Sonoelastography in the diagnosis of tendinopathies: an added value

Serial Ultrasonographic and Real-Time Elastosonographic Assessment of the Ovine Common Calcaneal Tendon, after an Experimentally Induced Tendinopathy

Real-time elastosonography (RTE) is a recently described, non-invasive, ultrasonographic technique developed to assess tissue elasticity. The main aim of this study was to investigate the ultrasonographic and elastosonographic appearance of the common calcaneal tendon (CCT) in an ovine model, and to monitor the progression of tendon healing after an experimentally-induced tendinopathy. Sound tendons were initially evaluated (T₀) with a caliper and by a single operator with ultrasound. Ultrasonographic and elastosonographic images were then acquired. Subsequently, ultrasound-guided tendon lesions were induced by injecting 500 IU of Type IA collagenases proximally to the calcaneal tuberosity. Caliper measurement, ultrasonography and elastosonography were then repeated at 15 (T₁), 30 (T₂) and 60 (T₃) days. Clinically measured width of the tendon, ultrasonographic thickness and width and percentage of hard (Elx-t%hrd) and soft (Elx-t%sft) tissue were recorded. Statistical analysis was performed on the data collected; statistical significance was set at p < 0.05. Intra-class correlation coefficient (ICC) revealed good (0.68) repeatability of elastosonographic evaluation of the CCT. The tendon width was significantly increased when comparing T₀ with T_1–2 and decreased when comparing T_1–2 with T₃. Ultrasound-assessed thickness was significantly increased between T₀–T₁ and decreased between T₁-T_2–3. Elx-t%hrd was significantly decreased at T_1–2–3 and Elx-t%sft was significantly increased at T_1–2–3. In conclusion, the ovine CCT is a highly stiff structure that undergoes a severe loss of stiffness during the healing process. Thickness and width of the tendon increased during the first 30 days and then reduced progressively along the subsequent 30 days. Ultrasonographic appearance of the tendon remained severely abnormal and the tendon showed severely reduced elastic proprieties 60 days after lesion induction.

Intraoperative ultrasonography assistance for minimally invasive repair of the acute Achilles tendon rupture

Background

Minimally invasive repair is a better option for Achilles tendon rupture with low re-rupture and wound-related complications than conservative treatment or traditional open repair. The major problem is sural nerve injury. The purpose of this study was to evaluate the effect and advantage of the intraoperative ultrasonography assistance for minimally invasive repair of the acute Achilles tendon rupture.

Methods

A retrospective study was performed on 36 cases of acute Achilles tendon rupture treated with minimally invasive repair assisted with intraoperative ultrasonography from January 2015 to December 2017. The relationship of the sural nerve and small saphenous vein was confirmed on the preoperative MRI. The course of the small saphenous vein and the sural nerve was identified and marked by intraoperative ultrasonography. The ruptured Achilles tendon was repaired with minimally invasive Bunnell suture on the medial side of the small saphenous vein (SSV).

Results

All patients were followed up for at least 12 months. No sural nerve injury or other complications was found intraoperatively and postoperatively. All the patients returned to work and light sporting activities at a mean of 12.78 ± 1.40 weeks and 17.28 ± 2.34 weeks, respectively. The Mean American Orthopaedic Foot & Ankle Society (AOFAS) scores improved from 59.17 ± 5.31 preoperatively to 98.92 ± 1.63 at the time of 12 months follow-up. There was a statistically significant difference (P < 0.001). No patient complained of a negative effect on their life.

Conclusions

The minimally invasive repair assisted with intraoperative ultrasonography can yield good clinical outcomes, less surgical time, and less complications, especially sural nerve injury. It is an efficient, reliable, and safe method for acute Achilles tendon (AT) rupture.

Relationships between Quadriceps Tendon Elasticity and Knee Flexion Angle in Young Healthy Adults

Background and objectives: Although tendon elasticity by elastography is useful for diagnosing tendon disorders and planning rehabilitation regimens of the tendon, there are few reports on the quadriceps tendon. Moreover, relationships between the quadriceps tendon elasticity and knee angle have not been investigated. The purpose of this study was to clarify the relationship between quadriceps tendon elasticity and knee flexion angle in young healthy adults using elastography, and to investigate the difference in elasticity by sex and leg dominance. Materials and Methods: A total of 40 knees in 20 young healthy adults were included in this study (age: 25.5 (23.3⁻27.5) years). At knee flexion of 30°, 60°, and 90°, quadriceps tendon elasticity was measured using ShearWave™ Elastography during the ultrasound examination. Results: There were significant differences in the elasticity between all angles (p < 0.001). Elasticity was increased more at 60° than at 30° and at 90° than at 60°. Elasticity in men was higher than that in women at 60° (p = 0.029). There were no differences (p = 0.798) in elasticity at each angle between the dominant and non-dominant legs. Conclusions: The quadriceps tendon elasticity increased according to the knee flexion angle in young healthy adults. Moreover, elasticity was affected by sex, but not by leg dominance. Clinically, in a rehabilitation regimen, attention should be paid to exercises that could increase stiffness accompanying flexion of the knee to avoid further tendon damage as risk management in the acute phase.

Real-time sonoelastography: principles and clinical applications in tendon disorders. A systematic review

Background

Sonoelastography (SE) is a new ultrasound-based method adopted in an increased number of scientific reports to analyse normal and pathological tendons. The aim of this study is to provide a systematic overview of clinical applications of SE in normal and pathological tendons.

Methods

A systematic research of PubMed, Ovid, and Cochrane Library electronic databases was performed according to PRISMA guideline. Two Authors searched and evaluated the articles independently; a third Author was involved to solve any disagreement. The Oxford Level of Evidence (LoE) was used to assess each article.

Results

There is an increasing interest in the application of SE in the evaluation of healthy and diseased tendons. Many different tendons are amenable for SE evaluation, such as the Achilles and patellar tendons, rotator cuff, common extensor tendons, quadriceps tendon, and the plantar fascia.

Conclusion

SE appears to be a very useful diagnostic tool, in particular in tendon pathology. This is a dynamic examination, provides an immediate evaluation of the tissue elasticity, and may be useful in recognizing tendon abnormalities and in implementing the information available with conventional US.

Level of evidence

IV.

Spanish Consensus Statement: Clinical Management and Treatment of Tendinopathies in Sport

On October 15, 2016, experts met at Clínica CEMTRO in Madrid, Spain, under the patronage of the Spanish Society for Sports Traumatology (SETRADE), the Spanish Society of Sports Medicine (SEMED), the Spanish Association of Medical Services for Football Clubs (AEMEF), the Spanish Association of Medical Services for Basketball Clubs (AEMB), F.C. Barcelona, and Clínica CEMTRO. The purpose was to consider the most appropriate clinical management and treatment of tendinopathies in sports, based on proven scientific data described in the medical literature as well as on each expert’s experience. Prior to the meeting, each expert received a questionnaire regarding clinical management and treatment of tendinopathies in sports. The present consensus document summarizes the answers to the questionnaire and the resulting discussion and consensus regarding current concepts on tendinopathies in sports.

Triceps surae elasticity modulus measured by shear wave elastography is not correlated to the plantar flexion torque

Background

Supersonic Shear Imaging (SSI) is a technique which analyses quantitatively the tissue properties in real time. The relation between joint torque and Young's modulus (E) of the agonist muscles is important for obtaining stratification values and ranges of normality. The aim of this study was to evaluate the intra and intersessions reliability of the E values of the Achilles tendon and medial gastrocnemius muscle, bilaterally, during rest, and correlate them with the isometric plantarflexion peak torque.

Methods

Shear modulus maps were acquired bilaterally in Achilles tendon (AT) and medial gastrocnemius (MG) muscle of 24 healthy male volunteers. Two 5-second plantarflexion maximal voluntary contractions were performed with a 40-seconds interval and correlated with E values.

Results

a good intrasession reliability (intraclass correlation coefficient- ICC= 0.821-0.986) and a weak Pearson's correlation was found between E values and peak torque (r= 0.022 to -0.202) for both limbs (P > .05).

Conclusion

E values cannot be predictive of the triceps surae force production in untrained men. It could be helpful, otherwise, to monitor a chronic strength adaptation after an exercise intervention or rehabilitation program.

Level of evidence

IIb, individual cohort study.

Shoulder ultrasonography performed by orthopedic surgeons increases efficiency in diagnosis of rotator cuff tears

Background

Rotator cuff tears are very common and their incidence increases with age. Shoulder ultrasonography has recently gained popularity in detecting rotator cuff tears because of its efficiency, cost-effectiveness, time-saving, and real-time nature of the procedure. Well-trained orthopedic surgeons may utilize shoulder ultrasonography to diagnose rotator cuff tears. The wait time of patients planned to have shoulder MRI (magnetic resonance imaging) to rule in rotator cuff tears may decrease after orthopedic surgeon start doing shoulder ultrasonography as a screening tool for that. Patients with rotator cuff tears may be detected earlier by ultrasonography and have expedited surgical repair. The efficacy in determination of rotator cuff tears will also increase.

Methods

Patients were retrospectively reviewed from January 2007 to December 2012. They were divided into 2 groups: Ultrasound (-) group and the Ultrasound (+) group. Age, gender, wait time from outpatient department (OPD) visit to MRI exam, MRI exam to operation (OP), and OPD visit to OP, patient number for MRI exam, and number of patients who finally had rotator cuff repair within two groups were compared.

Results

The wait time of OPD visit to OP and MRI to OP in patients who received shoulder ultrasonography was significantly less than that in patients did not receive shoulder ultrasonography screening. Only 23.8% of the patients with a suspected rotator cuff injury undergone arthroscopic rotator cuff repair before ultrasonography was applied as a screening tool. The percentage increased to 53.6% after orthopedic surgeon started using ultrasonography as a screening tool for rotator cuff tears.

Conclusions

Office-based shoulder ultrasound examination can reduce the wait time for a shoulder MRI. The efficacy of determination of rotator cuff tears will also increase after the introduction of shoulder ultrasonography.

Assessment of enthesitis in patients with psoriatic arthritis using clinical examination and ultrasound

BACKGROUND

Enthesitis is a major feature of psoriatic arthritis. However, clinical assessment of enthesitis is known to lack accuracy and have poor interobserver reliability.

OBJECTIVE

To determine effect of training on clinical assessment of enthesitis and to compare ultrasonography with clinical examination for the detection of entheseal abnormalities.

METHODS

20 rheumatologists performed repeated assessment of enthesitis in patients with established psoriatic arthritis before and after a 2-hour training session in standardised enthesitis count according to Leeds Enthesitis Index (LEI) and Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC). Moreover, 20 patients underwent clinical and ultrasonographic examination of entheses to evaluate consensus-based elementary lesions of enthesitis.

RESULTS

Training significantly increased Intra-class Correlation Coefficient for LEI from 0.18 to 0.82 and for SPARCC from 0.38 to 0.67. Ultrasound examination showed high associations between hypoechogenicity and increased thickness of the entheses and clinical examination. There was no correlation between erosions and enthesophytes found by ultrasound and clinical assessments.

CONCLUSION

Training in standardised enthesitis scoring systems significantly improved clinical assessments of enthesitis and should be performed before use in daily clinical practice. Ultrasound revealed more advanced stages of enthesitis, such as enthesophytes and erosions, which were not detected with clinical examination.