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Achilles tendons in people with type 2 diabetes show mildly compromised structure: an ultrasound tissue characterisation study
  1. Suzan de Jonge1,
  2. Robert Rozenberg2,
  3. Bruno Vieyra2,
  4. Henk J Stam2,
  5. Henk-Jan Aanstoot3,
  6. Harrie Weinans1,
  7. Hans T M van Schie1,4,
  8. Stephan F E Praet2
  1. 1Department of Orthopaedics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
  2. 2MOVEFIT-Sports Medicine, Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
  3. 3Diabeter, Center for Pediatric and Adolescent Diabetes Care and -Research, Rotterdam, The Netherlands
  4. 4Department Scientific Research, UTC Imaging, Stein, The Netherlands
  1. Correspondence to Suzan de Jonge, Department Sports Medicine, Medical Center The Hague, Burg Banninglaan 1, Leidschendam 2262 BA, the Netherlands; s.dejonge{at}


Background Musculotendinous overuse injuries are prevalent in people with type 2 diabetes. Non-enzymatic glycosylation of collagen resulting in tendon stiffening may play a role. In this case–control study we determined whether patients with diabetes had poorer ultrasonographic structure in their Achilles tendons compared to age-matched controls.

Methods People with type 1 diabetes or type 2 diabetes, and age-matched controls, had computerised ultrasound tissue characterisation of both Achilles tendons. In contiguous ultrasonographic images of the tendon, echopatterns were quantified and categorised into four echo-types. Tendon abnormality was quantified as sum of echo-types III+IV. Furthermore, skin autofluorescence (AF) of the forearm (AF-value) was gathered.

Results Twenty four type 2 diabetes patients, 24 controls, 24 type 1 diabetes patients and 20 controls were included. AF-value was higher in type 1 diabetes (1.55±0.17) than in their controls (1.39±0.18, p<0.001) and in type 2 diabetes (2.28±0.38) compared to their controls (1.84±0.32, p<0.001) Achilles tendons of type 2 diabetes patients contained more echo-types III+IV (14.1±7.9%) than matched controls (8.0±5.4%, p<0.001). There was a trend towards a difference in echo-types III+IV between type 1 diabetes patients (9.5±5.3%) and their controls (6.5±3.7%, p=0.055). In a stepwise linear regression analysis, body mass index (BMI) was moderately associated with tendon abnormality in patients with diabetes and controls (β=0.393, p<0.001).

Conclusions Type 2, and possibly type 1, diabetes patients showed poorer ultrasonographic Achilles tendon structure that may be a risk factor for tendinopathy. Although markers for accumulation of advanced glycation end products were elevated in both diabetes populations, only BMI was associated with these abnormalities.

Trial registration number NTR2209.

  • Achilles
  • Ultrasound
  • Diabetes

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