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Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach
  1. H T M van Schie1,2,
  2. R J de Vos1,3,
  3. S de Jonge3,
  4. E M Bakker4,
  5. M P Heijboer1,
  6. J A N Verhaar1,
  7. J L Tol3,
  8. H Weinans1
  1. 1Department of Orthopaedics, Erasmus university Medical Centre, Rotterdam, The Netherlands
  2. 2Department of Equine Sciences, Utrecht university, Utrecht, The Netherlands
  3. 3The Hague Medical Centre Antoniushove, Leidschendam, The Netherlands
  4. 4Leiden Institute of Advanced Computer Science, Leiden University, Leiden, The Netherlands
  1. Correspondence to Dr H T M van Schie, Department of Orthopaedics, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, Dr Molenwaterplein 50, Room Ee1614, Rotterdam 3015, The Netherlands; j.vanschie{at}


Objective To assess whether three-dimensional imaging of the Achilles tendon by ultrasonographic tissue characterisation (UTC) can differentiate between symptomatic and asymptomatic tendons.

Design Case-control study.

Setting Sports Medical Department of the Hague Medical Centre.

Patients Twenty-six tendons from patients with chronic midportion Achilles tendinopathy were included. The “matched” control group consisted of 26 asymptomatic tendons.

Interventions Symptomatic and asymptomatic tendons were scanned using the UTC procedure. One researcher performed the ultrasonographic data collection. These blinded data were randomised, and outcome measures were determined by two independent observers.

Main outcome measurements The raw ultrasonographic images were analysed with a customdesigned algorithm that quantifies the three-dimensional stability of echo patterns, qua intensity and distribution over contiguous transverse images. This threedimensional stability was related to tendon structure in previous studies. UTC categorises four different echotypes that represent (I) highly stable; (II) medium stable; (III) highly variable and (IV) constantly low intensity and variable distribution. The percentages of echo-types were calculated, and the maximum tendon thickness was measured. Finally, the inter-observer reliability of UTC was determined.

Results Symptomatic tendons showed less pixels in echo-types I and II than asymptomatic tendons (51.5% vs 76.6%, p<0.001), thus less three-dimensional stability of the echo pattern. The mean maximum tendon thickness was 9.2 mm in the symptomatic group and 6.8 mm in the asymptomatic group (p<0.001). The Intraclass Correlation Coefficient (ICC) for the interobserver reliability of determining the echo-types I+II was 0.95. The ICC for tendon thickness was 0.84.

Conclusion UTC can quantitatively evaluate tendon structure and thereby discriminate symptomatic and asymptomatic tendons. As such, UTC might be useful to monitor treatment protocols.

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  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the Medical Ethics Committee METC Zuid-West Holland.

  • Provenance and peer review Not commissioned; externally peer reviewed.