than that of controls' ( P = 0.05) only. There was not any difference between the tendon thickness measurements of either group of patients with and without arthritic involvement. Conclusion Our first and preliminary findings pertaining to increased tendon thicknesses in FMF ( TT) and BD ( QT and AT) patients should be complemented with future histological and clinical studies. The functional relevance of tendon thickening, its probable reflection on the rupture risk and the role of each disease related contributing factor remain to be uncovered.

Anatomy of the Achilles tendon (tendo calcaneus) with respect to tendon thickness measurements.

267 normal controls of different ages underwent achilles tendon thickness measurements by ultrasonography (US) for reference. 96 recruits and 10 young women additionally underwent magnetic resonance imaging of the achilles tendons and calves for more systematic evaluation of the factors influencing tendon thickness. Children under 10 had a tendon thickness (mean +/- SD) of 4.6 +/- 0.8 mm, 10-17 year-olds 6.1 +/- 0.8 mm, 18-30 year-olds 6.3 +/- 0.5 mm and over 30 year-olds 6.9 +/- 1.0 mm. Women had slightly thinner tendons than men, but the difference was statistically significant only in the oldest age group. Normal variation in shape of the tendon caused up to a 25% variation in the measured thickness values. In the large sample of recruits a statistically significant correlation was found between the tendon thickness and body height. Differences in population height could account for the measured differences in normal achilles tendon thickness found in studies on Japanese subjects compared with studies on European and American subjects.