Article Text

Download PDFPDF
Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon
  1. P Malliaras1,
  2. C Purdam2,
  3. N Maffulli3,
  4. J Cook4
  1. 1Brunel University, Uxbridge, Middlesex, UK
  2. 2Australian Institute of Sport, Bruce, ACT, Australia
  3. 3Keele University, Keele, UK
  4. 4Deakin University, Burwood, Victoria, Australia
  1. Correspondence to P Malliaras, Brunel University, Uxbridge, Middlesex, UK, UB8 3PH; p.malliaras{at}


Objective Ultrasound (US) imaging has revealed distinct types of greyscale abnormalities in the patellar and Achilles tendons, including diffusely thickened tendons and tendons containing a hypoechoic region. The relationship between these greyscale abnormalities and their clinical relevance is unknown. This study investigated the temporal sequence in greyscale abnormalities as well as the relationship between greyscale abnormalities, Doppler flow and pain.

Methods Patellar tendon pain (single leg decline squat test) and ultrasound imaging (greyscale (normal, diffuse thickening, hypoechoic), presence of Doppler flow) were assessed bilaterally among 58 volleyball players at monthly intervals during a 5-month season. The probability of transition between the greyscale ultrasound groups was calculated for each month and totalled over the season (prospective) and the relationship between these groups and the presence and intensity of pain and the presence of Doppler flow were investigated (cross-sectional investigation).

Results Tendons with normal US were more likely to transition to diffuse thickening than to a hypoechoic region. Tendons containing a hypoechoic region were more likely to transition to diffuse thickening rather than to a normal US appearance. Hypoechoic regions were more likely to be painful (59%) and contain Doppler flow (42%) than tendons with diffuse thickening (pain in 43% and Doppler flow in 6%).

Conclusions The transitions identified between normal, diffusely thickened tendons and those containing a hypoechoic region suggests that these greyscale US changes may represent different phases of tendon pathology. Tendons containing a hypoechoic region are more likely to be painful and contain Doppler flow than diffusely thickened tendons.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Competing interests None.

  • Ethics approval Ethics approval was obtained from La Trobe University, Melbourne, Australia.