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Wegener F, Ritterbusch A, Saal C, Baumgart C, Hoppe MW. Myotonometry and extended field-of-view ultrasound imaging allow reliable quantification of patellar tendon stiffness and length at rest and during maximal load, whereas several restrictions exist for the Achilles tendon. Front Sports Act Living 2024; 6:1379506. [PMID: 38859890 PMCID: PMC11163091 DOI: 10.3389/fspor.2024.1379506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/07/2024] [Indexed: 06/12/2024] Open
Abstract
Introduction Stiffness and length are well-established tendon parameters in sports and medicine. Myotonometry and ultrasound imaging are the commonly used methods to quantify these parameters. However, further studies are needed to clarify the reliability of these methods, especially when assessing maximally loaded tendons and when conducted by different experienced investigators. This study aimed to determine the intra- and interrater reliabilities of measuring the stiffness and length of the patellar tendon (PT) and Achilles tendon (AT) using the myotonometry method and the extended field-of-view ultrasound (EFOV-US) technique at rest and maximal load performed by different experienced investigators. Methods Twenty-seven participants were examined on three different days by one experienced investigator and one novice investigator. Primary outcomes were the intraclass correlation coefficient (ICC) and associated 95% confidence interval (95% CI), coefficient of variation (CV), standard error of measurement (SEM), and minimal detectable change (MDC) across the measurement days and investigators. Results For PT measurements at rest and maximal load, the estimated ICCs for stiffness and length were ≥.867 and ≥.970, respectively, with 95% CIs ranging from poor (.306) to excellent (.973) and good (.897) to excellent (.999). The CV, SEM, and MDC for PT stiffness and length were ≤5.2% and ≤2.0%, ≤39.3 N/m and ≤0.9 mm, and ≤108.9 N/m and ≤2.6 mm, respectively. For AT measurements, some restrictions were evident for stiffness at rest and both parameters at maximal load. However, regarding AT length at rest, the estimated ICC was ≥.996, with an excellent 95% CI (.987-.999). The CV, SEM, and MDC for AT length at rest were 2.8%, ≤1.1 mm, and ≤2.9 mm, respectively. Conclusion The estimated ICCs show good to excellent reliability for the myotonometry method and the EFOV-US technique for measuring PT stiffness and length at rest and maximal load for experienced and novice investigators. However, some restrictions are evident for the AT, especially for measurements at maximal load.
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Affiliation(s)
- Florian Wegener
- Movement and Training Science, Faculty of Sport Science, Leipzig University, Leipzig, Germany
| | - Arne Ritterbusch
- Movement and Training Science, Faculty of Sport Science, Leipzig University, Leipzig, Germany
| | - Christian Saal
- Movement and Training Science, Faculty of Sport Science, Leipzig University, Leipzig, Germany
| | - Christian Baumgart
- Department of Movement and Training Science, Faculty of Humanities and Social Sciences, University of Wuppertal, Wuppertal, Germany
| | - Matthias W. Hoppe
- Department of Exercise Science, Institute of Sport Science and Motology, Faculty of Educational Sciences, Philipps University of Marburg, Marburg, Germany
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Validity and reliability of a novel 3D ultrasound approach to assess static lengths and the lengthening behavior of the gastrocnemius medialis muscle and the Achilles tendon in vivo. Knee Surg Sports Traumatol Arthrosc 2022; 30:4203-4213. [PMID: 35906410 PMCID: PMC9668947 DOI: 10.1007/s00167-022-07076-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE Human muscle-tendon units (MTUs) are highly plastic and undergo changes in response to specific diseases and disorders. To investigate the pathological changes and the effects of therapeutic treatments, the use of valid and reliable examination methods is of crucial importance. Therefore, in this study, a simple 3D ultrasound approach was developed and evaluated with regard to: (1) its validity in comparison to magnetic resonance imaging (MRI) for the assessment of the gastrocnemius medialis (GM) MTU, muscle belly, and Achilles tendon lengths; and (2) its reliability for static and dynamic length measurements. METHODS Sixteen participants were included in the study. To evaluate the validity and reliability of the novel 3D ultrasound approach, two ultrasound measurement sessions and one MRI assessment were performed. By combining 2D ultrasound and 3D motion capture, the tissue lengths were assessed at a fixed ankle joint position and compared to the MRI measurements using Bland-Altman plots. The intra-rater and inter-rater reliability for the static and dynamic length assessments was determined using the coefficient of variation, standard error of measurement (SEM), minimal detectable change (MDC95), and intraclass correlation coefficient (ICC). RESULTS The 3D ultrasound approach slightly underestimated the length when compared with MRI by 0.7%, 1.5%, and 1.1% for the GM muscle belly, Achilles tendon, and MTU, respectively. The approach showed excellent intra-rater as well as inter-rater reliability, with high ICC (≥ 0.94), small SEM (≤ 1.3 mm), and good MDC95 (≤ 3.6 mm) values, with even better reliability found for the static length measurements. CONCLUSION The proposed 3D ultrasound approach was found to be valid and reliable for the assessment of the GM MTU, muscle belly, and Achilles tendon lengths, as well as the tissue lengthening behavior, confirming its potential as a useful tool for investigating the effects of training interventions or therapeutic treatments (e.g., surgery or conservative treatments such as stretching and orthotics). LEVEL OF EVIDENCE Level II.
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Valera-Calero JA, Ojedo-Martín C, Fernández-de-Las-Peñas C, Cleland JA, Arias-Buría JL, Hervás-Pérez JP. Reliability and Validity of Panoramic Ultrasound Imaging for Evaluating Muscular Quality and Morphology: A Systematic Review. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:185-200. [PMID: 33189413 DOI: 10.1016/j.ultrasmedbio.2020.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/12/2020] [Accepted: 10/17/2020] [Indexed: 06/11/2023]
Abstract
Panoramic ultrasound (US) is a novel method used to assess linear dimensions, cross-sectional area, fatty infiltrate and echo-intensity features of muscles that cannot be measured with B-mode US. However, a structured overview of its validity and reliability is lacking. MEDLINE, PubMed, SCOPUS and Web of Science databases were systematically searched for studies evaluating reliability or validity data on panoramic US imaging to determine the muscular morphology and/or quality of skeletal muscles. Most studies had acceptable methodological quality. Seventeen studies analyzing reliability (n = 16) or validity (n = 5) were included. Twelve studies assessed cross-sectional area, seven studies assessed echo-intensity, five assessed linear dimensions (fascicle/tendon length, muscle/subcutaneous adipose thickness or between-structure distance) and one assessed intramuscular fat. Panoramic US seems to be a reliable and valid tool for the assessment of muscle morphology and quality in healthy populations at specific locations, particularly the lower extremities. Studies including scanning procedures are needed to confirm these findings in locations not included in this revision and in both clinical and healthy populations.
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Affiliation(s)
- Juan Antonio Valera-Calero
- Department of Physiotherapy, Faculty of Health, Universidad Camilo José Cela, Villanueva de la Cañada, Madrid, Spain; Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Alcorcón, Spain.
| | - Cristina Ojedo-Martín
- Department of Physiotherapy, Faculty of Health, Universidad Camilo José Cela, Villanueva de la Cañada, Madrid, Spain
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain; Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Joshua A Cleland
- Doctor of Physical Therapy Program, Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - José Luis Arias-Buría
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain; Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Juan Pablo Hervás-Pérez
- Department of Physiotherapy, Faculty of Health, Universidad Camilo José Cela, Villanueva de la Cañada, Madrid, Spain
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Functional anatomy, histology and biomechanics of the human Achilles tendon — A comprehensive review. Ann Anat 2020; 229:151461. [DOI: 10.1016/j.aanat.2020.151461] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 11/12/2019] [Accepted: 01/07/2020] [Indexed: 12/30/2022]
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Huang L, Korhonen RK, Turunen MJ, Finnilä MAJ. Experimental mechanical strain measurement of tissues. PeerJ 2019; 7:e6545. [PMID: 30867989 PMCID: PMC6409087 DOI: 10.7717/peerj.6545] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 01/31/2019] [Indexed: 12/22/2022] Open
Abstract
Strain, an important biomechanical factor, occurs at different scales from molecules and cells to tissues and organs in physiological conditions. Under mechanical strain, the strength of tissues and their micro- and nanocomponents, the structure, proliferation, differentiation and apoptosis of cells and even the cytokines expressed by cells probably shift. Thus, the measurement of mechanical strain (i.e., relative displacement or deformation) is critical to understand functional changes in tissues, and to elucidate basic relationships between mechanical loading and tissue response. In the last decades, a great number of methods have been developed and applied to measure the deformations and mechanical strains in tissues comprising bone, tendon, ligament, muscle and brain as well as blood vessels. In this article, we have reviewed the mechanical strain measurement from six aspects: electro-based, light-based, ultrasound-based, magnetic resonance-based and computed tomography-based techniques, and the texture correlation-based image processing method. The review may help solving the problems of experimental and mechanical strain measurement of tissues under different measurement environments.
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Affiliation(s)
- Lingwei Huang
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Rami K Korhonen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Mikael J Turunen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Mikko A J Finnilä
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.,Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
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Abstract
The hierarchical structure of tendon allows for attenuation of mechanical strain down decreasing length scales. While reorganization of collagen fibers accounts for microscale strain attenuation, cross-linking between collagen molecules contributes to deformation mechanisms at the fibrillar and molecular scales. Divalent and trivalent enzymatic cross-links form during the development of collagen fibrils through the enzymatic activity of lysyl oxidase (LOX). By establishing connections between telopeptidyl and triple-helical domains of adjacent molecules within collagen fibrils, these cross-links stiffen the fibrils by resisting intermolecular sliding. Ultimately, greater enzymatic cross-linking leads to less compliant and stronger tendon as a result of stiffer fibrils. In contrast, nonenzymatic cross-links such as glucosepane and pentosidine are not produced during development but slowly accumulate through glycation of collagen. Therefore, these cross-links are only expected to be present in significant quantities in advanced age, where there has been sufficient time for glycation to occur, and in diabetes, where the presence of more free sugar in the extracellular matrix increases the rate of glycation. Unlike enzymatic cross-links, current evidence suggests that nonenzymatic cross-links are at least partially isolated to the surface of collagen fibers. As a result, glycation has been proposed to primarily impact tendon mechanics by altering molecular interactions at the fiber interface, thereby diminishing sliding between fibers. Thus, increased nonenzymatic cross-linking decreases microscale strain attenuation and the viscous response of tendon. In conclusion, enzymatic and nonenzymatic collagen cross-links have demonstrable and distinct effects on the mechanical properties of tendon across different length scales.
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Affiliation(s)
- Jeremy D Eekhoff
- a Department of Biomedical Engineering , Washington University in St. Louis , St. Louis , USA
| | - Fei Fang
- b Department of Orthopedic Surgery , Columbia University , New York , USA
| | - Spencer P Lake
- a Department of Biomedical Engineering , Washington University in St. Louis , St. Louis , USA.,c Department of Mechanical Engineering and Materials Science , Washington University in St. Louis , St. Louis , USA.,d Department of Orthopaedic Surgery , Washington University in St. Louis , St. Louis , USA
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Silbernagel KG, Shelley K, Powell S, Varrecchia S. Extended field of view ultrasound imaging to evaluate Achilles tendon length and thickness: a reliability and validity study. Muscles Ligaments Tendons J 2016; 6:104-10. [PMID: 27331037 DOI: 10.11138/mltj/2016.6.1.104] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Achilles tendon structural changes are common after injury and correlate with recovery of function. Having simple, inexpensive, yet valid and reliable measures of Achilles tendon structure are useful both in research and clinical. The purpose of this study was to perform reliability and validity measures of extended field of view (EFOV) ultrasound (US) imaging of the Achilles tendon. METHODS eight cadavers (16 tendons) were used for the validation study to compare Achilles tendon length measurements from US images with actual measured length from dissected tendons. Nine healthy subjects (18 tendons) were included in the test-retest evaluation. RESULTS the correlation between the US images and cadaveric measurements was excellent (ICC=0.895) for the length between calcaneus and the gastrocnemius and good (ICC=0.744) for the length between the calcaneus and the soleus. The between-limb reliability was excellent (ICC 0.886-0.940) for the tendon length measurements with standard error of measurements (SEM) of 0.64 cm for calcaneus to soleus and 0.67 cm for calcaneus to gastrocnemius. Between-day test-retest reliability was also excellent (ICC=0.898-0.944). CONCLUSION this study supports the use of EFOV US imaging as a reliable and valid method to determine Achilles tendon length and thickness, and using the uninjured limb for comparison.
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Affiliation(s)
| | - Kristen Shelley
- Department of Physical Therapy for University of the Sciences, Philadelphia, USA
| | - Stephen Powell
- Department of Physical Therapy for University of the Sciences, Philadelphia, USA
| | - Shaun Varrecchia
- Department of Physical Therapy for University of the Sciences, Philadelphia, USA
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Barfod KW, Riecke AF, Boesen A, Hansen P, Maier JF, Døssing S, Troelsen A. Validation of a novel ultrasound measurement of achilles tendon length. Knee Surg Sports Traumatol Arthrosc 2015; 23:3398-406. [PMID: 25038882 DOI: 10.1007/s00167-014-3175-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 07/08/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE A clinically applicable and accurate method for measuring Achilles tendon length is needed to investigate the influence of elongation of the Achilles tendon after acute rupture. The purpose of this study was to develop and validate an ultrasonographic (US) length measurement of the Achilles tendon-aponeurosis complex. METHODS Both legs of 19 non-injured subjects were examined by magnetic resonance imaging (MRI) and US. The length from calcaneus to the medial head of m. Gastrocnemius was measured by three independent US examiners. Repeated US measurements were performed and compared to MRI measurements. Intra-rater and inter-rater reliability and the agreement between MRI and US were determined. Data were evaluated using the intraclass correlation coefficient (ICC), the standard error of the measurement (SEM) and the minimal detectable change (MDC). RESULTS Intra-rater reliability of US assessment showed no significant differences between test days: ICC 0.96, SEM 4 mm and MDC 10 mm. Inter-rater reliability showed a systematic difference between US observers of 2-5 mm (p = 0.001-0.036); ICC 0.97, SEM 3 mm and MDC 9 mm. MRI measurements were on average 4 mm longer than US (p = 0.001). CONCLUSION The novel ultrasound measurement showed good reliability and accuracy. For comparison between groups of non-injured subjects differences of more than 4 mm can be detected. For repeated assessment of individual subjects differences of more than 10 mm can be detected. The measurement needs to be further assessed in the setting of acute Achilles tendon rupture. CLINICAL RELEVANCE This new ultrasound measurement might allow for length measurement of ruptured Achilles tendons in the acute and chronic state after rupture. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Kristoffer Weisskirchner Barfod
- Department of Orthopedics, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Denmark.
| | - Anja Falk Riecke
- Department of Orthopedics, Copenhagen University Hospital Køge, Lykkebækvej 1, 4600, Køge, Denmark
| | - Anders Boesen
- Institute of Sports Medicine, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - Philip Hansen
- Department of Radiology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - Jens Friedrich Maier
- Department of Radiology, Copenhagen University Hospital Køge, Lykkebækvej 1, 4600, Køge, Denmark
| | - Simon Døssing
- Department of Orthopedics, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopedics, Clinical Orthopedic Research Hvidovre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Denmark
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Obst SJ, Newsham-West R, Barrett RS. In vivo measurement of human achilles tendon morphology using freehand 3-D ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:62-70. [PMID: 24139914 DOI: 10.1016/j.ultrasmedbio.2013.08.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 07/17/2013] [Accepted: 08/12/2013] [Indexed: 06/02/2023]
Abstract
This study investigated the accuracy of phantom volume and length measurements and the reliability of in vivo Achilles tendon (AT) volume, length and cross-sectional area measurements obtained using freehand 3-D ultrasound. Participants (n = 13) were scanned on consecutive days under active and passive loading conditions. In vivo AT length was evaluated using a two-point method and an approach that accounted for AT curvature (centroid method). Three-dimensional ultrasound provided accurate measures of phantom volume and length (mean difference = 0.05 mL and 0.2 mm, respectively) and reliable in vivo measures of AT volume, length and average cross-sectional area, with all intra-class correlations coefficients greater than 0.98. The mean minimally detectable changes for in vivo AT volume, two-point length and centroid length were 0.2 mL, 1.5 mm and 2.0 mm, respectively. Two-point AT length underestimated centroid AT length by 0.7 mm, suggesting that the effect of curvature on in vivo AT length is negligible.
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Affiliation(s)
- Steven J Obst
- School of Rehabilitation Sciences and Centre for Musculoskeletal Research, Griffith Health Institute, Griffith University, Southport, Queensland, Australia.
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Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2011. [DOI: 10.1097/bco.0b013e318239a4eb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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